Medicines and other factors causing deaths in English and welsh care homes: five-years of preventing future death reports by coroners

BACKGROUND

Whilst information has been published on the impact, severity and causes of incidents involving medicines in care homes, it has not been systematically described. This review explored whether coroners' Preventing Future Death (PFD) reports involving medicines for people living in care homes could add to this evidence base.

METHODS

PFD reports made publicly available between 2017 and 2021 classified as 'care home-related deaths' were reviewed. Reports describing medicines and/or medicines processes were identified. Contributory factors within these reports were then identified.

RESULTS

Within the timeframe, 156 reports were published, and 25 described medicines (n = 27) or medicines processes (n = 5) concerning people living in care homes. The impact of medicines and/or medicines processes was quantified as no impact (n = 7), contributory (n = 6) and direct (n = 14) per report. Two key themes emerged. Four deaths had an association between their falls risk, prescribed anticoagulants, and the failure of the service to seek timely emergency care following a fall and two deaths concerned endocrine medicines, where people refused insulin or blood sugar monitoring and staff did not seek timely advice.

CONCLUSION

This study demonstrated PFD reports provide an insight into the potential association between medicines, and other aspects of the person's care in causing harm.

The relationship between the pharmacist's role, patient understanding and satisfaction during the provision of a cost-effective pharmacist-led intervention

RATIONALE, AIMS AND OBJECTIVES

This study aimed to investigate the relationship between the pharmacist's role, patient understanding and satisfaction during the provision of a cost-effective pharmacist-led intervention using structural equation modelling (SEM). SEM is a group of statistical techniques used in different disciplines to model latent variables and evaluate theories.

METHODS

A validated questionnaire was used to gather patient views on a pharmacist-led intervention. A conceptual model was developed to test the statistical significance of the relationship between patient understanding and satisfaction, the pharmacist's role and patient understanding, the pharmacist's role and patient satisfaction. In addition, the study evaluated the model's in-sample and out-of-sample predictive power. The analysis tested fours hypotheses (H): 1) There was no significant relationship between patient understanding and patient satisfaction; 2) There was no significant relationship between the pharmacist's role and patient understanding; 3) There was no significant relationship between the pharmacist's role and patient satisfaction; 4) The in-sample and out-of-sample predictive power of the model. Data were analysed using Smart-PLS software version 3.2.8.

RESULTS

Two hundred and forty-six patients returned the questionnaire. Construct reliability, validity (Cronbach's alpha〉0.70, ⍴A>0.70, ⍴C>0.70), average extracted variance (AVE〉0.50) and discriminant validity (HTMT<0.85) were confirmed. The structural model and hypothesis testing results showed that all hypotheses were supported in this study. Path coefficients and effect sizes suggested that the pharmacist's role played a significant part in patient understanding (H2, β=0.650, f² =0.730, p<0.001), which then influenced patient satisfaction (H1, β=0.474, f² =0.222, p<0.001). The in-sample and out-of-sample predictive powers were moderate.

CONCLUSIONS

Patient satisfaction is becoming an integral component in healthcare provision and evaluation of healthcare quality. The results support using structural equation modelling to assess the link between the pharmacist's role and patient understanding and satisfaction when delivering cost-effective pharmacist-led interventions.

Evaluation of the effectiveness of the Super Enhanced Single Vision Lens 01 (SESL01) in reducing symptoms of computer vision syndrome (CVS): A study protocol for a double-blind, two-arm parallel randomized controlled trial

BACKGROUND

The increased use of digital devices has implications for health and, particularly, the eyes, due to Computer Vision Syndrome (CVS). Millions of individuals of all ages are at risk of CVS, and its prevalence ranges from 25% to 93%. This trial will evaluate the effectiveness of the Super Enhanced Single Vision Lens 01 (SESL01) versus standard single vision lens in reducing symptoms of CVS assessed by the Computer Vision Syndrome Questionnaire (CVS-Q®) scores.

METHOD

A double-blind, two-arm parallel randomized controlled trial will be conducted at the University of Central Lancashire, Preston (UK), recruiting students and staff with CVS-Q score ≥ 6. A 1:1 randomization and a sample size of 300 participants will be sufficient to detect a 2-point difference in the CVS-Q score between the intervention and control groups with an alpha of 5%, two-sided, allowing for a dropout of 10%. The control group will use standard single vision lenses, and the intervention group SESL01. The primary outcome to week 14 will be the difference in the CVS-Q score between SESL01 and standard single vision lenses. Secondary outcomes include the percentage of participants with CVS-Q score < 6 (no symptoms) and CVS-Q score ≥ 6 (symptoms) in the SESL01 and the standard single vision group at weeks 6, 10 and 14; the percentage of participants in each group with a total CVS-Q score < 6, 6-12, 13-19, and ≥ 20 at weeks 6, 10 and 14. The primary analysis will be the intention to treat.

DISCUSSION

Findings may inform decisions about adopting the SESL01 lenses to reduce CVS.

TRIAL REGISTRATION

clinicaltrial.gov identifier: NCT05545878. Registered: Sept. 19, 2022.

Primate-specific transposable elements shape transcriptional networks during human development

The human genome contains more than 4.5 million inserts derived from transposable elements (TEs), the result of recurrent waves of invasion and internal propagation throughout evolution. For new TE copies to be inherited, they must become integrated in the genome of the germline or pre-implantation embryo, which requires that their source TE be expressed at these stages. Accordingly, many TEs harbor DNA binding sites for the pluripotency factors OCT4, NANOG, SOX2, and KLFs and are transiently expressed during embryonic genome activation. Here, we describe how many primate-restricted TEs have additional binding sites for lineage-specific transcription factors driving their expression during human gastrulation and later steps of fetal development. These TE integrants serve as lineage-specific enhancers fostering the transcription, amongst other targets, of KRAB-zinc finger proteins (KZFPs) of comparable evolutionary age, which in turn corral the activity of TE-embedded regulatory sequences in a similarly lineage-restricted fashion. Thus, TEs and their KZFP controllers play broad roles in shaping transcriptional networks during early human development.

Spoken propositional idea density, a measure to help second language English speaking students: A multicentre cohort study

PURPOSE

Idea density has been shown to influence comprehension time for text in various populations. This study aims to explore the influence of spoken idea density on attainment in young, healthy subjects using demographic characteristics.

METHODS

Students watched two online lectures and answered 10 multiple choice questions on them. Students received one more idea dense (MID) and one less idea dense (LID) lecture on two different subjects.

RESULTS

Seventy-five students completed the study achieving a higher median score after a less idea-dense lecture (LID = 7(3), MID = 6(3), p = 0.04). Artificial neural network models revealed the first language as the main predictor of exam performance. The odds ratio (OR) of obtaining ≥70% after a more idea-dense lecture was six-time higher for the first language versus second language English speakers (OR = 5.963, 95% CI 1.080-32.911, p = 0.041). The odds ratio was not significant when receiving a less dense lecture (OR = 2.298, 95% CI 0.635-8.315, p = 0.205). Second-language speakers benefited from receiving a lower idea density, achieving a 10.8% score increase from high to low density, versus a 3.2% increase obtained by first language speakers.

CONCLUSIONS

The propositional idea density of lectures directly influences students' comprehension, and disproportionately for second language speakers; revealing the possibility of reduced spoken idea density in levelling the attainment differential between first and second language speakers.

Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review

Medicines-related incidents are a leading cause of preventable harm across all patient groups, including care home residents. Despite national guidance, there is little information on assessing medication error rates and evaluating changes to reduce them. This review explored the scientific and gray literature on medicine-related incidents, causation and evaluation of changes in care homes in the United Kingdom. The research identified 2951 documents, 32 analyzed; some of them covered more than one area. Seven reported rate and causes, eleven causes, eleven made recommendations, and four reported the evaluation of changes to processes and systems. Three areas emerged; 1) medicine-related incident rates ranged between 1% and 38%, 2) incident rates increased where formulations were not tablets or capsules ranging from 12% to 50% depending on the formulation, 3) three evaluations of changes aimed at reducing medicine incidents. Therefore, information on medicine-related incidents in care homes is available, but not systematically described.

Pedagogic Interest Group: a novel and proven collaborative, adhocracy research group structure

This article was migrated. The article was marked as recommended. Background: Teaching is a core activity for universities, and pedagogic research is essential for improving student experience, staff satisfaction, and research and teaching quality. Pedagogic research is often performed as a secondary research area or by part-time staff, requiring good collaboration. Existing research structures in universities often result in pedagogic research falling through the gaps and for quality work and pedagogic improvements to be missed. Aim: The aim was to develop a clear and flexible structure to improve participation and output of pedagogic research in the School of Pharmacy and Biomedical Sciences at the University of Central Lancashire. Method: A collaborative adhocracy called the Pedagogic Interest Group (PIG) was created in January 2020. It was designed to allow collaborative, flexible research projects to be easily set up by any staff member. The group supervises and organises a bespoke team of people for each project, drawing on all previously involved staff's expertise and contacts through an initial project meeting organised by an independent group chair. Each project group runs independently, with further help available from the group chairs. Results: Under the PIG structure, seven projects have been undertaken in less than one year. Two papers were published, one under review, two in preparation, one abstract accepted at an international conference, and fifteen funded undergraduate research projects completed. Part-time teaching staff are more involved in the research. Internally, three departments and externally, three other UK universities have been collaboratively involved in research projects. Conclusion: The PIG structure works and depends on staff's continued engagement and at least two independent chairs for impartiality and transparency.

Evaluation of students' performance and engagement using post-laboratory integrated assessments within a pharmacy course in the United Kingdom: a pilot cohort cross-over study

INTRODUCTION

This pilot study investigated the impact of practice integrated, post-laboratory assessment on the scientific education and attitudes of first-year pharmacy students. Median assessment performance, achievement of full marks, and engagement in laboratory classes were evaluated.

METHODS

The pilot randomised cross-over study was conducted at the University of Central Lancashire. Students were randomly assigned to two groups, and after undertaking four identical pharmaceutics laboratory classes, answered two science-based questions that were either integrated with practice using a contextualizing scenario or had no integration. Student performance and engagement were subsequently analysed.

RESULTS

Thirty students completed the study. Students performed better in the integrated assessment (median 3.5; interquartile range [IQR] 2.00-4.00) compared to the non-integrated assessment (median 2; IQR 1.75-3.00) (P < .001). Twenty-five students (83%) achieved full marks with the integrated assessment (P = .006). Correlation (R²) for the integrated assessment was 0.90 and for the non-integrated assessment was 0.12. Engagement was positive in both groups but significantly improved in the domains of "instructor contribution" and "value of activity" (P = .01) when receiving the integrated assessment.

CONCLUSIONS

Integrated and contextualized assessment of science teaching as a lone intervention increased pharmacy students' performance and engagement in laboratory classes without requiring any change to the teaching session itself.

Patient as teacher sessions contextualize learning, enhancing knowledge, communication, and participation of pharmacy students in the United Kingdom

PURPOSE

This study aimed to evaluate the impact of Patient As Teacher (PAT) sessions on the knowledge, communication skills, and participation of pharmacy students in the United Kingdom.

METHODS

During the academic year 2019-2020, year 1 and 2 pharmacy students at the University of Central Lancashire were invited to complete a questionnaire following PAT sessions. Data were analyzed by means of descriptive statistics, including mean and standard deviation (SD) for: continuous variables and reliability analysis. Pearson's Chi-Square or Fisher Exact Test, odds ratio, and Phi were used for analyzing dichotomous variables. Thematic analysis was used for free text comments.

RESULTS

Sixty eight of 228 students participated, (response rate of 29.8%). No statistical difference was found between gender (p=0.090); a statistically significant difference was found between year (p=0.008). Cronbach's alpha (0.809) confirmed a good internal consistency. 97.0% of the students learned a lot, and 85.3% appreciated and valued the PAT sessions; 89.7% wanted more sessions. 92.7% perceived the sessions to contextualize their learning. Five questions were dichotomized by grouping the responses into negative and positive; 90.3% of responses were positive and did not show statistically significant differences in gender and year of study. Overall students' free text comments were positive, but active listening and consultation appeared in the positive and negative domains, highlighting the need for more student engagement.

CONCLUSIONS

PAT sessions had a positive impact on students' knowledge, communication skills, and participation, and contextualized learning. They provide a valuable contribution to the pharmcy students' experience in the United Kingdom.

A conceptual model for students' satisfaction with team-based learning using partial least squares structural equation modelling in a faculty of life sciences, in the United Kingdom

PURPOSE

Students' satisfaction is an essential element in higher education. This study aimed to identify paths and predictive power of students' satisfaction during team-based learning (TBL) activities in the faculty of life sciences using partial least squares structural equation modelling (PLS-SEM).

METHODS

In 2018-2019, at the University of Sussex (Falmer, UK), 180 life science students exposed to TBL were invited to participate in the study. Team-Based-Learning-Student-Assessment-Instrument was used. A conceptual model was developed for testing six hypotheses. H1: What was the effect of TBL on student satisfaction? H2: What was the effect of lectures on student satisfaction? H3: What was the effect of TBL on accountability? H4: What was the effect of lectures on accountability? H5: What was the effect of accountability on student satisfaction? H6: What were the in-sample and out-of-sample predictive power of the model? The analysis was conducted using the PLS-SEM approach.

RESULTS

Ninety-nine students participated in the study giving a 55% response rate. Confirmatory tetrad analysis suggested a reflective model. Construct reliability, validity, average extracted variance, and discriminant validity were confirmed. All path coefficients were positive, and 5 were statistically significant (H1: β=0.587, P<0:001; H2: β=0.262, P<0.001; H3: β=0.532, P<0.001; H4: β=0.063, P=0.546; H5: β=0.200, P=0.002). The in-sample predictive power was weak for Accountability, (R2=0.303; 95% confidence interval [CI], 0.117-0.428; P<0.001) and substantial for Student Satisfaction (R2=0.678; 95% CI, 0.498-0.777; P<0.001). The out-of-sample predictive power was moderate.

CONCLUSION

The results have demonstrated the possibility of developing and testing a TBL conceptual model using PLS-SEM for the evaluation of path coefficients and predictive power relative to students' satisfaction.

Perception of team-based learning using the team-based learning student assessment instrument: an exploratory analysis within pharmacy and biomedical students in the United Kingdom

PURPOSE

This study aimed to evaluate students' perception of team-based learning (TBL) amongst a cohort who was exposed to this methodology for the first time at an university in the United Kingdom .

METHODS

Between November and December 2018, 26 first year Master of Pharmacy and 90 second year B.Sc. Biomedical Science students of School of Life Sciences, University of Sussex, United Kingdom were invited to participate and requested to complete a questionnaire that contained quantitative and qualitative questions. The quantitative component was based on the team-based-learning student assessment instrument (TBL-SAI) instrument. It additionally contained questions about key student characteristics.

RESULTS

The response rate was 60% (70/116), 74% (n=52) were females and 26% (n=18) males. The percentage of agreement in the TBL-SAI suggested a favourable response to TBL. The overall mean score for the TBL-SAI was 115.6 (SD 5.6) [maximum score: 140] which was above the threshold of 102, thus suggesting a preference for TBL. Statistically significant differences were not found according to demographics characteristics. Students who predicted a final result of ≥70% strongly agreed that TBL help improve their grades. Some students highlighted issues with working in teams and only 56% of students agreed that they could learn better in a team setting.

CONCLUSION

This study shows that students exposed to TBL for the first-time favour several aspects of it. However, more focused strategies including team-building exercises activities and expert facilitation skills could potentially tackle resistance to working in teams.

A single blind, multicenter, randomized controlled trial to evaluate the effectiveness and cost of a novel nutraceutical (LopiGLIK®) lowering cardiovascular disease risk

Context

Cardiovascular disease (CVD) costs the economy €210 billion per year in Europe. There is an association between low-density lipoprotein cholesterol (LDL-C) and CVD risk.

Objective

To evaluate the cost and effectiveness of LopiGLIK^® (LOPI) in lowering LDL-C and CVD risk.

Design

Single blind multicenter randomized controlled trial; patients were divided into two groups, subjected to centralized randomization.

Setting

Four Italian regions.

Participants

Thirty-one physicians enrolled 573 adult patients with mild hypercholesterolemia between January 2016 and January 2018.

Intervention

Patients were treated for 16 weeks either with LOPI (intervention) or Armolipid Plus^® (AP; control).

Outcome measures

Primary outcome: percentage of patients who achieved LDL-C <130 mg/dL. Secondary outcomes: reduction of HbA1c, survival analysis and HR linked to 38.67 mg/dL reduction of LDL-C and 1% reduction of HbA1c. Costs were assessed per unit and cure.

Results

Three hundred and seventy patients treated with LOPI and 203 treated with AP were randomized and completed the study. At baseline 8.9% (n=18) patients treated with AP and 9.5% (n=35) treated with LOPI had LDL-C levels <130 mg/dL (P=0.815). At the 16-week follow-up, 41.4% (n=84) of patients treated with AP and 67.6% (n=250) with LOPI achieved LDL-C levels <130 mg/dL (P<0.001). LOPI patients were three times more likely to achieve LDL-C levels <130 mg/dL; adjusted OR 2.97 (95% CI; 2.08-4.24; P<0.001), number needed to treat was four (95% CI; 5.60-2.90; P<0.001). Survival analysis demonstrated the superiority of LOPI vs AP relative to 38.67 mg/dL LDL-C reduction (P<0.002); HR was 0.761 (95% CI; 0.62-0.94; P<0.001). Both products reduced the HbA1c without a significant difference between them (P=0.156). Survival analysis and HR (0.91; 95% CI; 0.70-1.18) estimated for 1% HbA1c reduction, showed differences between LOPI and AP, which were not significant (P=0.411; P=0.464). The cost of LOPI was €2.11 (unit), €211 (cure), and AP €3.77 and €377, respectively.

Conclusion

LOPI appeared more effective and less expensive than AP in lowering LDL-C and CVD risk.

Trial registration

NCT02898805, September 8, 2016.

Novel pharmacist-led intervention secures the minimally important difference (MID) in Asthma Control Test (ACT) score: better outcomes for patients and the healthcare provider

Introduction

A key priority in asthma management is achieving control. The Asthma Control Test (ACT) is a validated tool showing a numerical indicator which has the potential to provide a target to drive management. A novel pharmacist-led intervention recently evaluated and introduced in the Italian setting with a cluster randomised controlled trial (C-RCT) showed effectiveness and cost-effectiveness. This paper evaluates whether the intervention is successful in securing the minimally important difference (MID) in the ACT score and provides better health outcomes and economic savings.

Methods

Clinical data were sourced from 816 adult patients with asthma participating in the C-RCT. The success of the intervention was measured looking at the proportion of patients reaching MID in the ACT score. Different levels of asthma control were grouped according to international guidelines and graded using the traffic light rating system. Asthma control levels were linked to economic (National Health Service (NHS) costs) and quality-adjusted life years outcomes using published data.

Results

The median ACT score was 19 (partially controlled) at baseline, and 20 and 21 (controlled) at 3-month and 6-month-follow up, respectively (p<0.01). The percentage of patients reaching MID at 3 and 6 months was 15.8% (129) and 19.9% (162), respectively. The overall annual NHS cost savings per 1000 patients attached to the shift towards the MID target were equal to €346 012 at 3 months and increased to €425 483 at 6 months. Health utility gains were equal to 35.42 and 45.12 years in full health gained, respectively.

Discussion

The pharmacist-led intervention secured the MID in the ACT score and provided better outcomes for both patients and providers.

Transcriptional addiction in cancer cells is mediated by YAP/TAZ through BRD4

Cancer cells rely on dysregulated gene expression. This establishes specific transcriptional addictions that may be therapeutically exploited. Yet, the mechanisms that are ultimately responsible for these addictions are poorly understood. Here, we investigated the transcriptional dependencies of transformed cells to the transcription factors YAP and TAZ. YAP/TAZ physically engage the general coactivator bromodomain-containing protein 4 (BRD4), dictating the genome-wide association of BRD4 to chromatin. YAP/TAZ flag a large set of enhancers with super-enhancer-like functional properties. YAP/TAZ-bound enhancers mediate the recruitment of BRD4 and RNA polymerase II at YAP/TAZ-regulated promoters, boosting the expression of a host of growth-regulating genes. Treatment with small-molecule inhibitors of BRD4 blunts YAP/TAZ pro-tumorigenic activity in several cell or tissue contexts, causes the regression of pre-established, YAP/TAZ-addicted neoplastic lesions and reverts drug resistance. This work sheds light on essential mediators, mechanisms and genome-wide regulatory elements that are responsible for transcriptional addiction in cancer and lays the groundwork for a rational use of BET inhibitors according to YAP/TAZ biology.

Virulence-associated factors in Vibrio cholerae non-O1/non-O139 and V. mimicus strains isolated in ornamental fish species

During recent decades, ornamental fish have proven to be one of the fastest growing categories of pets in Europe. In this framework, we evaluated both the potential pathogenic and zoonotic risks caused by 53 Vibrio cholerae non-O1/non-O139 and a Vibrio mimicus strain isolated from ornamental fish species mostly originating from South-East Asia countries between 2000 and 2015 in Italy. All the strains were firstly identified at species level by biochemical, phylogenetic and mass spectrometry (matrix-assisted laser desorption ionization time of flight) methods, and then studied to reveal the presence of the main virulence and colonization-associated factors, as ctxA, ace, zot, stn/sto, toxR, rtxA, hlyA and tcpA by multiplex and single endpoint PCR assays. Findings showed that 21 of 54 strains harboured at least one virulence factor with a predominance for the toxR⁺ , rtxA⁺ and hlyAET⁺ genotype. Interestingly, the V. mimicus strain harboured the colonization factor and the CTX prophage receptor, tcpA, indicating the ability to capture and integrate it in its genome increasing its pathogenicity. Although these enterotoxins can sporadically cause gastroenteritis, the results highlight their probable involvement in causing severe implications for public health, suggesting the need for an European microbiological monitoring.

A cluster randomised control trial to evaluate the effectiveness and cost-effectiveness of the Italian medicines use review (I-MUR) for asthma patients

Background

The economic burden of asthma, which relates to the degree of control, is €5 billion annually in Italy. Pharmacists could help improve asthma control, reducing this burden. This study aimed to evaluate the effectiveness and cost-effectiveness of Medicines Use Reviews provided by community pharmacists in asthma.

Methods

This cluster randomised, multi-centre, controlled trial in adult patients with asthma was conducted in 15 of the 20 regions of Italy between September 2014 and July 2015. After stratification by region, community pharmacists were randomly allocated to group A (trained in and delivered the intervention at baseline) or B (training and delivery 3 months later), using computerised random number generation in blocks of 10. Each recruited up to five patients, with both groups followed for 9 months.

The intervention consisted of a systematic, structured face-to-face consultation with a pharmacist, covering asthma symptoms, medicines used, attitude towards medicines and adherence, recording pharmacist-identified pharmaceutical care issues (PCIs). The primary outcome was asthma control, assessed using the Asthma-Control-Test (ACT) score (ACT ≥ 20 represents good control). Secondary outcomes were: number of active ingredients, adherence, cost-effectiveness compared with usual care. Although blinding was not possible for either pharmacists or patients, assessment of outcomes was conducted by researchers blind to group allocation.

Results

Numbers of pharmacists and patients enrolled were 283 (A = 136; B = 147) and 1263 (A = 600; B = 663), numbers completing were 201 (A = 97; B = 104) and 816 (A = 400; B = 416), respectively. Patients were similar in age and gender and 56.13% (458/816) had poor/partial asthma control. Pharmacists identified 1256 PCIs (mean 1.54/patient), mostly need for education, monitoring and potentially ineffective therapy. Median ACT score at baseline differed between groups (A = 19, B = 18; p < 0.01). Odds ratio for improved asthma control was 1.76 (95% CI 1.33–2.33) and number needed to treat 10 (95% CI 6–28). Number of active ingredients reduced by 7.9% post-intervention (p < 0.01). Adherence improved by 35.4% 3 months post-intervention and 40.0% at 6 months (p < 0.01). The probability of the intervention being more cost-effective than usual care was 100% at 9 months.

Conclusions

This community pharmacist-based intervention demonstrated both effectiveness and cost-effectiveness. It has since been implemented as the first community pharmacy cognitive service in Italy.

Trial registration

TRN: ISRCTN72438848 (registered 5^th January 2015, retrospectively).

Designer matrices for intestinal stem cell and organoid culture

Epithelial organoids recapitulate multiple aspects of real organs, making them promising models of organ development, function and disease. However, the full potential of organoids in research and therapy has remained unrealized, owing to the poorly defined animal-derived matrices in which they are grown. Here we used modular synthetic hydrogel networks to define the key extracellular matrix (ECM) parameters that govern intestinal stem cell (ISC) expansion and organoid formation, and show that separate stages of the process require different mechanical environments and ECM components. In particular, fibronectin-based adhesion was sufficient for ISC survival and proliferation. High matrix stiffness significantly enhanced ISC expansion through a yes-associated protein 1 (YAP)-dependent mechanism. ISC differentiation and organoid formation, on the other hand, required a soft matrix and laminin-based adhesion. We used these insights to build a fully defined culture system for the expansion of mouse and human ISCs. We also produced mechanically dynamic matrices that were initially optimal for ISC expansion and subsequently permissive to differentiation and intestinal organoid formation, thus creating well-defined alternatives to animal-derived matrices for the culture of mouse and human stem-cell-derived organoids. Our approach overcomes multiple limitations of current organoid cultures and greatly expands their applicability in basic and clinical research. The principles presented here can be extended to identify designer matrices that are optimal for long-term culture of other types of stem cells and organoids.

Randomised evaluation of the Italian medicines use review provided by community pharmacists using asthma as a model (RE I-MUR)

Background

The Italian Ministry of Health decided to introduce community professional services in 2010. This trial provides an opportunity to evaluate the outcomes of a new professional pharmacy service: Italian Medicines Use Review (I-MUR) aimed at reducing the severity of asthma and its associated costs.

Methods/Design

This is a cluster randomised controlled trial of the I-MUR service. Data will be collected over time before, during and after pharmacists’ intervention. Fifteen Italian regions will be involved and it is aimed to recruit 360 community pharmacists and 1800 patients. Each pharmacist will receive training in medicines use review, recruit five patients, administer the Asthma Control Test and provide the I-MUR service. Pharmacists will be allocated to different groups, one group will be trained in and provide the I-MUR service immediately after completion of the baseline ACT score, the other group will receive training in the I-MUR and provide this service three months later. Group allocation will be random, after stratification by region of Italy. The I-MUR service will involve gathering data following each patient consultation including demographic details, patients regular medications, including those used for asthma, their attitude towards their medications and self-reported adherence to treatments. In addition, pharmacists will identify and record pharmaceutical care issues and any advice given to patients during the I-MUR, or recommendations given to doctors. Pharmacists will upload trial data onto a web platform for analysis. The primary outcome measure is the severity of asthma before, during and after the I-MUR assessed using the Asthma Control Test score. Secondary measures: number of all active ingredients used by patients during and after the I-MUR, number of pharmaceutical care issues identified during the I-MUR, patients’ self-reported adherence to asthma medication during and after the I-MUR, healthcare costs based on the severity of asthma, before, during and after the I-MUR service provision.

Discussion

This study has been developed because of the need for a new way of working for pharmacists and pharmacies; it is the first trial of any community pharmacy-based pharmaceutical care intervention in Italy. The results will inform future policy and practice in Italian community pharmacy.

Trial registration number

ISRCTN72438848.

High incidence of antibiotic multi-resistant bacteria in coastal areas dedicated to fish farming

Marine bacteria exposed to antibiotics in fish farms can acquire antimicrobial resistance by mobile genetic elements and horizontal gene transfer. A total of 872 autochthonous marine bacterial strains was isolated from samples collected from four different fish farms located at northern and southern Italian Adriatic Sea. Resistance to only tetracycline (17%) and to trimethoprim-sulfadiazine (7%) were the most frequent patterns obtained, while flumequine resistance has recorded in only 0.3% of the strains. Comparing strains isolated from coastal areas and fish farms, a significant higher incidence (4% versus 10%) of multi-resistant strains in aquaculture centers was found. Significant differences in antibiotic resistance incidence were also detected among the four fish farms due probably to different approaches in farm management and the more or less frequent use of antibiotics. Antibiotic-resistant and multi-resistant strains isolated constitute an environmental reservoir directly involved in the seafood chain and might represent a public health concern.

Signaling crosstalk between TGFβ and Dishevelled/Par1b

Crosstalk of signaling pathways is critical during metazoan development and adult tissue homeostasis. Even though the transforming growth factor-beta (TGFβ) transduction cascade is rather simple, in vivo responsiveness to TGFβ ligands is tightly regulated at several steps. As such, TGFβ represents a paradigm for how the activity of one signaling system is modulated by others. Here, we report an unsuspected regulatory step involving Dishevelled (Dvl) and Par1b (also known as MARK2). Dvl and Par1b cooperate to enable TGFβ/bone morphogenetic protein (BMP) signaling in Xenopus mesoderm development and TGFβ responsiveness in mammalian cells. Mechanistically, the assembly of the Par1b/Dvl3/Smad4 complex is fostered by Wnt5a. The association of Smad4 to Dvl/Par1 prevents its inhibitory ubiquitination by ectodermin (also known as transcriptional intermediary factor 1 gamma or tripartite motif protein 33). We propose that this crosstalk is relevant to coordinate TGFβ responses with Wnt-noncanonical and polarity pathways.

USP15 is a deubiquitylating enzyme for receptor-activated SMADs

The TGFβ pathway is critical for embryonic development and adult tissue homeostasis. On ligand stimulation, TGFβ and BMP receptors phosphorylate receptor-activated SMADs (R-SMADs), which then associate with SMAD4 to form a transcriptional complex that regulates gene expression through specific DNA recognition. Several ubiquitin ligases serve as inhibitors of R-SMADs, yet no deubiquitylating enzyme (DUB) for these molecules has so far been identified. This has left unexplored the possibility that ubiquitylation of R-SMADs is reversible and engaged in regulating SMAD function, in addition to degradation. Here we identify USP15 as a DUB for R-SMADs. USP15 is required for TGFβ and BMP responses in mammalian cells and Xenopus embryos. At the biochemical level, USP15 primarily opposes R-SMAD monoubiquitylation, which targets the DNA-binding domains of R-SMADs and prevents promoter recognition. As such, USP15 is critical for the occupancy of endogenous target promoters by the SMAD complex. These data identify an additional layer of control by which the ubiquitin system regulates TGFβ biology.

A MicroRNA targeting dicer for metastasis control

Although specific microRNAs (miRNAs) can be upregulated in cancer, global miRNA downregulation is a common trait of human malignancies. The mechanisms of this phenomenon and the advantages it affords remain poorly understood. Here we identify a microRNA family, miR-103/107, that attenuates miRNA biosynthesis by targeting Dicer, a key component of the miRNA processing machinery. In human breast cancer, high levels of miR-103/107 are associated with metastasis and poor outcome. Functionally, miR-103/107 confer migratory capacities in vitro and empower metastatic dissemination of otherwise nonaggressive cells in vivo. Inhibition of miR-103/107 opposes migration and metastasis of malignant cells. At the cellular level, a key event fostered by miR-103/107 is induction of epithelial-to-mesenchymal transition (EMT), attained by downregulating miR-200 levels. These findings suggest a new pathway by which Dicer inhibition drifts epithelial cancer toward a less-differentiated, mesenchymal fate to foster metastasis.

Direct identification of Photobacterium damselae subspecies piscicida by PCR-RFLP analysis

Fish pasteurellosis is an infectious disease that affects several teleost species living in temperate marine waters. The pathogen responsible, Photobacterium damselae subspecies piscicida, shows high genetic similarity with P. damselae subsp. damselae, making subspecies discrimination extremely laborious. Here we report for the first time a PCR-RFLP method for the identification of P. damselae subsp. piscicida without prior isolation in pure culture. Genomic sequence information was obtained through cloning and sequencing of RAPD products. Two P. damselae-specific primer pairs were developed and tested on 17 strains of P. damselae subsp. piscicida, 10 strains of P. damselae subsp. damselae, and 6 closely related control species. High sensitivity was achieved in PCR amplification on serially diluted samples (<180 fg of pure bacterial DNA or <10 fg, depending on the amplified fragment). Restriction analysis of PCR products showed a unique digestion profile for all P. damselae subsp. piscicida strains. The same PCR-RFLP method was implemented on total DNA samples extracted from experimentally infected sea bream and sea bass. Positive results were obtained on fish with clear signs of the disease as well as on challenged, but asymptomatic, fish. The method presented here might provide a useful tool for both prevention and rapid diagnosis of fish pasteurellosis.

Detection and characterization of vancomycin-resistant enterococci in farm animals and raw meat products in Italy

The emergence of vancomycin-resistant enterococci (VRE) in Europe has been ascribed to the long-time use of the glycopeptide antibiotic avoparcin as feed additive in food animals, until its ban in 1997 in EU. The pres- ence of VRE in food of animal origin is believed to represent a potential risk for the consumer. We studied the fecal carriage of VRE in broiler chickens and slaughter pigs in Italy before the avoparcin ban and eval- uated the impact of avoparcin withdrawal on the presence of VRE in raw meat products. Broilers and pigs were both found to be frequently colonized by VRE, as 36% and 24.6% of the flocks or the herds, respec- tively, were positive. Molecular typing of VRE strains by PFGE showed that animals housed in different pens within the same farm were colonized by clonally related strains. After the avoparcin ban, a decrease in the rate of VRE contamination in meat products was observed. Such a decrease was statistically significant in poultry (from 18.8% to 9.6%) but not in pork products (from 9.7% to 6.9%). The majority of VRE from all sources carried the vanA resistance gene and included Enterococcus faecium, E. faecalis, E. hirae, E. durans, and E. gallinarum. None of the strains carried the vanB gene, whereas constitutively resistant vanC-positive strains were frequently found. Our results show that avoparcin withdrawal has been successful in reducing VRE contamination in meat products. However, this measure needs to be complemented by a prudent use of glycopeptide antibiotics in human medicine.

Sodium serum levels in hypoalbuminemic adults at general medical wards

Hypoalbuminemia may cause interstitial edema and hemodilution, which we hypothesized may influence serum sodium levels. Our purpose was to compare serum sodium levels of hospitalized adults with or without hypoalbuminemia. All sodium and albumin serum levels of 142 adults hospitalized at general medical wards over a six-month period were searched at a University Hospital mainframe computer. Relevant laboratory data and clinical details were also registered. Hypoalbuminemia was defined by serum albumin concentration < 3.3 g/dl Fisher, Mann-Whitney, and Student's t tests were applied to compare groups with or without hypoalbuminemia. Ninety-nine patients, classified as hypoalbuminemic, had lower blood hemoglobin (10.68 +/- 2.62 vs. 13.54 +/- 2.41), and sodium (135.1 +/- 6.44 vs. 139.9 +/- 4.76 mEq/l) and albumin (2.74 +/- 0.35 vs. 3.58 +/- 0.28 g/dl) serum levels than non-hypoalbuminemic (n = 43). Pearson's coefficient showed a significant direct correlation between albumin and sodium serum levels (r = 0.40) and between serum albumin and blood hemoglobin concentration (r = 0.46). Our results suggest that hypoalbuminemic adults have lower serum sodium levels than those without hypoalbuminemia, a phenomenon that may be at least partially attributed to body water retention associated with acute phase response syndrome.