Impact of integrating genomic data into the electronic health record on genetics care delivery.

PURPOSE: Integrating genomic data into the electronic health record (EHR) is key for optimally delivering genomic medicine. METHODS: The PennChart Genomics Initiative (PGI) at the University of Pennsylvania is a multidisciplinary collaborative that has successfully linked orders and results from genetic testing laboratories with discrete genetic data in the EHR. We quantified the use of the genomic data within the EHR, performed a time study with genetic counselors, and conducted key informant interviews with PGI members to evaluate the effect of the PGI's efforts on genetics care delivery. RESULTS: The PGI has interfaced with 4 genetic testing laboratories, resulting in the creation of 420 unique computerized genetic testing orders that have been used 4073 times to date. In a time study of 96 genetic testing activities, EHR use was associated with significant reductions in time spent ordering (2 vs 8 minutes, P < .001) and managing (1 vs 5 minutes, P < .001) genetic results compared with the use of online laboratory-specific portals. In key informant interviews, multidisciplinary collaboration and institutional buy-in were identified as key ingredients for the PGI's success. CONCLUSION: The PGI's efforts to integrate genomic medicine into the EHR have substantially streamlined the delivery of genomic medicine.

Association of psychosocial risk screening in pediatric cancer with psychosocial services provided.

OBJECTIVE: How screening for psychosocial risk in pediatric oncology may relate to the number and type of psychosocial services provided is a critical step in linking screening with treatment. We predicted that screening at diagnosis would be associated with the delivery of more psychosocial services over 8 weeks and that these services would be consistent with Universal, Targeted, or Clinical psychosocial risk level based on the Pediatric Psychosocial Preventative Health Model (PPPHM). METHODS: Parents of children newly diagnosed with cancer received either the Psychosocial Assessment Tool (PAT; n = 49) or psychosocial care as usual (PAU; n = 47), based on their date of diagnosis and an alternating monthly schedule. Medical record review and surveys completed by social workers and child life specialists were used to determine psychosocial services provided to patients and their families over the first eight weeks of treatment. RESULTS: As predicted, families in the PAT condition received more services than those in PAU based on social worker and child life specialist report and medical record review. Within the PAT group, families at the Targeted and Clinical levels of risk received more intensive services than those at the Universal level. CONCLUSIONS: This initial report shows how psychosocial risk screening may impact psychosocial care in pediatric cancer, supporting the importance of screening as well as matching services to risk level.

Screening for psychosocial risk at pediatric cancer diagnosis: the psychosocial assessment tool.

BACKGROUND: To investigate the feasibility of integrating an evidence-based screening tool of psychosocial risk in pediatric cancer care at diagnosis. METHODS: Parents of children newly diagnosed with cancer received either the Psychosocial Assessment Tool (PAT; n=52) or psychosocial care as usual (n=47; PAU), based on their date of diagnosis and an alternating monthly schedule. Time to completion of the PAT, time to communication of PAT results to clinical care teams, distribution of PAT risk scores, and identification of psychosocial risks in the medical record were examined. RESULTS: Of families receiving the PAT, 88% completed it within 48 hours. PAT was scored and results communicated within 48 hours in 98% of cases. Most families (72%) were classified as Universal risk based on the underlying Pediatric Psychosocial Preventative Health Model, 24% were classified as Targeted risk, and 4% scored in the Clinical range. Significantly more psychosocial risks were recorded in the medical record during PAT intervals than during PAU. CONCLUSIONS: An evidence-based psychosocial screener is feasible in pediatric oncology care and is associated with documentation of psychosocial risks in the medical record. Although the majority of families report low levels of psychosocial risk, about one-quarter report problems.

Anterior chamber-associated immune deviation.

The eye possesses a critical method of self-preservation in response to intraocular antigen presentation. Instead of conventional immunity by means of delayed-type hypersensitivity (DTH), the eye participates in a systemic immune response involving the thymus and spleen, ultimately leading to suppression of cell-mediated (T helper 1) immunity. The immune response begins with intraocular capture of antigen by specialized ocular antigen-presenting cells (APCs). These activated APCs then migrate preferentially to the marginal zone of the spleen, where they become part of an intricate and highly specific cluster of immune cells. The end result is the emergence of a population of antigen-specific T-regulatory lymphocytes that return to the eye and suppress DTH.

Treatment of equine glaucoma by transscleral neodymium:yttrium aluminum garnet laser cyclophotocoagulation: a retrospective study of 23 eyes of 16 horses.

Contact neodymium:yttrium aluminum garnet (Nd:YAG) laser transscleral cyclophotocoagulation (TSCP) was performed on 23 eyes of 16 horses for treatment of glaucoma. The mean highest preoperative IOP was 51 +/- 17 mmHg. Follow-up evaluation was available for 19 eyes 1 day after surgery, 14 eyes from 1 to 2 weeks, 16 eyes from 4 to 6 weeks, 9 eyes from 12 to 16 weeks, and 10 eyes greater than 20 weeks after laser treatment. The mean intraocular pressure (IOP) the day following surgery was 34 +/- 13 mmHg. The mean IOP for each follow-up period was: one to two weeks postoperative, 23 +/- 9 mmHg; four to six weeks, 24 +/- 7 mmHg; 12-16 weeks, 28 +/- 10 mmHg; and >/= 20 weeks, 22 +/- 9 mmHg. IOP measurements were significantly different from pretreatment values for all follow-up intervals except for weeks 12-16 (P < 0.05). Treatment success was defined as maintenance of IOP < 30 mmHg. Treatment success was achieved in 93%, 88%, 78%, and 70% of the treated eyes at the 1-2 weeks, 4-6 weeks, 12-16 weeks, and the >/= 20 weeks re-evaluation, respectively. No significant difference was found between the number of eyes visual at presentation (52.2%) and visual at 20 weeks (60%). The most common laser complications were conjunctival hyperemia (21.7%) and corneal ulcers (13.0%). Results of this study indicate that Nd:YAG TSCP is an effective method of controlling IOP and preserving vision in horses with glaucoma. An effective Nd:YAG laser protocol for TSCP in the equine glaucomatous eye is a power setting of 11 W, duration of 0.4 s, applied 5 mm posterior to the limbus at 60 sites, resulting in a total energy dose of 264 J.

Regional and zonal variations in the sulfation patterns of chondroitin sulfate in normal equine corneal stroma.

OBJECTIVE: To determine regional and zonal variation in sulfation patterns of chondroitin sulfate in normal equine corneal stroma. SAMPLE POPULATION: 22 normal eyes from 11 horses. PROCEDURE: Corneas were collected within 24 hours of death from equine necropsy specimens. After papain-chondroitinase digestion of corneal tissue, disaccharides deltaDi4S and deltaDi6S were quantified by use of capillary zone electrophoresis in the superficial, middle, and deep zones of central and peripheral regions of the cornea. RESULTS: For the 2 regions combined, deltaDi6S/deltaDi4S values were significantly lower in the deep and middle zones, compared with that of the superficial zone. In the central region, deep and middle zones had significantly lower deltaDi6S/deltaDi4S values than the superficial zone did. In the peripheral region, the deep zone had significantly lower deltaDi6S/deltaDi4S values, compared with superficial and middle zones. In the deep zone, the peripheral region had significantly lower deltaDi6S/deltaDi4S values than the central region did. CONCLUSIONS AND CLINICAL RELEVANCE: Distribution of deltaDi6S/deltaDi4S values follows a gradient across the healthy equine cornea, being smallest in the deep and middle zones of the central region and the deep zone of the peripheral region. Regional and zonal differences in the distribution of stromal deltaDi6S and deltaDi4S may influence the role of glycosaminoglycans in health, disease, and wound repair of the equine cornea.