Development of the dyspepsia educational tool was funded by a grant received from The Netherlands Organization for Health Research and Development (ZonMw), in the context of the &#39;to do or not to do&#39; program by the Netherlands Federation of University Medical Centers (NFU). We also would like to thank all the staff from Medify bv. for support, equipment, and expertise. In addition we would like to thank all our participants.

All procedures described in this protocol were approved by the Radboud university medical center Institutional Review Board (file no. 2016-3074).
1. Preliminary research
<ol>
	<li>Focus groups to assess unmet needs in dyspepsia management
	<ol>
		<li>Create a structure for a focus group with dyspeptic patients and with general practitioners.</li>
		<li>Conduct a focus group. Keep conducting additional focus groups until saturation of information is reached. 
		NOTE: For this study two focus groups were conducted.
		<ol>
			<li>Recruit participants from patient organization platforms and the gastroenterology outpatient clinic.</li>
			<li>Recruit general practitioners through local general practitioner networks.</li>
			<li>Provide all participants with a patient information form, explaining the concept and goal of the focus group. Do not present the questions of the focus group in the information form.</li>
			<li>Obtain written informed consent from all participants. 
			&#8203;NOTE: Informed consent was obtained from all participants in this study.</li>
			<li>Conduct the focus groups with two researchers. Appoint a moderator and an observer. As a moderator, emphasize that there are no wrong answers, ensure all participants have the opportunity to express their views, and monitor the time. As an observer, observe and take notes of the group dynamics and body language of participants.</li>
			<li>Start the recording of the session using a voice recorder.</li>
			<li>Present each question to the group and encourage discussion about varying views. Ask the following questions; &#39;Could you describe the symptoms you feel?&#39;, &#39;How do the symptoms influence your day-to-day life?&#39;, &#39;What measures have you taken yourself to relieve your symptoms?&#39;, &#39;Where did you get most information about your disease?&#39;, and &#39;Which elements lacked in the management of your disease?&#39;.</li>
			<li>Transcribe the voice recording. Process the focus groups and interviews using the qualitative data analysis software (e.g., ATLAS.ti version 8.3.16).</li>
			<li>Highlight and connect topics and views that overlap. Use the observer notes for interpretation of discussion and opposite views of participants.</li>
			<li>Extract the main themes resulting from the focus group to form the structure of the tool.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Existing scientific evidence
	<ol>
		<li>Based on the main outlines that resulted from assessment of needs, make an overview of the topics that should be supported by literature. Examples are pathophysiology of dyspepsia, dietary interventions, pharmacological treatment, and (the value of) diagnostics.</li>
		<li>Use the online databases Medline and EMBASE to search for recent literature. To build a search, MeSH terms (Medline) or Emtree terms (EMBASE) should be combined with free text words.</li>
		<li>Select the most relevant articles to use as scientific background in the tool.</li>
		<li>Find local and national guidelines related to dyspepsia management. Make a selection of recommendations most relevant to the target audience.</li>
		<li>Summarize existing national patient information on dyspepsia. Use approved primary and secondary care information, as well as government supported web-based information.</li>
	</ol>
	</li>
</ol>
2. Content development
<ol>
	<li>Software development partner
	<ol>
		<li>Select a partner for software production to involve in the development. Make a selection based on available products, such as 3D visualization, video recording, user friendly content management system, and possibilities to do adjustments after pilot test. 
		&#8203;NOTE: For this study, Medify Media B.V. was contracted for software development.</li>
	</ol>
	</li>
	<li>Organization of data
	<ol>
		<li>Combine all collected data in one file and merge related topics. Create a clear overview of all items that should be addressed in the tool.</li>
		<li>Categorize the information into manageable chapters.</li>
		<li>Organize the items into a logical flow that will be maintained in the tool, for example by drawing up a flowchart illustrating the flow and content of each chapter and interconnection between chapters.</li>
		<li>Organize the chapters in a nonlinear structure, allowing completion of chapters in random order.</li>
	</ol>
	</li>
	<li>Process session
	<ol>
		<li>Organize a process session with all stakeholders, including involved researchers, doctors, software developers, and visual designers.</li>
		<li>Within the process session, identify all elements that can be visualized through real-life videos or animation or should appear as text.</li>
	</ol>
	</li>
	<li>Creation of content
	<ol>
		<li>Start every chapter with an overview of the chapter, introduce important items and terms.</li>
		<li>At the end of every chapter, give a chapter summary. Refrain from giving redundant information that may distract attention.</li>
		<li>Highlight essential information using bullet points and/or bold text.</li>
		<li>Use plain language writing when writing texts.
		<ol>
			<li>Clearly consider the target audience and write from that perspective.</li>
			<li>Maintain a 7th to 8th grade reading level.</li>
			<li>Use active rather than passive sentences, writing in a conversational style, including the frequent use of questions and personal pronouns (e.g., &#39;do you regularly feel full after a normal sized meal? Try to avoid fatty foods.&#39;, rather than &#39;if a full feeling after a normal sized meal is regularly encountered, avoiding fatty foods may be tried.&#39;).</li>
			<li>Limit the amount of text per paragraph to a maximum of 10 sentences.</li>
		</ol>
		</li>
		<li>For the videos:
		<ol>
			<li>Make a list of people needed for the real-life videos (e.g., patients, doctors, dieticians).</li>
			<li>Write detailed scripts and log files for all videos.</li>
			<li>Select an entourage for shooting of the videos, appropriate to the subject of the video, and with reduced noise level.</li>
		</ol>
		</li>
		<li>For 3D visualization of elements of the content:
		<ol>
			<li>Use visual references for each step of the desired 3D animation.</li>
			<li>Split animations into clips of 8&#8722;12 s. Before and after a clip, provide text blocks with information about the clip.</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>
3. Building the digital educational tool
<ol>
	<li>Add all the content to a content management system to adjust the order and appearance. 
	NOTE: In this study, the Medify B.V. content management system was used.</li>
	<li>Add all the text and the videos to panels. Choose a background image or a 3D visualization. Add customized questionnaires.</li>
	<li>Check whether everything is correctly incorporated in the tool.</li>
	<li>When all content is built into the content management system, create a pilot version of the educational tool.</li>
</ol>
4. User experience and validation
<ol>
	<li>Administer the pilot educational tool to two patients and two general practitioners and ask for feedback on lay-out, content, and user friendliness.</li>
	<li>Adjust the tool based on the test comments.</li>
	<li>Validate the efficacy and usability of the educational tool in a randomized controlled trial.</li>
</ol>

<ol>
	<li>Barello, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=eHealth+for+Patient+Engagement:+A+Systematic+Review.">eHealth for Patient Engagement: A Systematic Review.</a> Frontiers in Psychology. 6, 2013 (2015).</li><li>Halpert, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Irritable+Bowel+Syndrome:+Patient-Provider+Interaction+and+Patient+Education.">Irritable Bowel Syndrome: Patient-Provider Interaction and Patient Education.</a> Journal of Clinical Medicine. 7 (1), (2018).</li><li>Schulz, P. J., Rubinelli, S., Zufferey, M. C., Hartung, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Coping+With+Chronic+Lower+Back+Pain:+Designing+and+Testing+the+Online+Tool+ONESELF.">Coping With Chronic Lower Back Pain: Designing and Testing the Online Tool ONESELF.</a> Journal of Computer-Mediated Communication. 15 (4), 625-645 (2010).</li><li>Tack, J., Bisschops, R., Sarnelli, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pathophysiology+and+treatment+of+functional+dyspepsia.">Pathophysiology and treatment of functional dyspepsia.</a> Gastroenterology. 127 (4), 1239-1255 (2004).</li><li>Talley, N. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+dyspepsia:+new+insights+into+pathogenesis+and+therapy.">Functional dyspepsia: new insights into pathogenesis and therapy.</a> Korean Journal of Internal Medicine. 31 (3), 444-456 (2016).</li><li>Chiarioni, G., Pesce, M., Fantin, A., Sarnelli, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complementary+and+alternative+treatment+in+functional+dyspepsia.">Complementary and alternative treatment in functional dyspepsia.</a> United European Gastroenterology Journal. 6 (1), 5-12 (2018).</li><li>Ford, A. C., Marwaha, A., Lim, A., Moayyedi, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=What+is+the+prevalence+of+clinically+significant+endoscopic+findings+in+subjects+with+dyspepsia?+Systematic+review+and+meta-analysis.">What is the prevalence of clinically significant endoscopic findings in subjects with dyspepsia? Systematic review and meta-analysis.</a> Clinical Gastroenterology and Hepatology. 8 (10), 830-837 (2010).</li><li>Matsuzaki, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Burden+of+impaired+sleep+quality+on+work+productivity+in+functional+dyspepsia.">Burden of impaired sleep quality on work productivity in functional dyspepsia.</a> United European Gastroenterology Journal. 6 (3), 398-406 (2018).</li><li>Keefer, L., Palsson, O. S., Pandolfino, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Best+Practice+Update:+Incorporating+Psychogastroenterology+Into+Management+of+Digestive+Disorders.">Best Practice Update: Incorporating Psychogastroenterology Into Management of Digestive Disorders.</a> Gastroenterology. 154 (5), 1249-1257 (2018).</li><li>Feinle-Bisset, C., Azpiroz, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dietary+and+lifestyle+factors+in+functional+dyspepsia.">Dietary and lifestyle factors in functional dyspepsia.</a> Nature Reviews Gastroenterology &amp; Hepatology. 10 (3), 150-157 (2013).</li><li>Manes, G., Balzano, A., Marone, P., Lioniello, M., Mosca, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Appropriateness+and+diagnostic+yield+of+upper+gastrointestinal+endoscopy+in+an+open-access+endoscopy+system:+a+prospective+observational+study+based+on+the+Maastricht+guidelines.">Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system: a prospective observational study based on the Maastricht guidelines.</a> Alimentary Pharmacology &amp; Therapeutics. 16 (1), 105-110 (2002).</li><li>de Jong, J. J., Lantinga, M. A., Drenth, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevention+of+overuse:+A+view+on+upper+gastrointestinal+endoscopy.">Prevention of overuse: A view on upper gastrointestinal endoscopy.</a> World Journal of Gastroenterology. 25 (2), 178-189 (2019).</li><li>Baldwin, J. L., Singh, H., Sittig, D. F., Giardina, T. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patient+portals+and+health+apps:+Pitfalls,+promises,+and+what+one+might+learn+from+the+other.">Patient portals and health apps: Pitfalls, promises, and what one might learn from the other.</a> Healthcare (Amsterdam). 5 (3), 81-85 (2017).</li><li>Sleurs, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mobile+health+tools+for+the+management+of+chronic+respiratory+diseases.">Mobile health tools for the management of chronic respiratory diseases.</a> Allergy. , (2019).</li><li>Yuan, S. L. K., Marques, A. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+ProFibro+-+a+mobile+application+to+promote+self-care+in+patients+with+fibromyalgia.">Development of ProFibro - a mobile application to promote self-care in patients with fibromyalgia.</a> Physiotherapy. 104 (3), 311-317 (2018).</li><li>Huckvale, K., Morrison, C., Ouyang, J., Ghaghda, A., Car, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+evolution+of+mobile+apps+for+asthma:+an+updated+systematic+assessment+of+content+and+tools.">The evolution of mobile apps for asthma: an updated systematic assessment of content and tools.</a> BMC Medicine. 13, 58 (2015).</li><li>Mayer, R. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Applying+the+science+of+learning:+evidence-based+principles+for+the+design+of+multimedia+instruction.">Applying the science of learning: evidence-based principles for the design of multimedia instruction.</a> American Psychologist. 63 (8), 760-769 (2008).</li><li>Zhang, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interactive+Multimedia-Based+E-Learning:+A+Study+of+Effectiveness.">Interactive Multimedia-Based E-Learning: A Study of Effectiveness.</a> American Journal of Distance Education. 19 (3), 149-162 (2005).</li><li>Northrup, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+framework+for+designing+interactivity+intoWeb-based+instruction.">A framework for designing interactivity intoWeb-based instruction.</a> Educational Technology. 41 (2), 31-39 (2001).</li><li>Stalmeijer, R. E., McNaughton, N., Van Mook, W. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+focus+groups+in+medical+education+research:+AMEE+Guide+No.+91.">Using focus groups in medical education research: AMEE Guide No. 91.</a> Medical Teacher. 36 (11), 923-939 (2014).</li></ol>

The authors have nothing to disclose.

The digital dyspepsia educational tool, developed using the abovementioned protocol, is a novel multimedia educational tool to assist patients and physicians in management of dyspepsia. This tool may be deployed to stimulate patient engagement, and improve health outcomes while curtailing inappropriate use of medical resources.
A similar procedure has been described for development of a fibromyalgia app15. As with dyspepsia, management of fibromyalgia focuses initially ...

Patient education is an important component of healthcare, enabling active engagement of patients in responsible management of their health1. To improve efficacy and appropriate use of healthcare resources, contemporary and disease-specific measures are needed to facilitate patient engagement. 
Nowadays, digital tools increasingly replace paper versions of patient education, benefiting from their sustainability, effective distribution, and potential to visualize information. For chronic illnesses that lack curative treatment and biological substrate, education is essential for motivation of patients to engage in self-management2,3. Dyspepsia is a condition that often causes long-term complaints. Exact origin of symptoms remains unclear, although evidence indicates three main pathophysiological mechanisms, including 1) hypersensitivity to gastric distension, 2) impaired gastric accommodation, causing inadequate distension in reaction to a meal, and 3) delayed gastric emptying4. Additionally, duodenal perturbations, brain-gut disturbances, and dietary factors have been suggested to play a role5. Main symptoms comprise post-prandial fullness, epigastric pain, early satiety, and epigastric burning. Upper gastrointestinal (GI) endoscopy in dyspeptic patients reveals no cause of symptoms in over 70%; these cases are referred to as functional dyspepsia. Pharmacological treatment options for dyspepsia are limited, often inciting patients to resolve to complementary and alternative therapies6,7. Quality of life in dyspepsia patients is often reduced as dyspepsia is associated with concomitant issues, such as impaired sleep quality and loss of work productivity8. Dyspepsia management benefits from active patient engagement, as behavioral interventions are a main component of dyspepsia treatment9,10. These interventions require a significant effort from patients, which may be facilitated by personalized and interactive support. 
Correct management of dyspepsia is essential to improve healthcare outcomes and prevent overuse of medical resources. Upper gastrointestinal (GI) endoscopy for dyspepsia is a well-known form of overuse as its diagnostic yield is limited11. Several methods have been proposed to reduce the number of upper GI endoscopies, mostly focused on physician education or drug-based symptom reduction12. Uncertainty about the cause of dyspepsia is often unsatisfactory for patients, and diagnostic tests may be performed in excess as a consequence. Consequently, education of patients about pathogenesis, treatment options, and conservative management would be an effective strategy to reduce the number of upper GI endoscopies. 
While digital tools potentially provide an excellent platform for patient education, several functionalities of a digital tool are required, in order to maximize patient adoption and subsequent patient engagement in disease management13. The expected success of digital education mainly depends on its development process and measures taken to optimize information transfer. However, development processes of digital educational tools are infrequently published, impairing reproduction, progression, and evaluation of the validity and safety1,14.
There is need for a detailed description and evaluation of development of a patient-centered digital educational tool. We describe the development of our dyspepsia educational tool, to serve as a template for future educational tool development.

<table border="0" cellpadding="0" cellspacing="0" style="width:591px;" width="589">
	<tbody>
		<tr height="62">
			<td height="62" style="height:63px;width:223px;">Dyspepsia e-learning</td>
			<td style="width:73px;">Dyspepsia e-learning</td>
			<td style="width:123px;"></td>
			<td style="width:172px;">Digital educational tool for dyspepsia management</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:223px;">Paper Food Diary</td>
			<td style="width:73px;">Any</td>
			<td style="width:123px;"></td>
			<td>Schedule to record food consumption and symptoms</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:223px;">Computer</td>
			<td style="width:73px;">Any</td>
			<td style="width:123px;"></td>
			<td>A computer or tablet should be used to complete the e-learning</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:223px;">Medify Content Management System</td>
			<td style="width:73px;">Medify BV</td>
			<td style="width:123px;"></td>
			<td>A content management system to process the e-learning content</td>
		</tr>
	</tbody>
</table>

the dyspepsia educational tool as a novel aid in dyspepsia management

Digital educational tools have a well-established role in current healthcare. In particular, disorders that are managed non-pharmacologically benefit from this development, as it enables patient engagement in self-management. Dyspepsia is a condition thought to arise from gastric and duodenal perturbations, brain-gut axis disturbances, and dietary factors. Behavioral interventions are a major part of dyspepsia treatment, hence patient engagement and motivation through education is essential. Protocols that describe the development process of such educational tools are scarce. We provide a methodology describing development of a dyspepsia educational tool. Assessment of users' needs is the first step, followed by a literature search. The content is developed based on the main themes and entered into a content management system, to build the program. Final adjustments are made after a pilot test of the tool. The presented protocol can be used as a guide for development of a digital dyspepsia educational tool or as a tool for similar situations.

Results of focus groups
Five patients, recruited through patient networks (n = 2) or at the outpatient clinic (n = 3), were invited to join a focus group. All focus group patients were diagnosed with dyspepsia based on the opinion of a gastroenterologist. Characteristics of included patients are presented in Table 1.
Most participants ...

Watch this Scientific Journal Video about The Dyspepsia Educational Tool As a Novel Aid in Dyspepsia Management at JoVE.com

The Dyspepsia Educational Tool As a Novel Aid in Dyspepsia Management

This protocol describes the development process of a digital dyspepsia educational tool. Assessment of unmet needs and literature, content development, and building of the tool are presented. The methodology can be used as a guide for future development of digital educational tools.

Digital educational tools have a well-established role in current healthcare. In particular, disorders that are managed non-pharmacologically benefit from ...

the-dyspepsia-educational-tool-as-a-novel-aid-in-dyspepsia-management

Research

JoVE Journal

Medicine

6.5K Views.  Radboud University Medical Center. This protocol describes the development process of a digital dyspepsia educational tool. Assessment of unmet needs and literature, content development, and building of the tool are presented. The methodology can be used as a guide for future development of digital educational tools. 

Video: The Dyspepsia Educational Tool As a Novel Aid in Dyspepsia Management

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

A Strategy to Identify de Novo Mutations in Common Disorders such as Autism and Schizophrenia

There are several lines of evidence supporting the role of de novo mutations as a mechanism for common disorders, such as autism and schizophrenia. First, the de novo mutation rate in humans is relatively high, so new mutations are generated at a high frequency in the population. However, de novo mutations have not been reported in most common diseases. Mutations in genes leading to severe diseases where there is a strong negative selection against the phenotype, such as lethality in embryonic stages or reduced reproductive fitness, will not be transmitted to multiple family members, and therefore will not be detected by linkage gene mapping or association studies. The observation of very high concordance in monozygotic twins and very low concordance in dizygotic twins also strongly supports the hypothesis that a significant fraction of cases may result from new mutations. Such is the case for diseases such as autism and schizophrenia. Second, despite reduced reproductive fitness1 and extremely variable environmental factors, the incidence of some diseases is maintained worldwide at a relatively high and constant rate. This is the case for autism and schizophrenia, with an incidence of approximately 1% worldwide. Mutational load can be thought of as a balance between selection for or against a deleterious mutation and its production by de novo mutation. Lower rates of reproduction constitute a negative selection factor that should reduce the number of mutant alleles in the population, ultimately leading to decreased disease prevalence. These selective pressures tend to be of different intensity in different environments. Nonetheless, these severe mental disorders have been maintained at a constant relatively high prevalence in the worldwide population across a wide range of cultures and countries despite a strong negative selection against them2. This is not what one would predict in diseases with reduced reproductive fitness, unless there was a high new mutation rate. Finally, the effects of paternal age: there is a significantly increased risk of the disease with increasing paternal age, which could result from the age related increase in paternal de novo mutations. This is the case for autism and schizophrenia3. The male-to-female ratio of mutation rate is estimated at about 4&#x2013;6:1, presumably due to a higher number of germ-cell divisions with age in males. Therefore, one would predict that de novo mutations would more frequently come from males, particularly older males4. A high rate of new mutations may in part explain why genetic studies have so far failed to identify many genes predisposing to complexes diseases genes, such as autism and schizophrenia, and why diseases have been identified for a mere 3% of genes in the human genome. Identification for de novo mutations as a cause of a disease requires a targeted molecular approach, which includes studying parents and affected subjects. The process for determining if the genetic basis of a disease may result in part from de novo mutations and the molecular approach to establish this link will be illustrated, using autism and schizophrenia as examples.

Molecular genetic strategy for finding de novo mutations causing common disorders such as autism and schizophrenia.

There are several lines of evidence supporting the role of de novo mutations as a mechanism for common disorders, such as autism and schizophrenia. First, ...

Osteopathic Manipulative Treatment as a Useful Adjunctive Tool for Pneumonia

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in the hospitalization of 1.1 million patients2. With an average length of in-patient hospital stay of five days2, pneumonia and influenza comprise significant financial burden costing the United States $40.2 billion in 20053. Under the current Infectious Disease Society of America/American Thoracic Society guidelines, standard-of-care recommendations include the rapid administration of an appropriate antibiotic regiment, fluid replacement, and ventilation (if necessary). Non-standard therapies include the use of corticosteroids and statins; however, these therapies lack conclusive supporting evidence4. (Figure 1)

Osteopathic Manipulative Treatment (OMT) is a cost-effective adjunctive treatment of pneumonia that has been shown to reduce patients&#8217; length of hospital stay, duration of intravenous antibiotics, and incidence of respiratory failure or death when compared to subjects who received conventional care alone5. The use of manual manipulation techniques for pneumonia was first recorded as early as the Spanish influenza pandemic of 1918, when patients treated with standard medical care had an estimated mortality rate of 33%, compared to a 10% mortality rate in patients treated by osteopathic physicians6. When applied to the management of pneumonia, manual manipulation techniques bolster lymphatic flow, respiratory function, and immunological defense by targeting anatomical structures involved in the these systems7,8, 9, 10.

The objective of this review video-article is three-fold: a) summarize the findings of randomized controlled studies on the efficacy of OMT in adult patients with diagnosed pneumonia, b) demonstrate established protocols utilized by osteopathic physicians treating pneumonia, c) elucidate the physiological mechanisms behind manual manipulation of the respiratory and lymphatic systems. Specifically, we will discuss and demonstrate four routine techniques that address autonomics, lymph drainage, and rib cage mobility: 1) Rib Raising, 2) Thoracic Pump, 3) Doming of the Thoracic Diaphragm, and 4) Muscle Energy for Rib 1.5,11

Pneumonia is one of the top ten leading causes of death in the U.S. Osteopathic manipulative techniques (OMT) may be utilized as an adjunctive therapy in the treatment of pneumonia to enhance biomechanical and immune function; and ultimately, to reduce hospital stay, duration of antibiotics, incidence of respiratory failure, and mortality. In this video-article, we will review randomized controlled studies on the use of OMT in pneumonia patients, as well as demonstrate specific hands-on techniques that are routinely practiced by osteopathic physicians when treating pulmonary infections.

Pneumonia, the inflammatory state of lung tissue primarily due to microbial infection, claimed 52,306 lives in the United States in 20071 and resulted in ...

Excitotoxic Stimulation of Brain Microslices as an In vitro Model of Stroke

Examining molecular mechanisms involved in neuropathological conditions, such as ischemic stroke, can be difficult when using whole animal systems. As such, primary or &#39;neuronal-like&#39; cell culture systems are commonly utilized. While&#160;these systems are relatively easy to work with, and are useful model systems in which various functional outcomes (such as cell death) can be readily quantified, the examined outcomes and pathways in cultured immature neurons (such as excitotoxicity-mediated cell death pathways) are not necessarily the same as those observed in mature brain, or in intact tissue. Therefore, there is the need to develop models in which cellular mechanisms in mature neural tissue can be examined. We have developed an in vitro technique that can be used to investigate a variety of molecular pathways in intact nervous tissue. The technique described herein utilizes rat cortical tissue, but this technique can be adapted to use tissue from a variety of species (such as mouse, rabbit, guinea pig, and chicken) or brain regions (for example, hippocampus, striatum, etc.). Additionally, a variety of stimulations/treatments can be used (for example, excitotoxic, administration of inhibitors, etc.). In conclusion, the brain slice model described herein can be used to examine a variety of molecular mechanisms involved in excitotoxicity-mediated brain injury.

Excitotoxic Stimulation of Brain Microslices as an In vitro Model of Stroke

We have developed a brain slice model which can be used to examine molecular mechanisms involved in excitotoxicity-mediated brain injury.&#160;This technique generates viable mature brain tissue and reduces animal numbers required for experimentation, whilst keeping the neuronal circuitry, cellular interactions, and postsynaptic compartments partly intact.

Examining molecular mechanisms involved in neuropathological conditions, such as ischemic stroke, can be difficult when using whole animal systems. As ...

Using Adeno-associated Virus as a Tool to Study Retinal Barriers in Disease

M&#252;ller cells are the principal glial cells of the retina. Their end-feet form the limits of the retina at the outer and inner limiting membranes (ILM), and in conjunction with astrocytes, pericytes and endothelial cells they establish the blood-retinal barrier (BRB). BRB limits material transport between the bloodstream and the retina while the ILM acts as a basement membrane that defines histologically the border between the retina and the vitreous cavity. Labeling M&#252;ller cells is particularly relevant to study the physical state of the retinal barriers, as these cells are an integral part of the BRB and ILM. Both BRB and ILM are frequently altered in retinal disease and are responsible for disease symptoms.
There are several well-established methods to study the integrity of the BRB, such as the Evans blue assay or fluorescein angiography. However these methods do not provide information on the extent of BRB permeability to larger molecules, in nanometer range. Furthermore, they do not provide information on the state of other retinal barriers such as the ILM. To study BRB permeability alongside retinal ILM, we used an AAV based method that provides information on permeability of BRB to larger molecules while indicating the state of the ILM and extracellular matrix proteins in disease states. Two AAV variants are useful for such study: AAV5 and ShH10. AAV5&#160;has a natural tropism for photoreceptors but it cannot get across to the outer retina when administered into the vitreous when the ILM is intact (i.e., in wild-type retinas). ShH10 has a strong tropism towards glial cells and will selectively label M&#252;ller glia in both healthy and diseased retinas. ShH10 provides more efficient gene delivery in retinas where ILM is compromised. These viral tools coupled with immunohistochemistry and blood-DNA analysis shed light onto the state of retinal barriers in disease.

To investigate the blood-retinal barrier permeability and the inner limiting membrane integrity in animal models of retinal disease, we used several adeno-associated virus (AAV) variants as tools to label retinal neurons and glia. Virus mediated reporter gene expression is then used as an indicator of retinal barrier permeability.

M&#252;ller cells are the principal glial cells of the retina. Their end-feet form the limits of the retina at the outer and inner limiting membranes ...

Evaluation of the Efficacy of the H. pylori Protein HP-NAP as a Therapeutic Tool for Treatment of Bladder Cancer in an Orthotopic Murine Model

Bladder cancer is one of the most common malignancies of the urogenital tract. Intravesical injection of Bacillus Calmette-Gu&#233;rin (BCG) is the gold standard treatment for the high-grade non-muscle invasive bladder cancer (NMIBC). However, since the treatment-related side effects are relevant, newer biological response modifiers with a better benefit/side effects ratio are needed.
The tumour microenvironment can influence both tumour development and therapy efficacy. In order to obtain a good model, it is desirable to implant tumour cells in the organ from which the cancer originates.
In this protocol, we describe a method for establishing a tumour in the bladder cavity of female mice and subsequent delivery of therapeutic agents; the latter are exemplified by our use of Helicobacter pylori neutrophil activating protein (HP-NAP). A preliminary chemical burn of the mucosa, followed by the injection of mouse urothelial carcinoma cell line MB49 via urethral catheterization, enables the cells to attach to the bladder mucosa. After a period, required to allow an initial proliferation of the cells, mice are treated with HP-NAP, administrated again via catheterization. The anti-tumour activity of HP-NAP is evaluated comparing the tumour volume, the extent of necrosis and the degree of vascularization between vehicle- and HP-NAP-treated animals.

Evaluation of the Efficacy of the H. pylori Protein HP-NAP as a Therapeutic Tool for Treatment of Bladder Cancer in an Orthotopic Murine Model

Here the method to establish a syngeneic mouse model of orthotopic bladder tumour to evaluate the anti-tumour efficacy of the bacterial protein HP-NAP is described.

Bladder cancer is one of the most common malignancies of the urogenital tract. Intravesical injection of Bacillus Calmette-Gu&#233;rin (BCG) is the gold ...

Neonatal Murine Cochlear Explant Technique as an In Vitro Screening Tool in Hearing Research

While there have been remarkable advances in hearing research over the past few decades, there is still no cure for Sensorineural Hearing Loss (SNHL), a condition that typically involves damage to or loss of the delicate mechanosensory structures of the inner ear. Sophisticated in vitro and ex vivo assays have emerged in recent years, enabling the screening of an increasing number of potentially therapeutic compounds while minimizing resources and accelerating efforts to develop cures for SNHL. Though homogenous cultures of certain cell types continue to play an important role in current research, many scientists now rely on more complex organotypic cultures of murine inner ears, also known as cochlear explants. The preservation of organized cellular structures within the inner ear facilitates the in situ evaluation of various components of the cochlear infrastructure, including inner and outer hair cells, spiral ganglion neurons, neurites, and supporting cells. Here we present the preparation, culture, treatment, and immunostaining of neonatal murine cochlear explants. The careful preparation of these explants facilitates the identification of mechanisms that contribute to SNHL and constitutes a valuable tool for the hearing research community.

Neonatal Murine Cochlear Explant Technique as an In Vitro Screening Tool in Hearing Research

The goal of this protocol is to demonstrate the preparation, culture, treatment, and immunostaining of neonatal murine cochlear explants. The technique can be utilized as an in vitro screening tool in hearing research.

While there have been remarkable advances in hearing research over the past few decades, there is still no cure for Sensorineural Hearing Loss (SNHL), a ...

Tubal Cytology of the Fallopian Tube as a Promising Tool for Ovarian Cancer Early Detection

Currently, it is widely accepted that the vast majority of ovarian high-grade serous carcinoma (HGSC) originate from the fallopian tube. However, due to the lack of markers or tools for the ovarian cancer identification, the early detection of HGSC remains challenging. Direct sampling of the fallopian tube can enhance sensitivity for detection of neoplastic cells when the tumor is not grossly visible. We developed a procedure to collect fallopian tube cells directly from freshly received surgical specimens, which has shown excellent correlation with histological findings. This approach lays a foundation for the future utility of minimally invasive laparoscopic screening in high-risk patient populations.

We explored a tubal cytologic method by sampling the fallopian tube directly post-surgical excision as a tool of ovarian cancer early detection. Here, we present a protocol to collect fallopian tube cells from freshly received surgical specimens.

Currently, it is widely accepted that the vast majority of ovarian high-grade serous carcinoma (HGSC) originate from the fallopian tube. However, due to ...

Ultrahigh Resolution Mouse Optical Coherence Tomography to Aid Intraocular Injection in Retinal Gene Therapy Research

HR-SD-OCT is utilized to monitor the progression of photoreceptor degeneration in live mouse models, assess the delivery of therapeutic agents into the subretinal space, and to evaluate toxicity and efficacy in vivo. HR-SD-OCT uses near infrared light (800-880 nm) and has optics specifically designed for the unique optics of the mouse eye with sub-2-micron axial resolution. Transgenic mouse models of outer retinal (photoreceptor) degeneration and controls were imaged to assess the disease progression. Pulled glass microneedles were used to deliver sub retinal injections of adeno-associated virus (AAV) or nanoparticles (NP) via a trans-scleral and trans-choroidal approach. Careful positioning of the needle into the subretinal space was required prior to a calibrated pressure injection, which delivers fluid into the sub retinal space. Real time subretinal surgery was conducted on our retinal imaging system (RIS). HR-SD-OCT demonstrated progressive uniform retinal degeneration due to expression of a toxic mutant human mutant rhodopsin (P347S) (RHOP347S) transgene in mice. HR-SD-OCT allows rigorous quantification of all the retinal layers. Outer nuclear layer (ONL) thickness and photoreceptor outer segment length (OSL) measurements correlate with photoreceptor vitality, degeneration, or rescue. The RIS delivery system allows real-time visualization of subretinal injections in neonatal (~P10-14) or adult mice, and HR-SD-OCT immediately determines success of delivery and maps areal extent. HR-SD-OCT is a powerful tool that can evaluate the success of subretinal surgery in mice, in addition to measuring vitality of photoreceptors in vivo. HR-SD-OCT can also be used to identify uniform animal cohorts to evaluate the extent of retinal degeneration, toxicity, and therapeutic rescue in preclinical gene therapy research studies.

Here we demonstrate a novel approach to using high resolution spectral-domain optical coherence tomography (HR-SD-OCT) to assist delivery of gene therapy agents into the subretinal space, assess its areal coverage, and characterize photoreceptor vitality.

HR-SD-OCT is utilized to monitor the progression of photoreceptor degeneration in live mouse models, assess the delivery of therapeutic agents into the ...

Contractility Measurements of Human Uterine Smooth Muscle to Aid Drug Development

Discovery and characterization of novel pharmaceutical compounds or biochemical probes rely on robust and physiologically relevant assay systems. We describe methods to measure ex vivo myometrium contractility. This assay can be used to investigate factors and molecules involved in the modulation of myometrial contraction and to determine their excitatory or inhibitory actions, and hence their therapeutic potential in vivo. Biopsies are obtained from women undergoing cesarean section delivery with informed consent. Fine strips of myometrium are dissected, clipped and attached to a force transducer within 1 mL organ baths superfused with physiological saline solution at 37 &#176;C. Strips develop spontaneous contractions within 2&#8211;3 h under set tension and remain stable for many hours (&#62;6 h). Strips can also be stimulated to contract such as by the endogenous hormones, oxytocin and vasopressin, which cause concentration-dependent modulation of contraction frequency, force and duration, to more closely resemble contractions in labor. Hence, the effect of known and novel drug leads can be tested on spontaneous and agonist-induced contractions.
This protocol specifically details how this assay can be used to determine the potency of known and novel agents by measuring their effects on various parameters of human myometrial contraction. We use the oxytocin- and V1a receptor antagonists, atosiban and SR49059 as examples of known compounds which inhibit oxytocin- and vasopressin-induced contractions, and demonstrate how this method can be used to complement and validate pharmacological data obtained from cell-based assays to aid drug development. The effects of novel agonists in comparison to oxytocin and vasopressin can also be characterized. Whilst we use the example of the oxytocin/ vasopressin system, this method can also be used to study other receptors and ion channels that play a role in uterine contraction and relaxation to advance the understanding of human uterine physiology and pathophysiology.

This article describes experimental protocols to study ex vivo contractions of human myometrium and their application in drug discovery. This technique is used to improve the understanding of myometrial physiology and pathophysiology as well as to validate pharmacological data from novel research probes or drug leads.

Discovery and characterization of novel pharmaceutical compounds or biochemical probes rely on robust and physiologically relevant assay systems. We ...