Plastic and Reconstructive Surgery Resident Indigent Care Clinic Optimization by Improving "No-Show" Rates.

ABSTRACT: Absenteeism among clinical patients is a significant source of inefficiency in the modern American health care system. Routine absenteeism limits access to care for indigent patients, thus providing additional strain on the health care system and timely administration of care.This quality improvement project set out to quantify, understand, and potentially reduce patient absenteeism in our weekly plastic and reconstructive surgery resident indigent care clinic. One year prior to our study was retrospectively reviewed to determine a baseline rate of absenteeism (no shows). The daily and monthly no-show percentages were calculated. Then, three consecutive 2-month Plan, Do, Study, Act (PDSA) cycles were performed and data were recorded.The initial year analysis demonstrated an average no-show rate of 25%. The first PDSA cycle attempted to ascertain factors contributing to absenteeism and to get patients rescheduled. The rate of clinical absenteeism was 27% over this period compared with a rate of 18% in the control period. During this period, we discovered a limitation of our institution's electronic medical record (EMR). Rescheduled patients were removed from the original schedule and were not counted as a missed appointment even though the opportunity for care was missed. The second PDSA cycle attempted to collect raw data while trying to understand the EMR error and rescheduling process. During this period, there was a 33% no-show rate compared with 27% in the control period. The third PDSA cycle attempted again to establish factors contributing to clinical absenteeism with a better understanding of the limitations of our EMR. A 33% no-show rate during this cycle was recorded compared with 22% in the control period. After three PDSA cycles were completed, our clinic had an average no-show rate of 31% compared with 25% during the same months in the previous year.This project brought to realization that our data were initially skewed by our ignorance of an EMR flaw that did not track patients who either canceled or rescheduled their appointments. We also learned that there is a certain subset of patients who are not able to be contacted and who do not follow up.

A New Method to Determine Antioxidant Activities of Biofilms Using a pH Indicator (Resazurin) Model System.

Biopolymeric films were prepared with gelatin, plasticizer, and three different types of antioxidants (ascorbic acid, phytic acid, and BHA) corresponding to different mechanisms in activity. The antioxidant activity of films was monitored for 14 storage days upon color changes using a pH indicator (resazurin). The instant antioxidant activity of films was measured by a DPPH free radical test. The system using resazurin was composed of an agar, an emulsifier, and soybean oil to simulate a highly oxidative oil-based food system (AES-R). Gelatin-based films (GBF) containing phytic acid showed higher tensile strength and energy to break than all other samples due to the increased intermolecular interactions between phytic acid and gelatin molecules. The oxygen barrier properties of GBF films containing ascorbic acid and phytic acid increased due to the increased polarity, while GBF films containing BHA showed increased oxygen permeability compared to the control. According to "a-value" (redness) of the AES-R system tested with films, films incorporating BHA showed the most retardation of lipid oxidation in the system. This retardation corresponds to 59.8% antioxidation activity at 14 days, compared with the control. Phytic acid-based films did not show antioxidant activity, whereas ascorbic acid-based GBFs accelerated the oxidation process due to its prooxidant activity. The comparison between the DPPH free radical test and the control showed that the ascorbic acid and BHA-based GBFs showed highly effective free radical scavenging behavior (71.7% and 41.7%, respectively). This novel method using a pH indicator system can potentially determine the antioxidation activity of biopolymer films and film-based samples in a food system.

Myc oncogene-induced genomic instability: DNA palindromes in bursal lymphomagenesis.

Genetic instability plays a key role in the formation of naturally occurring cancer. The formation of long DNA palindromes is a rate-limiting step in gene amplification, a common form of tumor-associated genetic instability. Genome-wide analysis of palindrome formation (GAPF) has detected both extensive palindrome formation and gene amplification, beginning early in tumorigenesis, in an experimental Myc-induced model tumor system in the chicken bursa of Fabricius. We determined that GAPF-detected palindromes are abundant and distributed nonrandomly throughout the genome of bursal lymphoma cells, frequently at preexisting short inverted repeats. By combining GAPF with chromatin immunoprecipitation (ChIP), we found a significant association between occupancy of gene-proximal Myc binding sites and the formation of palindromes. Numbers of palindromic loci correlate with increases in both levels of Myc over-expression and ChIP-detected occupancy of Myc binding sites in bursal cells. However, clonal analysis of chick DF-1 fibroblasts suggests that palindrome formation is a stochastic process occurring in individual cells at a small number of loci relative to much larger numbers of susceptible loci in the cell population and that the induction of palindromes is not involved in Myc-induced acute fibroblast transformation. GAPF-detected palindromes at the highly oncogenic bic/miR-155 locus in all of our preneoplastic and neoplastic bursal samples, but not in DNA from normal and other transformed cell types. This finding indicates very strong selection during bursal lymphomagenesis. Therefore, in addition to providing a platform for gene copy number change, palindromes may alter microRNA genes in a fashion that can contribute to cancer development.

DNA copy-number instability in low-dose gamma-irradiated TK6 lymphoblastoid clones.

Genomic instability that might occur early during low-dose, fractionated radiation exposures may be traceable in radiogenic compared to spontaneous cancers. Using a human 18K cDNA microarray-based comparative genome hybridization protocol, we measured changes in DNA copy number at over 14,000 loci in nine low-dose (137)Cs gamma-irradiated (acute exposure to 10 cGy/day x 21 days) and nine unirradiated TK6 clones and estimated locus-specific copy-number differences between them. Radiation induced copy-number hypervariability at thousands of loci across all chromosomes, with a sevenfold increase in low-level, randomly positioned DNA gains. Recurrent gains at 40 loci occurred among irradiated clones and were distributed nonrandomly across the genome, with the highest densities in 3q, 13q and 20q at sites that were hypodiploid without irradiation. Another nonrandomly distributed set of 94 loci exhibited relative recurrent gains from a hypodiploid state to a diploid state, suggesting hemizygous-to-homozygous transitions. Frequently recurring losses at 57 loci were concentrated on the single X-chromosome but were sparsely distributed at 0-2 loci per autosome. These results suggest induced mitotic homologous recombination as a possible mechanism of low-dose radiation-induced genomic instability. Genomic instability induced in TK6 cells resembled that seen in radiogenic tumors and suggests a way that radiation could induce genomic instability in preneoplastic cells.

Induction and loss of a TP53-dependent radioadaptive response in the human lymphoblastoid cell model TK6 and its abrogation by BCL2 over-expression.

PURPOSE: To characterize the radioadaptive response in the human lymphoblastoid cell model TK6, and determine: (i) Whether repeated low dose exposures are more effective than single acute exposures in inducing resistance, (ii) the time-course for induction and loss of resistance following chronic exposures, and (iii) the effect of TP53 deletion or BCL2 over-expression on the induction of an adaptive response. MATERIALS AND METHODS: TK6, a human B-lymphoblastoid cell line, TK6-BCL2, a TK6 line that over-expresses BCL2 and is resistant to radiation-induced apoptosis, and NH32, a TP53 knockout of TK6 that is also resistant to apoptosis were studied. Cells were exposed to chronic, daily doses of 10 cGy given over 1 -21 days before being challenged with 1 -5 Gy exposures. Cell survival and chromatid break induction following high dose challenge were used to evaluate adaptive radiation responses. RESULTS: Exposure to 10 cGy gamma rays induced resistance to killing and chromosome break induction in TK6 cells, but not in either TK6-BCL2 or NH32 cells. Resistance in TK6 was observed 4 h after exposure, and cells remained resistant for about 48 h. Maximal resistance was induced by a single 10 cGy dose. Repeated 10 cGy exposures had no additional effect on radiation sensitivity, except to maintain the induced radioresistance. CONCLUSION: An adaptive response is maximally and rapidly induced by a single low dose exposure in TK6 cells, and it has a limited lifespan. Induction of an adaptive response in TK6 cells can be abrogated by either TP53 loss or BCL2 over-expression. The characteristics of induced resistance in TK6 cells suggest that alterations in TP53-dependent apoptotic responses may be one mechanism for resistance.

New approach for characterization of gelatin biopolymer films using proton behavior determined by low field 1H NMR spectrometry.

The behavior of protons in biopolymer films (BFs) formed with gelatin, water, and glycerol was investigated at various relative humidities (RHs) and concentrations of glycerol using a low field 1H NMR spectrometer. At a RH of approximately 0%, the distributed spin-spin relaxation times (T2) of protons in BFs showed two components: a rapidly relaxing proton with the shortest T2 derived from protons in the rigid backbone of the gelatin polymer such as CH1-, CH2-, and CH3-, and a slowly relaxing component with longer T2 from protons of the functional groups in amino acid residues in gelatin such as -OH, -COOH, and -NH3. These two components are referred to as nonexchangeable (T2N) and exchangeable protons (T2E), respectively, indicating the different mobility of the protons. The T2E increased as RH increased indicating the increase in relative mobility of protons due to the larger free volume in the BF matrix. Above a RH of 33%, the slowest relaxing component was found in all BFs and referred to as hydration-water protons (T2W) with the highest relative mobility of all protons in the films. It suggests that the free volume in BFs can be formed above a RH of 33% in the absence of glycerol. The behaviors of T2N, T2E, and T2W reveal the formation of free volume in the BF matrix associated with the presence of plasticizers (water and glycerol). The T2 behavior in BFs is consistent with the behavior of spin-lattice relaxation (T1). Our result is the first attempt to characterize using low field 1H NMR technology how all protons in a film matrix behave and to develop correlations between proton mobility and free volume in protein-based BFs plasticized with water and glycerol.

Preparation of genomic DNA for microarray-based comparative genome hybridization.

Genome-wide assessment of DNA gains and losses can be accomplished by comparative hybridization using a variety of microarray platforms that employ oligo, cDNA, BAC and other sequences as probes. Here we describe the preparation of genomic DNA for hybridization to a set of chicken cDNA probes spotted on glass slide microarrays. Method 1 can be used to assess DNA copy-number differences between two genomes, typically an experimental genome and a normal, diploid genome. We then present a specialized application of array CGH for detecting DNA amplifications containing long, inverted repeat structures (palindromes). Method 2 describes the procedure for palindrome enrichment and the internal controls used to distinguish direct versus inverted, long repeat structures using the cDNA microarray platform.

Analysis of gene expression, copy number and palindrome formation with a Dt40 enriched cDNA microarray.

DT40 presents a unique opportunity to exploit newly available tools for chicken genomic analysis. A 13K chicken cDNA microarray representing 11447 non-overlapping ESTs has been developed. This array detects expression of 7086 DT40 genes of which_644 are over-expressed 3-fold or greater and 1585 are under-expressed 3-fold or greater relative to normal post-hatch bursal cell populations. Changes in RNA expression due to single gene alterations can be detected by expression profiling. For example, by this method, over expression of the oncogenic micro RNA bic up-regulates expression of VBP, a known regulator of Avian Leukosis Virus LTR- driven transcription with very little additional expression change, A degree of cytogenetic abnormality and instability of DT40 cells has been observed, which is characterized at the fine structure level using microarray-based comparative genome hybridization (array-CGH). The relationship between gene copy number and RNA expression levels can be assessed in the same tissue samples using the same microarray. A newly introduced technique for genome-wide analysis of palindrome formation (GAPF) detects long inverted repeats, or palindromes, which are early events in gene amplification and possibly other DNA structural change. Since both array CGH-detected copy number changes and GAPF-detected palindromes are abundant in DT40, these techniques, coupled with targeted gene deletion and replacement, may provide a powerful tool for analysis of genomic instability and its underlying genetic mechanisms.

Microarray comparative genomic hybridization reveals genome-wide patterns of DNA gains and losses in post-Chernobyl thyroid cancer.

Genetic gains and losses resulting from DNA strand breakage by ionizing radiation have been demonstrated in vitro and suspected in radiation-associated thyroid cancer. We hypothesized that copy number deviations might be more prevalent, and/or occur in genomic patterns, in tumors associated with presumptive DNA strand breakage from radiation exposure than in their spontaneous counterparts. We used cDNA microarray-based comparative genome hybridization to obtain genome-wide, high-resolution copy number profiles at 14,573 genomic loci in 23 post-Chernobyl and 20 spontaneous thyroid cancers. The prevalence of DNA gains in tumors from cases in exposed individuals was two- to fourfold higher than for cases in unexposed individuals and up to 10-fold higher for the subset of recurrent gains. DNA losses for all cases were low and more prevalent in spontaneous cases. We identified unique patterns of copy variation (mostly gains) that depended on a history of radiation exposure. Exposed cases, especially the young, harbored more recurrent gains that covered more of the genome. The largest regions, spanning 1.2 to 4.9 Mbp, were located at 1p36.32-.33, 2p23.2-.3, 3p21.1-.31, 6p22.1-.2, 7q36.1, 8q24.3, 9q34.11, 9q34.3, 11p15.5, 11q13.2-12.3, 14q32.33, 16p13.3, 16p11.2, 16q21-q12.2, 17q25.1, 19p13.31-qter, 22q11.21 and 22q13.2. Copy number changes, particularly gains, in post-Chernobyl thyroid cancer are influenced by radiation exposure and age at exposure, in addition to the neoplastic process.

Functional genomic analysis reveals distinct neoplastic phenotypes associated with c-myb mutation in the bursa of Fabricius.

Avian retroviral integration into the c-myb locus is casually associated with the development of lymphomas in the bursa of Farbricius of chickens; these arise with a shorter latency than bursal lymphomas caused by deregulation of c-myc. This study indicates that c-myb mutation in embryonic bursal precursors leads to an oligoclonal population of developing bursal follicles, showing a variable propensity to form a novel lesion, the neoplastic follicle (NF). About half of such bursas rapidly developed lymphomas. Detection of changes in gene expression, during the development of neoplasms, was carried out by cDNA microarray analysis. The transcriptional signature of lymphomas with mutant c-myb was more limited than, and only partially shared with, those of bursal lymphomas caused by Myc or Rel oncogenes. The c-myb-associated lymphomas frequently showed overexpression of c-myc and altered expression of other genes involved in cell cycle control and proliferation-related signal transduction. Oligoclonal, NF-containing bursas lacked detectable c-myc overexpression and demonstrated a pattern of gene expression distinct from that of normal bursa and partially shared with the short-latency lymphomas. This functional genomic analysis uncovered several different pathways of lymphomagenesis by oncogenic transcription factors acting in a B-cell lineage.

Array rank order regression analysis for the detection of gene copy-number changes in human cancer.

cDNA microarray technology has been applied to the detection of DNA copy-number changes in malignant tumors. Test and control genomic DNA samples are differentially labeled and cohybridized to a spotted cDNA microarray. The ratio of test to control fluorescence intensities for each spot reflects relative gene copy number. The low signal-to-noise ratios of this assay and the variable levels of gene amplification and deletion among tumors hamper the detection of deviations from the diploid complement. We describe a regression-based statistical method to test for altered copy number on each gene and apply the technique to copy-number profiles in 10 thyroid tumors. We show that a novel transformation of fluorescence ratios into array rank order efficiently normalizes the heterogeneity among copy-number profiles and improves the reproducibility of the results. Array rank order regression analysis enhances the detection of consistent changes in gene copy number in solid tumors by cDNA microarray-based comparative genome hybridization.