Implementation of disease activity measurement for rheumatoid arthritis patients in an academic rheumatology clinic

Alison Bays
Elizabeth Wahl
David I Daikh
Jinoos Yazdany
Gabriela Schmajuk
Implementation of disease activity measurement for rheumatoid arthritis patients in an academic rheumatology clinic
10.1186/s12913-016-1633-xR E S E A R C H A R T I C L E Open Access
Background: Treat-to-target is the recommended strategy for the management of rheumatoid arthritis (RA) and involves regular assessment of disease activity using validated measures and subsequent adjustment of medical therapy if patients are not in remission or low disease activity. Recommendations published in 2012 detailed the preferred disease activity measures but there have been few publications on implementation of disease activity measures in a real-world clinic setting. Methods: Plan-Do-Study-Act (PDSA) methodology was used over two cycles with a goal of increasing provider measurement of disease activity during all RA patient visits. In PDSA cycle 1, we implemented a paper-based form to help providers assess disease activity in RA patients. PDSA cycle 2 included the creation of separate patient and physician forms for collection of information, identification of patients prior to their clinic visit and incorporation of medical assistants into the workflow. Results: The first PDSA cycle improved the number of RA patients with documented disease activity measures from 24 % over a 4-week period, to an average of 44 % over an 8-week period. The second PDSA cycle showed a sustained and dramatic improvement, with 85 % of patients having a disease activity measure recorded over a 27week period. Conclusions: Implementation of disease activity measurement in a typical academic rheumatology clinic can be achieved by standardizing workflow using a simple paper form.

Background

Current management of many chronic diseases, such as diabetes, hyperlipidemia and hypertension employ treatment strategies to achieve a specific quantitative clinical measure [1]. Recently, this "treat-to-target" approach has been applied to rheumatoid arthritis (RA) [2]. Instead of targeting a laboratory test or blood pressure measurement, the "target" in RA is disease activity, which can be measured using a variety of validated tools. Most of these combine swollen and tender joint counts, physician and patient global assessments and sometimes laboratory values [3]. A systematic review in 2010 assessing treat to target versus usual care strategies in RA revealed consistent improvement in clinical outcomes with treat to target: Patients managed with treatto-target approaches had greater reductions in disease activity and a higher likelihood of achieving remission over usual care and additionally, experienced a reduction in radiographic erosions, improved physical function and quality of life [1,[4][5][6]. Current practice guidelines recommend patients with RA be treated with the goal of achieving remission or low disease activity [7].

In 2014, the National Quality Forum (NQF) endorsed measures requiring disease activity measurements in a majority of visits (greater than 50 %) in RA patients [8]. Acceptable measures of disease activity identified by the American College of Rheumatology include the Clinical Disease Activity Index (CDAI), Disease Activity Score with 28-joint counts (DAS28 ESR or CRP), Patient Activity Scales (PAS and PAS-II), Routine Assessment of Patient Index (RAPID-3) and Simplified Disease Activity Index (SDAI) [3].

Despite these recommendations for regular disease activity measurement in RA patients, routine use of these measurements has not been instituted in many rheumatology clinics. Reports from Physician Quality Reporting System (PQRS) indicate that in 2009, 630 of 83,849 physicians (<1 %), the majority of whom where rheumatologists, reported on one quality measure on RA patients. Among the physicians reporting one at least one measure for their RA patients (n = 630), they primarily reported disease-modifying antirheumatic drugs (DMARD) usage and only 29 % reported information on a disease activity measure (n = 183) [9].

Little has been published about how to best implement disease activity measurement in the clinic. Of the publications that discuss implementation, they are focused on the integration of software with their electronic health record [10,11]. However, not all rheumatology clinics have the IT support or ability to develop or purchase advanced modules to modify their system.

In this study, we describe methods for implementation of disease activity measurement in a tertiary care rheumatology clinic. The San Francisco Veterans Affairs (VA) hospital, associated with University of California, San Francisco (UCSF) provided an ideal place to implement use of disease activity measures for patients with RA. Trainees working in the rheumatology clinic were familiar with the use of disease activity measures at other locations within the UCSF healthcare system. Baseline use of disease activity measurement in the clinic was infrequent prior to the start of the study, in part because the electronic medical record (EMR) does not provide an easy method for documenting joint scores. Modifying the SFVA's EHR was not feasible in the shortterm, so we planned an intervention using a paper scoring form. We assessed whether standardization of the clinic's workflow to incorporate these forms increased the documentation of disease activity measures in the provider notes for patients with RA.

Methods

Study setting

The study took place in an academic rheumatology clinic at the VA Hospital in San Francisco. All providers working in the clinic were included in the intervention and analysis. The practice consists of nine rheumatology fellows (two fellows were present for only the preintervention period) one nurse practitioner and five attending physicians.

All patients with a diagnosis of rheumatoid arthritis in the medical record (reviewed by AB) were included. They study period lasted from June 2014 until April 2015. This project was considered exempt from IRB approval by the San Francisco VA IRB because it qualified as a quality improvement activity. Providers were aware of the interventions used. No funding sources were utilized for this quality improvement project.

Preliminary work to identify workflow challenges

Preliminary work involved interviewing staff, fellows and faculty to understand the barriers to documentation of RA disease activity. Prior to the intervention, a clinician wishing to document a disease activity measure would have to 1) identify RA patients requiring a measure, 2) request this patient's global assessment on a 0-10 or 0-100 Likert or visual analog scale during the clinical encounter 3) conduct the history and physical, including a 28-joint count, and 4) calculate the CDAI or DAS28 score and remember or look up the corresponding disease activity category 5) document a disease activity measure in the clinic note. No standard method existed for identifying patients ahead of clinic and providing them with a visual analog or Likert scale for rating their patient global assessment. Additionally, a ruler was often not available to score the patient and physician global if a visual analog scale was used. Other obstacles identified prior to the initiation of the first QI cycle were a lack of expectation on the part of the attending physicians to report a disease activity score, a lack of ability to modify the electronic medical record to incorporate the disease activity measures, and time constraints in clinic.

Upon reviewing the barriers to completing disease activity measures, the modifiable obstacles included attending physician expectations and availability of a form on which patients could indicate a global assessment and ruler with which to measure a visual analog scale line. The obstacles that were not immediately modifiable were changing the medical record (CPRS) and the time available to see a patient.

Disease activity measures

The Clinical Disease Activity Index (CDAI) incorporates a patient global score on a 0 to 10 scale, a physician global score on a 0 to 10 scale and a 28-joint count for both tenderness and swelling. The score is tabulated with up to 28 points for tenderness, 28 points for swelling, 10 points for the physician global and 10 points for the patient global. These scores are then translated into four categories: remission, low disease activity, moderate disease activity or high disease activity [3].

The disease activity score 28 or DAS28 (ESR or CRP) incorporates the patient global score on a scale of 0-100, a tender joint count of 28 joints, a swollen joint count of 28 joints and either the erythrocyte sedimentation rate (ESR) or the C-reactive protein (CRP) and the provider then uses a formula to calculate the disease activity score and it is again characterized as remission, low disease activity, moderate disease activity or high disease activity [3].

Interventions

A Plan-Do-Study-Act (PDSA) methodology provides a structure of iterative change that adapts to feedback to result in the desired outcome. The first stage, 'plan' , is a planning stage in which a change is identified with the goal of improvement. The second stage, 'do' , is when this change is tested. The third stage, 'study' , examines the success of the change and the 'act' stage identifies the next steps needed for beginning the next PDSA cycle [12]. We undertook two PDSA cycles in an attempt to improve use and documentation of disease activity measures at the San Francisco VA rheumatology clinic. There was a 4-week pre-intervention period where we assessed use of disease activity measures prior to any specific intervention. A first PDSA cycle was planned and assessment of its effect on disease activity measurement documentation was planned for 8 weeks later. A second PDSA cycle was planned and assessment of its effect on disease activity measurement documentation was again planned for 8 weeks later. Because of the success of PSDA cycle 2, we continued to follow the outcome for an additional 21 weeks (about 5 months).

Outcome

The outcome of interest was the proportion of RA patients seen on a given day in clinic who had a documented disease activity measure in the encounter note for that day. Eligible RA patients were identified prior to their clinic visit through medical chart review by one author (AB) based on the assessment sections on the most recent note. Presence or absence of the disease activity measure was determined by review of the entire note.

Data analysis

We divided the study period into three partspreintervention, PDSA cycle 1 and PDSA cycle 2. We created control charts to describe the proportion of encounters on each clinic day with a disease activity measure documented in the clinical note (p-charts). A continuous improvement of 6 or more points in the same direction is considered a trend [13].

Results

Between week 1 and week 39, there were 107 RA patients seen at the SFVA rheumatology clinic. Basic patient characteristics are listed in Table 1. Of these 107 patients, the average age at their most recent appointment was 67 years. In the 103 patients whose rheumatoid factor (RF) and/or cyclic citrullinated peptide antibody (CCP) status were known, 81 (79 %) of these patients were seropositive (73 were CCP positive and 71 were RF positive), 38 patients (35 %) were on biologic agents (Table 1).

Pre-intervention

During the 4-week pre-intervention period, there were 29 RA patient encounters. Twenty-four percent of preintervention visits had a documented disease activity measure in the clinical note. A single clinician was Rheumatoid factor or anti-cyclic citrullinated peptide antibody positive at any point, among patients tested responsible for nearly all of this disease activity score documentation.

PDSA cycle 1

The cycle 1 intervention consisted of 1) developing a paper form that would be readily available in clinic for collecting patient and physician global assessments and tabulating joint counts using the homunculus (Additional file 1) and 2) Making the form available in clinic 3) Brief one-on-one educational discussions with incoming fellows on the use of this form, the calculation of CDAI and DAS 28, and the purpose and goal of disease activity measurement. The providers were encouraged to download a CDAI and DAS-28 calculator onto their smartphones [14].

In the workflow (Fig. 1) for cycle 1, providers were to identify RA patients and retrieve a form located in the clinic that included the patient global visual analog scale, physician global visual analog scale, a 28-joint count with homunculus and instructions on how to calculate the CDAI and DAS-28 ESR and CRP. The form included a fold-over ruler, obviating the need for finding a ruler, in addition to instructions for calculating the CDAI.

PDSA cycle 1 lasted 8 weeks. During this period, providers had 59 visits with RA patients, and 26 (44 %) of those encounters had disease activity measures recorded in the note (see Fig. 2).

Follow-up interviews with clinicians identified several issues during cycle 1: 1) the patient and physician global were both completed on one form, so if the patient filled out the global score first, the physician would see the patient global score prior to the recording the physician global score, thus potentially biasing her rating; 2) the global assessment form had to be printed carefully so that the ruler lined up with the patient and physician global lines; 3) since RA patients were not pre-identified prior to their visits, providers would often forget to administer the patient global form.

PDSA cycle 2

The cycle 2 intervention involved: 1) the creation of two separate forms so that the patients would complete the patient global in the waiting room, prior to the clinic visit, and the providers would not see the score until after completing their own global assessment; 2) additional education for providers; 3) identification and flagging of RA patients prior to the clinic visit so that patients could fill out global assessments in the waiting room prior to the start of their visit.

The one form used previously was split into twothe first form was designed for patients and included a global assessment scale (see Additional file 2). The second form was for the providers and included a 28-joint count homunculus to record the swollen and tender joints, a physician global score (see Additional file 3). It also included an explanation of how to calculate the CDAI and DAS-28. On both forms, the global scores were changed from a visual analog scale to a numerical Likert scale, noted to be interchangeable in American College of Rheumatology's working group recommendations [3]. This eliminated the need for a ruler to calculate patient and provider global assessments.

Additional education was directed to providers. This included a post-clinic conference discussion of the history and utilization of disease activity measures and a division-wide Quality Improvement conference in which there was a discussion of the changes at the VA.

RA patients were identified via chart review and flagged by a single author (AB) prior to clinic (see Fig. 3). Appropriate forms were provided to medical assistants prior to clinic. On the day of clinic, the medical assistants were instructed to give the form to flagged patients while  taking their vital signs. The patients filled out the form while sitting in the waiting room. The patients would then either hand the form back to the medical assistant, who would attach it to the encounter form given to providers, or the patient could give the form directly to the clinician during the appointment. The physician would then conduct the history and physical, and enter the swollen and tender joint counts and the physician global into the table calculator on Form 2. The physician would then calculate the CDAI and/or DAS28 using simple addition or their IPhone app. When typing the note, the physician was instructed to include the score within the text of the note. PDSA cycle 2 lasted 27 weeks. During this period, providers had 182 clinic visits with RA patients, and 155 (85 %) of those encounters had disease activity measures recorded in the note (see Fig. 2). Starting during PDSA cycle 2, there were six occurrences over the p-bar, which continued throughout the PDSA cycle, with three exceptions. All providers showed improvement in disease activity measure documentation. There were no outliers.

Discussion

In this project, we describe the implementation of a reliable process for disease activity measurement for RA patients as recommended by the American College of Rheumatology in a single academic rheumatology clinic. Prior to the intervention, only 24 % of RA patients seen in clinic had documented disease activity measures and the majority of these patients had seen one third year fellow. By the end of the quality improvement initiative, we observed a sustained increase in the proportion of patients with of disease activity measures noted in the charts.

This project is generalizable to other clinics that may not have the capability to easily or immediately modify the electronic health system to incorporate disease activity measures. With minor changes to the workflow, we were able to incorporate the help of medical assistants, identify RA patients prior to their clinic appointment, and provide two forms for completion of global assessments, resulting in sustained improvement in reporting of disease activity measures. As disease activity measurement becomes a requirement of high quality care, we have shown that this "paper-and-pencil" intervention can result in successful documentation of disease activity measures without relying on changes to the electronic health record. This may be especially important for clinics with limited resources, or where changes to the health IT infrastructure may be difficult.

Our study has several limitations. First, it is difficult to disentangle which specific aspect of our intervention was the key improving disease activity measure documentation. Separating the effects of provider education or changes in culture from the effects of easy availability of patient global score for relevant patients is not possible given our study design. However, given the anemic improvement in the PDSA cycle 1, we can say that preclinic identification of patients and score collection in the waiting room seemed to be key attributes of a successful intervention. Second, our follow-up time is not long enough and our sample size not large enough to be The lower control limits vary as the denominator of patient encounters changed each week. The p-bar shows the average CDAI documentation rate. More than 6 values are seen above the p-bar after Cycle 2 was implemented, indicating a positive improvement able to witness changes in mean CDAI or DAS scores over time as a result of the implementation of this "treat to target" approach, although such improvements have been documented in trial settings previously [1,[4][5][6].

Future projects include exploring the possibility of modifying the electronic medical record to include the CDAI or DAS-28 as structured fields. This would allow for easy identification of patients with and without disease activity measures and allow clinicians to see trends in their performance over time. It would also make it easy to trend a single patient's disease activity over time to evaluate their response to therapy. Modifying the electronic medical record so that it stores disease activity over time and allows providers to see trends over time is an ideal system that would assist providers in being able to assess trends over time. This has been implemented and has shown improvement in quality of care, efficiency of care and productivity [11]. However, this is not possible with all electronic medical records.

Conclusions

Through utilization of a simple paper form and changes to workflow, rheumatology clinics can implement the use of standardized disease activity measures to offer patients high quality care consistent with the recommendations of the American College of Rheumatology [3,15]. Funding GS received salary support from the National Institutes of Health, through K23 AR063770 (GS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Availability of data and materials

All data supporting our findings is included in this manuscript and appendix files.

Authors' contributions AB contributed to the study design, acquisition of data, analysis and interpretation of data, drafting the article, final approval of the article. EW contributed to and interpretation of data, critical revision of the article, final approval of the article. DD participated study concept and design, acquisition of data, analysis and interpretation of data, critical revision the article, final approval of the article. JY participated in study design, interpretation of data, critical revision the article, final approval of the article. GS contributed to the study concept and design, acquisition of data, analysis and interpretation of data, drafting the article, final approval of the article. All authors read and approved the final version of the manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Ethics approval and consent to participate

This project was considered exempt from IRB approval by the San Francisco VA IRB because it qualified as a quality improvement activity. Therefore, the need to obtain informed consent was deemed unnecessary and not obtained from patients.

prior results and compares trend Physican discusses treatment changes with patient Physician records disease activity in note

Fig. 1
1Cycle 1 workflow

Fig. 2
2Percent completion of CDAI by week of intervention. The pre-intervention, PDSA Cycle 1, and PDSA Cycle 2 phases are separated by red bars. The dark blue line show sthe proportion of patient encounters with a documented CDAI by week. The upper control limits are not seen (>1).

:
Cycle 1 form (PDF 533 kb) Additional file 2: Cycle 2 patient form (PDF 137 kb) Additional file 3: Cycle 2 provider form (PDF 447 kb) Acknowledgements None.

Rheumatology, University of Washington, Harborview, 1959 NE Pacific Street, Box 356428, Seattle, WA, USA. 2 Division of Rheumatology,

Fig. 3
3Cycle 2 workflow

Table 1
1Characteristics of rheumatoid arthritis patients seen in the San Francisco VA rheumatology clinic during study periodCharacteristics
Rheumatoid arthritis patients

N = 107

Age, mean (SD)
67 (10)

Male, N (%)
93 (87 %)

Seropositive, a N (%) [N = 103]
81 (79 %)

Medications at end of study period, N (%)

Methotrexate
60 (56 %)

Prednisone
42 (39 %)

Biologic
38 (35 %)

a

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Prospects and applications of nanobiotechnology: a medical perspective

Md Fakruddin
Zakir Hossain
Hafsa Afroz
Prospects and applications of nanobiotechnology: a medical perspective
R E V I E W
Background: Nanobiotechnology is the application of nanotechnology in biological fields. Nanotechnology is a multidisciplinary field that currently recruits approach, technology and facility available in conventional as well as advanced avenues of engineering, physics, chemistry and biology. Method: A comprehensive review of the literature on the principles, limitations, challenges, improvements and applications of nanotechnology in medical science was performed.Results: Nanobiotechnology has multitude of potentials for advancing medical science thereby improving health care practices around the world. Many novel nanoparticles and nanodevices are expected to be used, with an enormous positive impact on human health. While true clinical applications of nanotechnology are still practically inexistent, a significant number of promising medical projects are in an advanced experimental stage. Implementation of nanotechnology in medicine and physiology means that mechanisms and devices are so technically designed that they can interact with sub-cellular (i.e. molecular) levels of the body with a high degree of specificity. Thus therapeutic efficacy can be achieved to maximum with minimal side effects by means of the targeted cell or tissue-specific clinical intervention. Conclusion: More detailed research and careful clinical trials are still required to introduce diverse components of nanobiotechnology in random clinical applications with success. Ethical and moral concerns also need to be addressed in parallel with the new developments.

Introduction

Nanotechnology is a novel scientific approach that involves materials and equipments capable of manipulating physical as well as chemical properties of a substance at molecular levels. On the other hand, biotechnology uses the knowledge and techniques of biology to manipulate molecular, genetic and cellular processes to develop products and services and is used in diverse fields from medicine to agriculture. Nanobiotechnology is considered to be the unique fusion of biotechnology and nanotechnology by which classical micro-technology can be merged to a molecular biological approach in real. Through this methodology, atomic or molecular grade machines can be made by mimicking or incorporating biological systems, or by building tiny tools to study or modulate diverse properties of a biological system on molecular basis. Nanobiotechnology may, therefore, ease many avenues of life sciences by integrating cutting-edge applications of information technology & nanotechnology into contemporary biological issues. This technology has potential to remove obvious boundaries between biology, physics and chemistry to some extent, and shape up our current ideas and understanding. For this reason, many new challenges and directions may also arise in education, research & diagnostics in parallel by the extensive use of nanobiotechnology with the passage of time.

Nanobiotechnology at a glance

Biotechnology and nanotechnology are two of the 21 st century's most promising technologies. Nanotechnology (sometimes referred to as nanotech) is defined as the design, development and application of materials & devices whose least functional make up is on a nanometer scale [1,2]. Generally, nanotechnology deals with developing materials, devices, or other structures possessing at least one dimension sized from 1 to 100 nanometers. Meanwhile, Biotechnology deals with metabolic and other physiological processes of biological subjects including microorganisms. Association of these two technologies, i.e. nanobiotechnology can play a vital role in developing and implementing many useful tools in the study of life.

Nanotechnology is very diverse, ranging from extensions of conventional device physics to completely new approaches based upon molecular self-assembly, from developing new materials with dimensions on the nanoscale to investigating whether we can directly control matters on/in the atomic scale/level. This idea entails the application of fields of science as diverse as surface science, organic chemistry, molecular biology, semiconductor physics, microfabrication, etc.

Advantages of nanobiotechnology

The pathophysiological conditions and anatomical changes of diseased or inflamed tissues can potentially trigger a great deal of scopes for the development of various targeted nanotechnological products. This development is like to be advantageous in the following ways: 1. Drug targeting can be achieved by taking advantage of the distinct pathophysiological features of diseased tissues [3]; 2. Various nanoproducts can be accumulated at higher concentrations than normal drugs [4]; 3. increased vascular permeability coupled with an impaired lymphatic drainage in tumors improve the effect of the nanosystems in the tumors or inflamed tissues through better transmission and retention [5,6]. 4. Nanosystems have capacity of selective localization in inflammed tissues [7]. 5. Nanoparticles can be effectively used to deliver/transport relevant drugs to the brain overcoming the presence of blood-brain barrier (meninges) [8,9]. 6. Drug loading onto nanoparticles modifies cell and tissue distribution and leads to a more selective delivery of biologically active compounds to enhance drug efficacy and reduces drug toxicity [10,11].

Applications of nanobiotechnology in medical and clinical fields

A number of clinical applications of nanobiotechnology, such as disease diagnosis, target-specific drug delivery, and molecular imaging are being laboriously investigated at present. Some new promising products are also undergoing clinical trials [12,13]. Such advanced applications of this approach to biological systems will undoubtedly transform the foundations of diagnosis, treatment, and prevention of disease in future. Some of these applications are discussed below.

(a) Diagnostic applications Current diagnostic methods for most diseases depend on the manifestation of visible symptoms before medical professionals can recognize that the patient suffers from a specific illness. But by the time those symptoms have appeared, treatment may have a decreased chance of being effective. Therefore the earlier a disease can be detected, the better the chance for a cure is. Optimally, diseases should be diagnosed and cured before symptoms even manifest themselves. Nucleic acid diagnostics will play a crucial role in that process, as they allow the detection of pathogens and diseases/diseased cells at such an early symptomless stage of disease progression that effective treatment is more feasible. Current technology, such as-polymerase chain reaction (PCR) leads toward such tests and devices, but nanotechnology is expanding the options currently available, which will result in greater sensitivity and far better efficiency and economy.

Detection:

Many currently used/conventional clinical tests reveal the presence of a molecule or a disease causing organism by detecting the binding of a specific antibody to the disease-related target. Traditionally, such tests are performed by conjugating the antibodies with inorganic/ organic dyes and visualizing the signals within the samples through fluorescence microscopy or electronic microscopy. However, dyes often limit the specificity and practicality of the detection methods. Nanobiotechnology offers a solution by using semiconductor nanocrystals (also referred to as "quantum dots"). These minuscule probes can withstand significantly more cycles of excitations and light emissions than typical organic molecules, which more readily decompose [14].

Individual target probes

Despite the advantages of magnetic detections, optical and colorimetric detections will continue to be chosen by the medical community. Nanosphere (Northbrook, Illinois) is one of the companies that developed techniques that allow/ allowing doctors to optically detect the genetic compositions of biological specimens. Nano gold particles studded with short segments of DNA form the basis of the easy-to-read test for the presence of any given genetic sequence. If the sequence of interest in the samples, it binds to complementary DNA tentacles on multiple nanospheres and forms a dense web of visible gold balls. This technology allows/facilitates the detection of pathogenic organisms and has shown promising results in the detection of anthrax, giving much higher sensitivity than tests that are currently being used [15].

Protein chips

Proteins play the central role in establishing the biological phenotype of organisms in healthy and diseased states and are more indicative of functionality. Hence, proteomics is important in disease diagnostics and pharmaceutics, where drugs can be developed to alter signaling pathways. Protein chips can be treated with chemical groups, or small modular protein components, that can specifically bind to proteins containing a certain structural or biochemical motif [16]. Two companies currently operating in this application space are Agilent, Inc. and NanoInk, Inc. Agilent uses a non-contact ink-jet technology to produce microarrays by printing oligos and whole cDNAs onto glass slides at the nanoscale. NanoInk uses dip-pen nanolithography (DPN) technology to assemble structure on a nanoscale of measurement [17].

Sparse cell detection

Sparse cells are both rare and physiologically distinct from their surrounding cells in normal physiological conditions (e.g. cancer cells, lymphocytes, fetal cells and HIV-infected T cells). They are significant in the detection and diagnosis of various genetic defects. However, it is a challenge to identify and subsequently isolate these sparse cells. Nanobiotechnology presents new opportunities for advancement in this area.

Scientists developed nanosystems capable of effectively sorting sparse cells from blood and other tissues. This technology takes advantage of/exploits the unique properties of sparse cells manifested in differences in deformation, surface charges and affinity for specific receptors and/or ligands. For example, by inserting electrodes into microchannels, cells can be precisely sorted based on surface charge. They can also be sorted by using biocompatible surfaces with precise nanopores. The nano-biotechnology center at Cornell University (NBTC) is currently using these technologies to develop powerful diagnostic tools for the isolation and diagnosis of various diseases [18]. 5. Nanotechnology as a tool in imaging Intracellular imaging can be made possible through labelling of target molecules with quantum dots (QDs) or synthetic chomophores, such as fluorescent proteins that will facilitate direct investigation of intracellular signalling complex by optical techniques, i. e. confocal fluorescence microscopy or correlation imaging [19,20].

(b)Therapeutic applications: Nanotechnology can provide new formulations of drugs with less side effects and routes for drug delivery.

1. Drug Delivery: Nanoparticles as therapeutics can be delivered to targeted sites, including locations that cannot be easily reached by standard drugs. For instance, if a therapeutic can be chemically attached to a nanoparticle, it can then be guided to the site of the disease or infection by radio or magnetic signals. These nanodrugs can also be designed to "release" only at times when specific molecules are present or when external triggers (such as infrared heat) are provided. At the same time, harmful side effects from potent medications can be avoided by reducing the effective dosage needed to treat the patient. By encapsulating drugs in nanosized materials (such as organic dendrimers, hollow polymer capsules, and nanoshells), release can be controlled much more precisely than ever before. Drugs are designed to carry a therapeutic payload (radiation, chemotherapy or gene therapy) as well as for imaging applications [21]. Many agents, which cannot be administered orally due to their poor bioavailability, will now have scope of use in therapy with the help of nanotechnology [22,23]. Nano-formulations offer protection for agents vulnerable to degradation or denaturation when exposed to extreme pH, and also prolong half-life of a drug by expanding retention of the formulation through bioadhesion [24,25]. Another broad application of nanotechnology is the delivery of antigens for vaccination [26,27]. Recent advances in encapsulation and development of suitable animal models have demonstrated that microparticles and nanoparticles are capable of enhancing immunization [28].

Gene delivery

Current gene therapy systems suffer from the inherent difficulties of effective pharmaceutical processing and development, and the chance of reversion of an engineered mutant to the wild type. Potential immunogenicity of viral vectors involved in gene delivery is also problematic [29,30]. To address this issue, nanotechnological tools in human gene therapy have been tested and nanoparticle-based nonviral vectors (usully 50-500 nm in size) in transportation of plasmid DNA described. Therefore, successful introduction of less immunogenic nanosize gene carriers as a substitution of the disputed viral vectors seems beneficial in repairing or replacing impaired genes in human [31].

Liposomes

A liposome being composed of a lipid bilayer can be used in gene therapy due to its ability to pass through lipid bilayers and cell membranes of the target. Recent use of several groups of liposomes in a local delivery has been found to be convincingly effective [32,33]. Liposomes can also help achieve targeted therapy. Zhang et al demonstrated widespread reporter expression in the brains of rhesus monkeys by linking nanoparticle (such as polyethylene glycol) treated liposomes to a monoclonal antibody for human insulin reporter [34]. These successful trials reflect the future of targeted therapy and the importance of nanometer-sized constructs for the advancement of molecular medicine.

Surfaces

In nature, there are a multitude of examples of the complicated interactions between molecules and surfaces. For example, the interactions between blood cells and the brain or between fungal pathogens and infection sites rely on complex interplays between cells and surface characteristics. Nanofabrication unravels the complexity of these interactions by modifying surface characteristics with nanoscale resolutions, which can lead to hybrid biological systems. This hybrid material can be used to screen drugs, as sensors, or as medical devices and implants. Nanosystems, owned by the Irish drug company Elan, developed a polymer coating capable of changing the surface of drugs that have poor water solubility [35].

Biomolecular Engineering

The expense and time involved in traditional biomolecule designing limit the availability of bioactive molecules. Nanoscale assembly and synthesis techniques provide an alternative to traditional methods. Improvements can be achieved due to the ability to carry out chemical and biological reactions on solid substrates, rather than through the traditional solution based processes. The use of solid substrate usually means less waste and the ability to manipulate the biomolecule far more precisely. EngeneOS (Waltham, Massachusetts) pioneered the field of biomolecular engineering. The company developed the engineered genomic operating systems that create programmable biomolecular machines employing natural and artificial building blocks. These biomolecule machines have broad range of commercial applications-as biosensors, in chemical synthesis and processing, as bioelectronic devices and materials, in nanotechnology, in functional genomics and in drug discovery. 6. Biopharmaceuticals Nanobiotechnology can develop drugs for diseases that conventional pharmaceuticals cannot target. The pharmaceutical industry traditionally focuses on developing drugs to treat a defined universe of about five hundred confirmed disease targets. But approximately 70 to 80 percent of the new candidates for drug development fail, and these failures are often discovered late in the development process, with the loss of millions of dollars in R&D investments. Nanoscale techniques for drug development will be a boon to small companies, which cannot employ hundreds of organic chemists to synthesize and test thousands of compounds. Nanobiotechnology brings the ability to physically manipulate targets, molecules and atoms on solid substrates by tethering them to biomembranes and controlling where and when chemical reactions take place, in a fast process that requires few materials (reagents and solutions). This advance will reduce drug discovery costs, will provide a large diversity of compounds, and will facilitate the development of highly specific drugs. Potentia Pharmaceuticals (Louisville, Kentucky) is an early-stage company that is attempting to streamline the drug development process with the use of nanotechnologies (Harvard Business School 2001).

Nanotechnology in cardiac therapy

Nanotechnology is currently offering promising tools for applications in modern cardiovascular science to explore existing frontiers at the cellular level and treat challenging cardiovascular diseases more effectively. These tools can be applied in diagnosis, imaging and tissue engineering [36]. Miniaturized nanoscale sensors like quantum dots (QDs), nanocrystals, and nanobarcodes are capable of sensing and monitoring complex immune signals in response to cardiac or inflammatory events [20]. Nanotechnology can also help detect and describe clinically-significant specific mechanisms implicated in cardiac disorders. In addition, it is useful in designing atomic-scale machines that can be incorporated into biological systems at the molecular level. Introduction of these newly designed nanomachines may positively change many ideas and hypotheses in the treatment of critical cardiovascular diseases. Nanotechnology could also have great impact in tackling issues like unstable plaques and clarification of valves. Thus, this approach could be a real milestone of success in achieving localized and sustained arterial and cardiac drug therapy for the management of cardiovascular diseases [37]. 8. Nanotechnology in dental care Nanotechnology will have future medical applications in the field of dentistry. The role of nanodentistry by means of the use of nanomaterials [38,39], biotechnology [40,41], and nanorobotics will ensure better oral health.

Millions of people currently receiving poor dental care will benefit from such remarkable breakthrough in the science of dental health [42,43]. Moreover, nanodental techniques in major tooth repair may also evolve.

Reconstructive dental nanorobots could be used in selective and precise occlusion of specific tubules within minutes, and this will facilitate quick and permanent recovery. The advantage of nanodentistry in natural tooth maintenance could also be significant [44]. Covalently-bonded artificial materials like sapphire may replace upper enamel layer to boost the appearance and durability of teeth [43]. 9. Nanotechnology in orthopedic applications Nanomaterials sized between 1 and 100 nm have role to play as new and functional constituents of bones being also made up of nanosized organic and mineral phases [45,46]. Nanomaterials, nanopolymers, carbon nanofibers, nanotubes, and ceramic nanocomposites may help with more efficient deposition of calcium-containing minerals on implants. Based on these evidences and observations, nanostructure materials represent a unique realm of research and development that may improve the attachment of an implant to the surrounding bone matters by enhancing bone cell interactions, and this will indeed aid in improving orthopedic implant efficacy while drastically minimizing patientcompliance problems.

Future prospects of nanobiotechnology

There is much debate on the future implications of nanobiotechnology. It could create and suggest implementation of a choice of various new materials and devices potentially useful in the field of medicine, electronics, biomaterials and energy production. Nevertheless, this approach raises many of the same issues as any new technology, including problems with toxicity and environmental impact of nanomaterials [47] and their potential effects on global economics, as well as speculation about various doomsday scenarios. These concerns have accounted for a debate among advocacy groups and governments on whether special statutory regulation of nanobiotechnology is warranted. Despite the existence of some disputes, this technology renders immense hope for the future. It may lead to innovations by playing a prominent role in various biomedical applications ranging from drug delivery and gene therapy to molecular imaging, biomarkers and biosensors. One of these applications being the prime research objective of the present time would be target-specific drug therapy and methods for early diagnosis and treatment of diseases [2]. Two types of medical applications are already emerging, both in clinical diagnosis and in R&D. Imaging applications, such as quantum dot technology are already being licensed and applications for monitoring cellular activities in tissue are coming soon. The second major type of application involves the development of highly specific and sensitive means of detecting nucleic acids and proteins [48]. By 2015 to 2020, we will see that products being tested in academic and government laboratories will be creeping into commercialization. Sparse cell isolation and molecular filtration applications should, by then, make it to market. Some of the drug delivery systems should be commercialized or in advanced clinical trials. For example -drug delivery systems have been developed by NanoSystems or by American Pharmaceutical Partners, which is testing the encapsulation of Taxol, a cancer drug in a nanopolymer called paclitaxel. Most medical devices and therapeutics are a decade or more away from market. Therefore, drug target manipulation as well as device implantation requires a complex technical infrastructure like nanotechnology as well as complex regulatory management [49].

Continuous advancements in nanomedicine have opened up its opportunities for application in a variety of medical disciplines. Its future application as diagnostic and regenerative medicine is currently being investigated. In diagnosis, detection of diseased cells would be faster, possibly at the point of a single sick cell, while allowing diseased cells to be cured at once before they spread into and affect other parts of the body. Also, individuals suffering from major traumatic injuries or impaired organ functions could benefit from the use of nanomedicine.

Challenges for nanobiotechnology

No single person can provide the answers to challenges that nanotechnology brings, nor can any single group or intellectual discipline. The five main challenges are to develop instruments to assess exposure to engineered nano-materials in the air and water. It is fairly understood that exposure of humans and animals to the environment potentially contaminated with nano-materials may need to be monitored for any adverse consequence. The challenge becomes increasingly difficult in more complex matrices like food. The second challenge would be to develop applicable methods to detect and determine the toxicity of engineered nano-materials within next 5 to 15 years. Then again, proposing models for predicting effects of these nano-materials on human health and the environment would be an inevitable issue. The next challenge would be to develop reverse systems to evaluate precise impact of engineered nano-materials on health and the environment over the entire life span that speaks to the life cycle issue. The fifth being more of a grand challenge would be to develop the tools to properly assess risk to human health and to the environment. Commercialization challenges of nanobiotechnology include uncertainty of effectiveness of innovation, scalability, funding, scarce resources, patience etc. A broad majority of company recognizes a great potential in nanotechnology for the development of new products and the improvement of existing products. A new potentially disruptive technology like nanotechnology raises fundamental questions about the need for new regulations. Authorities around the world should evaluate possible risks and an appropriate regulatory response to the extensive use of this advanced technology.

Potential hazards of nanoparticles

Nanoparticles, as a result of their extreme microscopic dimension, which gives unique advantage, have potential hazards similar to particulate matters [50]. These particles have the potential to cause varied pathologies of respiratory, cardiovascular and gastrointestinal system [51]. Intra-tracheal instillation of carbon nanotube particles in mice has shown that carbon nanotubes have the potential to cause varied lung pathologies like epitheloid granuloma, interstitial inflammation, peribronchial inflammation and necrosis of lung. The toxicity produced by carbon nanotube was found to be greater than that produced by carbon black and quartz [52].

It has been shown that nanomaterials can enter the human body through several ports. Accidental or involuntary contact during production or use is most likely to occur via the lungs, from which a rapid translocation is possible to other vital organs through the bloodstream. On the cellular level, an ability to act as a gene vector has been demonstrated for nanoparticles [53]. Nanoparticles can enter the central nervous system either directly through axons of olfactory pathway or through systemic circulation through the olfactory bulb [54].

Studies done on monkeys and rats have shown accumulation of carbon and manganese nanoparticles in the olfactory bulb through the olfactory pathway [55]. This shows that nanoparticle-mediated delivery can, in future, provide a means of alternate route, circumventing the blood brain barrier. However, this can also result in the inflammatory reactions/responses in the brain, which needs to be evaluated.

Radomski et al [56] have observed the pro-aggregatory effects of nanotubes on platelets in in vitro studies and acceleration of vascular thrombosis in rat. It was also observed that fullerenes do not have the property of inducing platelet aggregation. Thus, for designing nanoparticle-based drug delivery systems, fullerenes may be a safer approach as compared to nanotubes [57].

The toxicity of nanoparticles can also be extrapolated to gastrointestinal system, resulting in inflammatory bowel diseases. The toxicity of nanoparticles may be related to its ability to induce release of pro-inflammatory mediators resulting in inflammatory response and organ damage. If ingested, the nanoparticles can reach the circulation and reach different organs and systems and possibly result in toxicity [58]. These have been studied in vitro and in animal models and the effect on human system is difficult to extrapolate from such studies. Their use in humans requires further research and much needed caution.

Conclusion

Nanobiotechnology is still in its early stages. The multidisciplinary field of nanobiotechnology is bringing the science of the almost incomprehensibly small device closer and closer to reality. The effects of these developments will at some point be so vast that they will probably affect virtually all fields of science and technology. Nanobiotechnology offers a wide range of uses in medicine. Innovations such as drug delivery systems are only the beginnings of the start of something new. Many diseases that do not have cures today may be cured by nanotechnology in the future. Although the expectations from nanobiotechnology in medicine are high and the potential benefits are endlessly enlisted, the safety of nanomedicine is not yet fully defined. Use of nanotechnology in medical therapeutics needs adequate evaluation of its risk and safety factors. Scientists who are against the use of nanotechnology also agree that advancement in nanotechnology should continue because this field promises great benefits, but testing should be carried out to ensure the safety of the people. It is possible that nanomedicine in future would play a crucial/ unparallel role in treatment of human diseases and also in enhancement of normal human physiology. If everything runs smoothly, nanobiotechnology will, one day, become an inevitable part of our everyday life and will help save many lives.
 http://www.jnanobiotechnology.com/content/10/1/31
AcknowledgementThe authors acknowledge Mr. Reaz Mohammad Mazumdar, Scientific Officer, BCSIR Laboratories, Chittagong, for reviewing the manuscript critically.Competing interestsThe authors declare that they have no competing interests.
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