Medicine and Health Sciences Commons^™

Low Risk Of Attrition Among Adults On Antiretroviral Therapy In The Rwandan National Program: A Retrospective Cohort Analysis Of 6, 12, And 18 Month Outcomes, Harriet Nuwagaba-Biribonwoha, Aleksandra Jakubowski, Veronicah Mudisha, Paulin Basinga, Anita Asiimwe, Denis Nash, Batya Elul

Publications and Research

Background
We report levels and determinants of attrition in Rwanda, one of the few African countries with universal ART access.

Methods
We analyzed data abstracted from health facility records of a nationally representative sample of adults [≥18 years] who initiated ART 6, 12, and 18 months prior to data collection; and collected facility characteristics with a health facility assessment questionnaire. Weighted proportions and rates of attrition [loss to follow-up or death] were calculated, and patient- and health facility-level factors associated with attrition examined using Cox proportional hazard models.

Results
1678 adults initiated ART 6, 12 and 18 months prior to …

Synthesis And Characterization Of Nanostructured Nickel Diselenide Nise2 From The Decomposition Of Nickel Acetate, (Ch3co2)2ni, Ming Yin, Stephen O'Brien

Publications and Research

Solution processed NiSe2 nanorods were synthesized by a modified colloidal synthesis technique, by chemical reaction of TOPSe and nickel acetate at 150 ∘C. The rods exist as an oleic acid ligand stabilized solution, with oleic acid acting as a capping group. Structural characterization by X-ray diffraction and transmission electron microscopy indicates that the particles are rod-like shaped crystals with a high and relatively constant aspect ratio (30 : 1). TEM shows that the width and the length of the nanorods are in the range 10–20nm and 300–350 nm, respectively. XRD indicates that the nanorods are pure and well crystallized. The …

Review: Zinc’S Functional Significance In The Vertebrate Retina, Harris Ripps, Richard L. Chappell

Publications and Research

This review covers a broad range of topics related to the actions of zinc on the cells of the vertebrate retina. Much of this review relies on studies in which zinc was applied exogenously, and therefore the results, albeit highly suggestive, lack physiologic significance. This view stems from the fact that the concentrations of zinc used in these studies may not be encountered under the normal circumstances of life. This caveat is due to the lack of a zinc-specific probe with which to measure the concentrations of Zn2+ that may be released from neurons or act upon them. However, a …

Lineage-Specific Interface Proteins Match Up The Cell Cycle And Differentiation In Embryo Stem Cells, Angela Re, Christopher T. Workman, Levi Waldron, Alessandro Quattrone, Søren Brunak

Publications and Research

The shortage of molecular information on cell cycle changes along embryonic stem cell (ESC) differentiation prompts an in silico approach, which may provide a novel way to identify candidate genes or mechanisms acting in coordinating the two programs. We analyzed germ layer specific gene expression changes during the cell cycle and ESC differentiation by combining four human cell cycle transcriptome profiles with thirteen in vitro human ESC differentiation studies. To detect cross-talk mechanisms we then integrated the transcriptome data that displayed differential regulation with protein interaction data. A new class of non-transcriptionally regulated genes was identified, encoding proteins which interact …

Obesity Indicators And C - Reactive Protein In African And Haitian Americans With And Without Type 2 Diabetes, Fatma G. Huffman, Joan A. Vaccaro, T. M. Rowe, Gustavo G. Zarini, Shiryn D. Sukhram, Lemia H. Shaban, Susan Himburg

Publications and Research

Purpose: High sensitivity C-reactive protein (CRP) is a risk factor for cardiovascular disease based on finding in primarily non-Hispanic White populations. Obesity, another risk factor for cardiovascular disease, is higher in Blacks as compared to non-Hispanic Whites. The objective of this study was to assess the relationship between CRP, a marker of systemic inflammation, and obesity indicators by ethnicity, diabetes status and gender for two Black ethnicities.

Methods: Anthropometrics and venous blood were collected for African and Haitian Americans with and without type 2 diabetes in a cross-sectional study. A total of 434 participants; 190 African Americans, 244 Haitian Americans, …

Transpinal And Transcortical Stimulation Alter Corticospinal Excitability And Increase Spinal Output, Maria Knikou

Publications and Research

The objective of this study was to assess changes in corticospinal excitability and spinal output following noninvasive transpinal and transcortical stimulation in humans. The size of the motor evoked potentials (MEPs), induced by transcranial magnetic stimulation (TMS) and recorded from the right plantar flexor and extensor muscles, was assessed following transcutaneous electric stimulation of the spine (tsESS) over the thoracolumbar region at conditioning-test (C-T) intervals that ranged from negative 50 to positive 50 ms. The size of the transpinal evoked potentials (TEPs), induced by tsESS and recorded from the right and left plantar flexor and extensor muscles, was assessed following …

Increasing Maternal Or Post-Weaning Folic Acid Alters Gene Expression And Moderately Changes Behavior In The Offspring, Subit Barua, Kathryn K. Chadman, Salomon Kuizon, Diego Buenaventura, Nathan W. Stapley, Felicia Ruocco, Umme Begum, Sara R. Guariglia, W. Ted Brown, Mohamad Junaid

Publications and Research

Background: Studies have indicated that altered maternal micronutrients and vitamins influence the development of newborns and altered nutrient exposure throughout the lifetime may have potential health effects and increased susceptibility to chronic diseases. In recent years, folic acid (FA) exposure has significantly increased as a result of mandatory FA fortification and supplementation during pregnancy. Since FA modulates DNA methylation and affects gene expression, we investigated whether the amount of FA ingested during gestation alters gene expression in the newborn cerebral hemisphere, and if the increased exposure to FA during gestation and throughout the lifetime alters behavior in C57BL/6J mice.

Methods …

Solving The Jigsaw Puzzle Of Wound-Healing Potato Cultivars: Metabolite Profiling And Antioxidant Activity Of Polar Extracts, Keyvan Dastmalchi, Qing Cai, Kevin Zhou, Wenlin Huang, Olga Serra, Ruth E. Stark

Publications and Research

Potato (Solanum tuberosum L.) is a worldwide food staple, but substantial waste accompanies the cultivation of this crop due to wounding of the outer skin and subsequent unfavorable healing conditions. Motivated by both economic and nutritional considerations, this metabolite profiling study aims to improve understanding of closing layer and wound periderm formation and guide the development of new methods to ensure faster and more complete healing after skin breakage. The polar metabolites of wound-healing tissues from four potato cultivars with differing patterns of tuber skin russeting (Norkotah Russet, Atlantic, Chipeta, and Yukon Gold) were analyzed at three and seven days …

Physical Activity And Sedentary Behaviors Associated With Risk Of Progression From Gestational Diabetes Mellitus To Type 2 Diabetes Mellitus: A Prospective Cohort Study, Wei Bao, Deirdre K. Tobias, Katherine Bowers, Jorge Chavarro, Allan Vaag, Louise Groth Grunnet, Marin Strom, James Mills, Aiyi Liu, Michele Kiely, Cuilin Zhang

Publications and Research

Importance: Women with a history of gestational diabetes mellitus (GDM) are at substantially increased risk of type 2 diabetes mellitus (T2DM). The identification of important modifiable factors could help prevent T2DM in this high-risk population.

Objective: To examine the role of physical activity and television watching and other sedentary behaviors, and changes in these behaviors in the progression from GDM to T2DM.

Design, Setting, and Participants: Prospective cohort study of 4554 women from the Nurses' Health Study II who had a history of GDM, as part of the ongoing Diabetes & Women's Health Study. These women were followed up from …

Motor Cortex Electrical Stimulation Augments Sprouting Of The Corticospinal Tract And Promotes Recovery Of Motor Function, Jason B. Carmel, John H. Martin

Publications and Research

The corticospinal system—with its direct spinal pathway, the corticospinal tract (CST) – is the primary system for controlling voluntary movement. Our approach to CST repair after injury in mature animals was informed by our finding that activity drives establishment of connections with spinal cord circuits during postnatal development. After incomplete injury in maturity, spared CST circuits sprout, and partially restore lost function. Our approach harnesses activity to augment this injury-dependent CST sprouting and to promote function. Lesion of the medullary pyramid unilaterally eliminates all CST axons from one hemisphere and allows examination of CST sprouting from the unaffected hemisphere. We …

Practicing Patienthood Online: Social Media, Chronic Illness, And Lay Expertise, Collette Sosnowy

Publications and Research

The use of digital technologies and social media by people with serious illness to find, share, and create health information is much celebrated but rarely critiqued. Proponents laud “Health 2.0” as transforming health care practice and empowering patients. Critics, however, argue that a discourse of developing lay expertise online masks the disciplinary practices of the neoliberal state’s emphasis on individual responsibility. Notably, the perspectives of people who are engaging with social media related to their health and illness are under-represented in this debate. This research examines the experiences and perspectives of women who blog about their lives with Multiple Sclerosis …

Risk Factors For Posttraumatic Stress Disorder In Haitian Students, Gretel Silvestre, Pascale Anacréon, Michèle Théodore, Emmanuel Silvestre, Eugenia Garcia-Dubus

Publications and Research

The aim of this study was to assess the prevalence of posttraumatic stress disorder (PTSD) in undergraduate students after the Haiti earthquake on January 12, 2010, as well as to identify the risk factors involved in the development of PTSD symptoms in this sample. Evaluations concerning depression, anxiety, risk and protective factors, and PTSD symptoms were conducted in 246 Haitian undergraduate students enrolled in a Dominican private university. Results indicate a prevalence of 36% for PTSD 2 years after the earthquake, with a high prevalence also of depression (31.7%) and anxiety (21.1%). Some of the risk factors identified are being …

Association Between Symptomatic Vulvovaginal Candidiasis And Hiv Rna Levels In Plasma And Genital Secretions Among Women On Haart, Teke Apalata, William H. Carr, Benjamin Longo-Mbenza, Willem A. Sturm, P. Moodley

Publications and Research

Background. Genital tract (GT) inflammation plays a major role in HIV transmission. We aimed to determine the association between symptomatic vulvovaginal candidiasis (VVC) and HIV RNA levels in plasma and GTs of HIV-infected women on highly active antiretroviral therapy (HAART).

Method. Women with VVC on HAART were recruited from a primary healthcare clinic in KwaZulu-Natal Province, South Africa, between June 2011 and December 2011. VVC was diagnosed clinically, supported by Gram staining and culture of genital secretions. HIV RNA load was determined by reverse transcription polymerase chain reaction. CD4+ counts were obtained from patients’ medical records.

Results. Plasma HIV RNA …

Extreme Heat Awareness And Protective Behaviors In New York City, Kathryn Lane, Katherine Wheeler, Kizzy Charles-Guzman, Munerah Ahmed, Micheline Blum, Katherine Gregory, Nathan Graber, Nancy Clark, Thomas Matte

Publications and Research

Heat waves can be lethal and routinely prompt public warnings about the dangers of heat. With climate change, extreme heat events will become more frequent and intense. However, little is known about public awareness of heat warnings or behaviors during hot weather. Awareness of heat warnings, prevention behaviors, and air conditioning (AC) prevalence and use in New York City were assessed using quantitative and qualitative methods. A random sample telephone survey was conducted in September 2011 among 719 adults and follow-up focus groups were held in winter 2012 among seniors and potential senior caregivers. During summer 2011, 79 % of …

The Benefits Of Neighborhood Racial Diversity: Neighborhood Factors And Its Association With Increased Physical Activity In Acs Patients, Ellen-Ge Denton, Philip Green, Jonathan Newman, Ye Siqin, Karina W. Davidson, Joseph Schwartz

Publications and Research

Regular physical activity reduces the risk of adverse events after an acute coronary syndrome (ACS) [1]. Physical activity level is influenced by neighborhood factors such as racial diversity in the general population [2,3], but the impact of neighborhood factors on physical activity after an ACS is unknown. We therefore prospectively evaluated the relationship of post-ACS physical activity assessed by continuous activity monitors with neighborhood characteristics, including ethnic density, income, female headed households, and racial diversity, in patients enrolled in the Prescription Use, Lifestyle, and Stress Evaluation (PULSE) Study.

A Comparative Study Of The Sodium Content And Calories From Sugar In Toddler Foods Sold In Low- And High-Income New York City Supermarkets, Lalitha Samuel, Danna Ethan, Corey Basch, Benny Samuel

Publications and Research

Information from the nutrition facts labels of toddler foods marketed in low- and high-income New York City zip codes were analyzed for sodium content, the proportion of sugar-derived calories, and presence of sugar and/or high-fructose corn syrup as an added sweetener in the list of ingredients. Among the 272 toddler foods analyzed, more than a quarter were high in sodium, over one-third derived at least 20% their calories from sugar, and more than 41% of the foods had sugar and/or high-fructose corn syrup listed among the first five ingredients. The proportion of foods with such nutritional characteristics did not significantly …

From Punishment To Treatment: A Providers’ Perspective On The Implementation Of 2009 Rockefeller Drug Law Reforms In New York, Robert Riggs, Jim Parsons, Qing Wei, Ernest Drucker

Publications and Research

Background: In 2009, New York reformed its “Rockefeller Drug Laws”, terminating mandatory imprisonment for many drug charges and expanding the availability of treatment alternatives to incarceration. The reforms occurred in an environment characterized by high incarceration rates, racial/ethnic disparities in drug convictions and incarceration rates, and expanded use of alternatives to incarceration. Early administrative data show a large impact on the criminal justice system. Few studies have considered the reforms from the providers’ perspective and none have sought to understand how providers are experiencing the reforms in their everyday practice.

Methods: To provide a providers’ perspective, we use a qualitative, …

Expression Of Toll-Like Receptor (Tlr)-2 And Tlr4 In Monocytes Following Stimulations By Genital Secretions Of Hiv Infected And Uninfected Women With Symptomatic Vulvo-Vaginal Candidiasis, Teke Apalata, Benjamin Longo-Mbenza, A. Willem Sturm, William H. Carr, Prashini Moodley

Publications and Research

Vulvo-vaginal candidiasis (VVC) is a common condition in human immunodeficiency virus (HIV)- infected women. Toll-like receptor (TLR) 2 and TLR4 are key pattern-recognition receptors of the innate immune system in sensing Candida albicans. The aim of this study was to assess the expression of TLR2 and TLR4 signaling pathways in HIV-infected and uninfected women with VVC. Cervico-vaginal fluids (CVF) were obtained from 7 HIV infected and 11 HIV uninfected clinic attendees in KwaZulu-Natal between June, 2011 and December, 2011. VVC was diagnosed clinically and confirmed by Gram stain and culture of genital samples. Monocytes were isolated from a healthy adult …

Prepregnancy Low-Carbohydrate Dietary Pattern And Risk Of Gestational Diabetes Mellitus: A Prospective Cohort Study, Wei Bao, Katherine Bowers, Deirdre K. Tobias, Sjurdur F. Olsen, Jorge Chavarro, Allan Vaag, Michele Kiely, Cuilin Zhang

Publications and Research

Background: Low-carbohydrate diets (LCDs) have been vastly popular for weight loss. The association between a low-carbohydrate dietary pattern and risk of gestational diabetes mellitus (GDM) remains unknown.

Objective: We aimed to prospectively examine the association of 3 prepregnancy low-carbohydrate dietary patterns with risk of GDM.

Design: We included 21,411 singleton pregnancies in the Nurses’ Health Study II. Prepregnancy LCD scores were calculated from validated food-frequency questionnaires, including an overall LCD score on the basis of intakes of carbohydrate, total protein, and total fat; an animal LCD score on the basis of intakes of carbohydrate, animal protein, and animal …

Sample Limited Characterization Of A Novel Disulfide- Rich Venom Peptide Toxin From Terebrid Marine Snail Terebra Variegata, Prachi Anand, Alexandre Grigoryan, Mohammed H. Bhuiyan, Beatrix Ueberheide, Victoria Russell, Jose Quiñonez, Patrick Moy, Brian T. Chait, Sébastien F. Poget, Mandë Holford

Publications and Research

Disulfide-rich peptide toxins found in the secretions of venomous organisms such as snakes, spiders, scorpions, leeches, and marine snails are highly efficient and effective tools for novel therapeutic drug development. Venom peptide toxins have been used extensively to characterize ion channels in the nervous system and platelet aggregation in haemostatic systems. A significant hurdle in characterizing disulfide-rich peptide toxins from venomous animals is obtaining significant quantities needed for sequence and structural analyses. Presented here is a strategy for the structural characterization of venom peptide toxins from sample limited (4 ng) specimens via direct mass spectrometry sequencing, chemical synthesis and NMR …

Skin Cancer Prevention Coverage In Popular Us Women’S Health And Fitness Magazines: An Analysis Of Advertisements And Articles, Corey Hannah Basch, Danna Ethan, Grace Clarke Hillyer, Alyssa Berdnik

Publications and Research

The desire to be tan is a phenomenon that public health researchers have investigated, as exposure to UV radiation increases the chances of developing skin cancer. Media messages in women’s magazines have been shown to contribute to this problem. Much less is known about the prevalence of skin cancer prevention messages in these magazines. This study's aim was to identify the number and type of articles and advertised products devoted to skin health (sun protection and skin cancer prevention in particular) within five popular U.S. greater than women’s health and fitness magazines. We analyzed articles and advertisements over seven months …

Hepatitis C Virus Infection Among Hiv-Positive Men Who Have Sex With Men: Protocol For A Systematic Review And Meta-Analysis, Holly Hagan, Joshua Neurer, Ashly E. Jordan, Don C. Des Jarlais, Jennifer Wu, Kirk Dombrowski, Bilal Khan, Ronald Scott Braithwaite, Jason Kessler

Publications and Research

Background: Outbreaks of hepatitis C virus (HCV) infection have been reported in HIV-positive men who have sex with men (MSM) in North America, Europe and Asia. Transmission is believed to be the result of exposure to blood during sexual contact. In those infected with HIV, acute HCV infection is more likely to become chronic, treatment for both HIV and HCV is more complicated and HCV disease progression may be accelerated. There is a need for systematic reviews and meta-analyses to synthesize the epidemiology, prevention and methods to control HCV infection in this population.

Methods/design: Eligible studies will include quantitative empirical …

Evolutionary Cognitive Therapy Versus Standard Cognitive Therapy For Depression: A Protocol For A Blinded, Randomized, Superiority Clinical Trial, Cezar Giosan, Oana Cobeanu, Cristina Mogoase, Vlad Muresan, Loretta S. Malta, Katarzyna Wyka, Aurora Szentagotai

Publications and Research

Background: Depression is estimated to become the leading cause of disease burden globally by 2030. Despite existing efficacious treatments (both medical and psychotherapeutic), a large proportion of patients do not respond to therapy. Recent insights from evolutionary psychology suggest that, in addition to targeting the proximal causes of depression (for example, targeting dysfunctional beliefs by cognitive behavioral therapy), the distal or evolutionary causes (for example, inclusive fitness) should also be addressed. A randomized superiority trial is conducted to develop and test an evolutionary-driven cognitive therapy protocol for depression, and to compare its efficacy against standard cognitive therapy for depression.

Methods/design: …

Epidemiology Of Undiagnosed Trichomoniasis In A Probability Sample Of Urban Young Adults, Susan M. Rogers, Charles F. Turner, Marcia Hobbs, William C. Miller, Sylvia Tan, Anthony M. Roman, Elizabeth Eggleston, Maria A. Villarroel, Laxminarayana Ganapathi, James R. Chromy, Emily Erbelding

Publications and Research

T. vaginalis infection (trichomoniasis) is the most common curable sexually transmitted infection (STI) in the U.S. It is associated with increased HIV risk and adverse pregnancy outcomes. Trichomoniasis surveillance data do not exist for either national or local populations. The Monitoring STIs Survey Program (MSSP) collected survey data and specimens which were tested using nucleic acid amplification tests to monitor trichomoniasis and other STIs in 2006–09 among a probability sample of young adults (N = 2,936) in Baltimore, Maryland — an urban area with high rates of reported STIs. The estimated prevalence of trichomoniasis was 7.5% (95% CI 6.3, 9.1) …

Altering Murine Leukemia Virus Integration Through Disruption Of The Integrase And Bet Protein Family Interaction, Sriram Aiyer, G.V.T. Swapna, Nirav Malani, James M. Aramini, William M. Schneider, Matthew R. Plumb, Mustafa Ghanem, Ross C. Larue, Amit Sharma, Barbara Studamire, Mamuka Kvaratskhelia, Frederic D. Bushman, Gaetano T. Montelione, Monica J. Roth

Publications and Research

We report alterations to the murine leukemia virus (MLV) integrase (IN) protein that successfully result in decreasing its integration frequency at transcription start sites and CpG islands, thereby reducing the potential for insertional activation. The host bromo and extraterminal (BET) proteins Brd2, 3 and 4 interact with the MLV IN protein primarily through the BET protein ET domain. Using solution NMR, protein interaction studies, and next generation sequencing, we showthat the C-terminal tail peptide region ofMLV IN is important for the interaction with BET proteins and that disruption of this interaction through truncation mutations affects the global targeting profile of …

Chagas Disease In The 21st Century: A Public Health Success Or An Emerging Threat?, Kevin M. Bonney

Publications and Research

Chagas disease, caused by the protozoan parasite Trypanosoma cruzi, is a major public health burden in Latin America and a potentially serious emerging threat to a number of countries throughout the world. Although public health programs have significantly reduced the prevalence of Chagas disease in Latin America in recent decades, the number of infections in the United States and non-endemic countries in Europe and the Western Pacific Region continues to rise. Moreover, there is still no vaccine or highly effective cure available for the approximately 10 million people currently infected with T. cruzi, a third of which will develop potentially …

Capping Amyloid Β‑Sheets Of The Tau-Amyloid Structure Vqivyk With Hexapeptides Designed To Arrest Growth. An Oniom And Density Functional Theory Study, Joshua A. Plumley, Jorge Ali-Torres, Gabor Pohl, J. J. Dannenberg

Publications and Research

We present ONIOM calculations using density functional theory (DFT) as the high and AM1 as the medium level that explore the abilities of different hexapeptide sequences to terminate the growth of a model for the tau-amyloid implicated in Alzheimer’s disease. We delineate and explore several design principles (H-bonding in the side chains, using antiparallel interactions on the growing edge of a parallel sheet, using all-D residues to form rippled interactions at the edge of the sheet, and replacing the H-bond donor N−H’s that inhibit further growth) that can be used individually and in combination to design such peptides that will …

Genome-Wide Methylation Analyses In Glioblastoma Multiforme, Rose K. Lai, Yanwen Chen, Xiaowei Guan, Darryl Nousome, Charu Sharma, Peter Canoll, Jeffrey Bruce, Andrew E. Sloan, Etty Cortes, Jean-Paul Vonsattel, Tao Su, Lissette Delgado-Cruzata, Irina Gurvich, Regina M. Santella, Quinn Ostrom, Annette Lee, Peter Gregersen, Jill Barnholtz-Sloan

Publications and Research

Few studies had investigated genome-wide methylation in glioblastoma multiforme (GBM). Our goals were to study differential methylation across the genome in gene promoters using an array-based method, as well as repetitive elements using surrogate global methylation markers. The discovery sample set for this study consisted of 54 GBM from Columbia University and Case Western Reserve University, and 24 brain controls from the New York Brain Bank. We assembled a validation dataset using methylation data of 162 TCGA GBM and 140 brain controls from dbGAP. HumanMethylation27 Analysis Bead-Chips (Illumina) were used to interrogate 26,486 informative CpG sites in both the discovery …

Gender-Based Screening For Chlamydial Infection And Divergent Infection Trends In Men And Women, Susan M. Rogers, Charles F. Turner, William C. Miller, Emily Erbelding, Elizabeth Eggleston, Sylvia Tan, Anthony Roman, Marcia Hobbs, James Chromy, Ravikiran Muvva, Laxminarayana Ganapathi

Publications and Research

Objectives: To assess the potential impact of chlamydial screening policy that recommends routine screening of women but not men.

Methods: Population surveys of probability samples of Baltimore adults aged 18 to 35 years in 1997–1998 and 2006–2009 collected biospecimens to estimate trends in undiagnosed chlamydial infection. Survey estimates are compared to surveillance data on diagnosed chlamydial infections reported to the Health Department.

Results: Prevalence of undiagnosed chlamydial infection among men increased from 1.6% to 4.0%, but it declined from 4.3% to 3.1% among women (p = 0.028 for test of interaction). The annual (average) number of diagnosed infections was substantially …

Big Data Analytics In Healthcare: Promise And Potential, Wullianallur Raghupathi, Viju Raghupathi

Publications and Research

Objective To describe the promise and potential of big data analytics in healthcare.

Methods The paper describes the nascent field of big data analytics in healthcare, discusses the benefits, outlines an architectural framework and methodology, describes examples reported in the literature, briefly discusses the challenges, and offers conclusions.

Results The paper provides a broad overview of big data analytics for healthcare researchers and practitioners.

Conclusions Big data analytics in healthcare is evolving into a promising field for providing insight from very large data sets and improving outcomes while reducing costs. Its potential is great; however there remain challenges to overcome.