Correction to: A zebrafish model of foxe3 deficiency demonstrates lens and eye defects with dysregulation of key genes involved in cataract formation in humans.

The authors noticed that Fig. 5A and B aspect ratios appeared sub-optimal in the online published version. This has now been changed.

A zebrafish model of foxe3 deficiency demonstrates lens and eye defects with dysregulation of key genes involved in cataract formation in humans.

The Forkhead box E3 (FOXE3) gene encodes a transcription factor with a forkhead/winged helix domain that is critical for development of the lens and anterior segment of the eye. Monoallelic and biallelic deleterious sequence variants in FOXE3 cause aphakia, cataracts, sclerocornea and microphthalmia in humans. We used clustered regularly interspaced short palindromic repeats/Cas9 injections to target the foxe3 transcript in zebrafish in order to create an experimental model of loss of function for this gene. Larvae that were homozygous for an indel variant, c.296_300delTGCAG, predicting p.(Val99Alafs*2), demonstrated severe eye defects, including small or absent lenses and microphthalmia. The lenses of the homozygous foxe3 indel mutants showed more intense staining with zl-1 antibody compared to control lenses, consistent with increased lens fiber cell differentiation. Whole genome transcriptome analysis (RNA-Seq) on RNA isolated from wildtype larvae and larvae with eye defects that were putative homozygotes for the foxe3 indel variant found significant dysregulation of genes expressed in the lens and eye whose orthologues are associated with cataracts in human patients, including cryba2a, cryba1l1, mipa and hsf4. Comparative analysis of this RNA-seq data with iSyTE data identified several lens-enriched genes to be down-regulated in foxe3 indel mutants. We also noted upregulation of lgsn and crygmxl2 and downregulation of fmodb and cx43.4, genes that are expressed in the zebrafish lens, but that are not yet associated with an eye phenotype in humans. These findings demonstrate that this new zebrafish foxe3 mutant model is highly relevant to the study of the gene regulatory networks conserved in vertebrate lens and eye development.

Resonant metamaterial detectors based on THz quantum-cascade structures.

We present the design, fabrication and characterisation of an intersubband detector employing a resonant metamaterial coupling structure. The semiconductor heterostructure relies on a conventional THz quantum-cascade laser design and is operated at zero bias for the detector operation. The same active region can be used to generate or detect light depending on the bias conditions and the vertical confinement. The metamaterial is processed directly into the top metal contact and is used to couple normal incidence radiation resonantly to the intersubband transitions. The device is capable of detecting light below and above the reststrahlenband of gallium-arsenide corresponding to the mid-infrared and THz spectral region.

Comparison of Computer-based Clinical Decision Support Systems and Content for Diabetes Mellitus.

BACKGROUND: Computer-based clinical decision support (CDS) systems have been shown to improve quality of care and workflow efficiency, and health care reform legislation relies on electronic health records and CDS systems to improve the cost and quality of health care in the United States; however, the heterogeneity of CDS content and infrastructure of CDS systems across sites is not well known. OBJECTIVE: We aimed to determine the scope of CDS content in diabetes care at six sites, assess the capabilities of CDS in use at these sites, characterize the scope of CDS infrastructure at these sites, and determine how the sites use CDS beyond individual patient care in order to identify characteristics of CDS systems and content that have been successfully implemented in diabetes care. METHODS: We compared CDS systems in six collaborating sites of the Clinical Decision Support Consortium. We gathered CDS content on care for patients with diabetes mellitus and surveyed institutions on characteristics of their site, the infrastructure of CDS at these sites, and the capabilities of CDS at these sites. RESULTS: The approach to CDS and the characteristics of CDS content varied among sites. Some commonalities included providing customizability by role or user, applying sophisticated exclusion criteria, and using CDS automatically at the time of decision-making. Many messages were actionable recommendations. Most sites had monitoring rules (e.g. assessing hemoglobin A1c), but few had rules to diagnose diabetes or suggest specific treatments. All sites had numerous prevention rules including reminders for providing eye examinations, influenza vaccines, lipid screenings, nephropathy screenings, and pneumococcal vaccines. CONCLUSION: Computer-based CDS systems vary widely across sites in content and scope, but both institution-created and purchased systems had many similar features and functionality, such as integration of alerts and reminders into the decision-making workflow of the provider and providing messages that are actionable recommendations.

Subjective assessment of usefulness and appropriate presentation mode of alerts and reminders in the outpatient setting.

There is very little known about the limits of alerting in the setting of the outpatient Electronic Medical Record (EMR). We are interested in how users value and prefer such alerts. One hundred Kaiser Permanente primary care clinicians were sent a four-page questionnaire. It contained questions related to the usability and usefulness of different approaches to presenting reminder and alert information. The survey also contained questions about the desirability of six categories of alerts. Forty-three of 100 questionnaires were returned. Users generally preferred an active, more intrusive interaction model for "alerts" and a passive, less intrusive model for order messages and other types of reminders and notifications. Drug related alerts were more highly rated than health maintenance or disease state reminders. Users indicated that more alerts would make the system "more useful" but "less easy to use".

Experience using radio frequency laptops to access the electronic medical record in exam rooms.

Kaiser Permanente, Northwest, evaluated the use of laptop computers to access our existing comprehensive Electronic Medical Record in exam rooms via a wireless radiofrequency (RF) network. Eleven of 22 clinicians who were offered the laptops successfully adopted their use in the exam room. These clinicians were able to increase their exam room time with the patient by almost 4 minutes (25%), apparently without lengthening their overall work day. Patient response to exam room computing was overwhelmingly positive. The RF network response time was similar to the hardwired network. Problems cited by some laptop users and many of the eleven non-adopters included battery issues, different equipment layout and function, and inadequate training. IT support needs for the RF laptops were two to four times greater than for hardwired desktops. Addressing the reliability and training issues should increase clinician acceptance, making a successful general roll-out for exam room computing more likely.

Effects of interferon alpha-2b on barrier function and junctional complexes of renal proximal tubular LLC-PK1 cells.

BACKGROUND: Interferon alpha-2b (IFNalpha) treatment of diseases can be accompanied by impaired renal function and capillary leak syndrome. To explore potential mechanisms of IFNalpha-induced renal dysfunction, an in vitro cell culture model system was established to investigate the effects of IFNalpha on barrier function and junctional complexes. METHODS: LLC-PK1 cells were cultured on microporous membranes. Transepithelial resistance (TER) was measured, and the dose- and time-dependent effects of IFNalpha were assessed. The expression patterns of junctional proteins were examined by Western blot analysis and by confocal immunofluorescence microscopy. RESULTS: IFNalpha produced a dose- and time-dependent decrease in TER. The effect was reversible on removal of IFNalpha at doses up to 5 x 103 U/ml. Tyrphostin, an inhibitor of phosphotyrosine kinases, ameliorated the IFNalpha-induced decrease in TER. Increased expression of occludin and E-cadherin was detected by Western blot analysis after IFNalpha treatment. Immunofluorescence confocal microscopy revealed a broader staining of occludin and E-cadherin following IFNalpha treatment, with prominent staining at the basal cell pole in addition to localization at the junctional region. A marked increase in phosphotyrosine staining along the apico-lateral cell border was detected after IFNalpha treatment. CONCLUSIONS: These findings provide evidence that IFNalpha can directly affect barrier function in renal epithelial cells. The mechanisms involve enhanced tyrosine phosphorylation and overexpression and possibly displacement or missorting of the junctional proteins occludin and E-cadherin.

Successful implementation of a comprehensive computer-based patient record system in Kaiser Permanente Northwest: strategy and experience.

Kaiser Permanente Northwest (KPNW) has implemented a computer-based patient record (CPR) system for outpatients. Clinicians at KPNW use this comprehensive CPR to electronically document patient encounters; code diagnoses and procedures; maintain problem lists; order laboratory tests, radiology tests, and prescriptions; and send patient-specific messages and referrals to other medical providers. More than 700 clinicians, representing more than 20 medical and surgical specialties, and 2600 support staff in 31 geographically separate sites use this system as the information foundation of delivery and documentation of health care for KPNW's membership of 430,000. As of May 1998, more than four million visits and two million telephone calls had been processed and documented into the system. More than 5000 outpatient visits are processed and documented each weekday. From an integrated clinical workstation, clinicians also access e-mail, an extensive results-reporting system, and sites on both the internet and KPNW's intranet. This article describes a strategy for and experience with the implementation of a large-scale, comprehensive CPR in an integrated HMO. This information may be useful for persons attempting to implement CPRs in their own institutions.

Evaluation of online documentation.

The University of Iowa Hospitals and Clinics (UIHC) implemented an online documentation system for patient care orders in 1994-1996. Developed entirely in-house, the INFORMM NIS (Information Network for Online Retrieval & Medical Management Nursing Information System) features order-generated task lists, defaulted charting responses, computer-generated chart forms, and graphical data displays. To measure the impact of automation on user perceptions, and documentation compliance, completeness, time, and location, a team of nursing and information systems representatives captured data before and after implementation. Staff surveys show more positive user perceptions. Documentation results indicate increased compliance and completeness, and a decrease or no change in time. Online documentation occurs mainly at unit workstations.

Differential activities of H+ extrusion systems in MDCK cells due to extracellular osmolality and pH.

The aim of the present study was to obtain detailed information on MDCK cell proton secretion characteristics under various growth conditions. Confluent monolayers cultured on glass coverslips were adapted over 48 h to media with different osmolality and pH (200 mosmol/kgH2O, pH 7.4; 300 mosmol/kgH2O, pH 7.4; and 600 mosmol/kgH2O, pH 6.8) corresponding to the luminal fluid composition of the collecting duct segments found in the in renal cortex, the outer stripe of outer medulla and inner medulla. Proton fluxes were determined from the recovery of intracellular pH following an acid load induced by an NH4Cl pulse times the corresponding intrinsic buffering power (beta(i)). The intracellular buffering power was found to change only with culture medium osmolality but not with culture medium pH. In addition to an amiloride and Hoe-694-sensitive Na+/H+ exchange, Madin-Darby canine kidney (MDCK) cells possess a Sch-28080-sensitive, K+-dependent H+ extrusion mechanism that is increased upon adaptation of monolayers to hyperosmotic-acidic culture conditions. A significant contribution of the bafilomycin A1-sensitive vacuolar H+-ATPase could be found only in cells adapted to hyposmotic culture conditions. Exposure of MDCK cells to 10(-5) or 10(-7) M aldosterone for either 1 or 18 h did not alter the H+ extrusion characteristics significantly. The results obtained show that different extracellular osmolality and pH induce different MDCK phenotypes with respect to their H+-secreting systems.

Improving clinician acceptance and use of computerized documentation of coded diagnosis.

After the Northwest Division of Kaiser Permanente implemented EpicCare, a comprehensive electronic medical record, clinicians were required to directly document orders and diagnoses on this computerized system, a task they found difficult and time consuming. We analyzed the sources of this problem to improve the process and increase its acceptance by clinicians. One problem was the use of the International Classification of Diseases (ICD-9) as our coding scheme, even though ICD-9 is not a complete nomenclature of diseases and using it as such creates difficulties. In addition, the synonym list we used had some inaccurate associations, contributing to clinician frustration. Furthermore, the initial software program contained no adequate mechanism for adding qualifying comments or preferred terminology. We sought to address all these issues. Strategies included adjusting the available coding choices and descriptions and modifying the medical record software. In addition, the software vendor developed a utility that allows clinicians to replace the ICD-9 description with their own preferred terminology while preserving the ICD-9 code. We present an evaluation of this utility.

Implementation of a comprehensive computer-based patient record system in Kaiser Permanente's Northwest Region.

Kaiser Permanente, Northwest Region, has implemented a comprehensive outpatient computer-based patient record. Clinicians use this system to document encounters, code diagnoses and procedures, maintain problem lists, order laboratory and radiology tests, and send prescriptions electronically. Clinicians also use it to send patient-specific messages and referrals between medical providers. More than 300 primary care clinicians in 10 separate clinics are now using the system in the delivery of care. This article describes our strategy and experience in the implementation of a comprehensive computer-based patient record.

Mml1, a new common integration site in murine leukemia virus-induced promonocytic leukemias maps to mouse chromosome 10.

MuLV-induced myeloid leukemias (MML) having promonocytic characteristics are produced with high incidence in some strains of adult mice that are undergoing chronic peritoneal inflammation. Previously we showed that many leukemias have rearrangements of the c-myb locus due to insertional mutagenesis, however, we also identified a number of leukemias that had proviral integrations in the absence of c-myb rearrangement in the present study, a new locus, Mml1, was found to be a target of insertional mutagenesis in 10 of the promonocytic leukemias that lacked c-myb alterations. Chromosomal mapping studies, performed using progeny from interspecies backcross mice generated by mating (BALB/cAn x M. spretus)F1 females to BALB/cAN males, determined that Mml1 is located on the proximal end of mouse chromosome 10. Interestingly, there were no recombinants between c-myb and Mml1 in 101 backcross progeny and Mml1 was mapped approximately 20-25 kb upsteam of c-myb. Interestingly, c-myb mRNA and Myb protein are expressed at levels similar to the levels observed in myeloid progenitor cells, but are not overexpressed. It is anticipated that future experiments will determine whether Mml1 integration prevents down regulation of c-myb expression or activates another gene on chromosome 10.

Retroviral insertional mutagenesis in murine promonocytic leukemias: c-myb and Mml1.

Studies have focused on two genetic loci, c-myb and Mml1, whose activation by retroviral insertional mutagenesis contribute to promonocytic leukemia in our acute monocytic leukemia (AMoL) model. Multiple mechanisms of activation of c-myb by retroviral insertional mutagenesis implicate both transcriptional deregulation and protein truncation in conversion of this proto-oncogene to an oncogene. Because transformation by c-Myb can be viewed as a block to differentiation our studies moved into two in vitro systems to evaluate effects of truncated forms of c-Myb on cytokine induced maturation of myeloid progenitors to the granulocyte and macrophage lineages. Deregulated expression of truncated and full length c-Myb did not result in maintenance of the myelomonocytic progenitor state but rather a block in differentiation at intermediate to late steps in the maturation processes of myelomonocytic cells. Our results argue that inhibition of differentiation is due to c-Myb's ability to maintain the proliferative state of cells. Interestingly, the phenotype of continuously proliferating monocytic cells resembles that of the tumor cell phenotype. Recently we identified a new target of integration, Mml1, which is rearranged in ten promonocytic leukemias that do not have c-myb rearrangements. This locus which was mapped to chromosome 10 is presently being characterized.

Acceptance and performance by clinicians using an ambulatory electronic medical record in an HMO.

The Northwest Region of Kaiser Permanente implemented a comprehensive clinical information system in two sites between February and December 1994. By year end 46 primary care clinicians and 95 supporting personnel used the system on a daily basis to provide patient care. Clinicians use the product to select coded diagnoses, and directly order laboratory, imaging, and other tests, internal referrals, and prescriptions. They enter progress notes into the system, and use it to generate patient focused visit summaries. Clinicians took approximately 2 minutes longer, on average, to complete patient visits post-implementation. Most of this time was spent performing "orders and diagnosis" work, which included new required elements in the post-implementation period. Clinicians worked approximately 30 days before reaching their baseline visit rate and "lost" approximately 48 hours of productivity during the learning, including classroom training. User acceptance improved from 2 to 4 months of use.

Integrated clinical database in a health maintenance organization.

This paper describes the development and implementation of the first phase of a comprehensive clinical information system in the Kaiser Permanente Northwest Region. This system integrates information from disparate departmental systems into a single clinical database. By using periodic batch downloads of patient data from departmental systems into the clinical database, rather than requiring real-time updates, we have been able to implement this system with relative ease and speed. It contains patient demographics, lab, outpatient pharmacy, radiology, pathology, dictated consults, admission histories and physicals, discharge summaries, and other dictated reports for over 380,000 Health Plan Members. The system is fast, intuitive, reliable, and user-friendly. In March 1994, there were approximately 1,600 active users. These individuals accounted for approximately 410,000 transactions in the month, with an average daily transaction volume of 11,450. Quantifiable cost-savings, in terms of decreased chart pulls and decreased phone calls for information, have offset the cost of development and implementation to some extent. Less quantifiable improvements in the quality of care and the associated cost-savings may eclipse the quantifiable benefits. This system lays the foundation for our clinical information system efforts.

Clinical value of fructose 1,6 bisphosphatase in monitoring renal proximal tubular injury.

The usefulness of the gluconeogenic key enzyme fructose 1,6 bisphosphatase (FBPase), which is localized exclusively in the proximal nephron segment, as a marker compound to monitor injury of the proximal nephron segment during nephrotoxic therapy, was tested in a collective model of male patients treated for testicular cancer. These patients with normal kidney function were submitted to therapy with the nephrotoxic chemotherapeutics carboplatinum and a combination of cisplatinum, etoposide, bleomycin and ifosfamide. The release of FBPase activities into the urine was monitored during the initial two treatments over a period of eight days. The urinary enzyme activities measured were compared to the excretion of the "proximal tubular injury markers" N-acetyl-beta-D-glucosaminidase (NAG) and alpha 1-microglobulin (alpha 1m). The presence of glomerular damage was determined by measurement of urinary excretion rates of albumin (ALB) and IgG. In addition, protein excretion patterns following chemotherapy were monitored. The combined administration of cisplatin, etoposide and ifosfamide resulted in a pronounced proximal tubular injury as shown by the release of FBPase into the urine. This is substantiated by simultaneously increased excretion rates for NAG and alpha 1m. Proximal tubular toxicity was found to be less severe when cisplatin was combined with etoposide and bleomycin and was nearly absent following carboplatinum monotherapy. Carboplatinum only affected glomerular function and resulted in an elevated ALB and IgG excretion. From this model investigation it can be delineated that determination of urinary FBPase activities ensures a sensitive and reliable identification of proximal nephron damage.

The inducible form of nitric oxide synthase (NOS2) isolated from murine macrophages maps near the nude mutation on mouse chromosome 11.

Nitric oxide synthase has been shown to mediate streptozocin-induced diabetes and to act as an antimicrobial agent in murine macrophages. Using a cDNA probe for the inducible form of nitric oxide synthase (Nos2) isolated from murine macrophages we have determined that the gene maps within 1 cM of the nude mutation on mouse Chromosome 11. The position of Nos2 was also mapped relative to the markers 115, Evi2, Cchlbl (previously unmapped), and Gfap. This map location is discussed relative to map locations for disease susceptibility loci involved in mediating cutaneous leishmaniasis (ScII) and autoimmune type-I diabetes (Idd4).