End User Participation in the Development of an Ecological Momentary Intervention to Improve Coping With Cannabis Cravings: Formative Study

BACKGROUND

Cannabis misuse in young adults is a major public health concern. An important predictor of continued use is cannabis craving. Due to the time-varying nature of cravings, brief momentary interventions delivered while cravings are elevated may improve the use of strategies to cope with cravings and reduce cannabis use.

OBJECTIVE

The goal of this manuscript is to describe a formative study to develop coping strategy messages for use in a subsequent intervention.

METHODS

Young adults (aged 19-25 years; n=20) who reported using cannabis >10 of the past 30 days recruited via social media participated in this formative study. Participants rated an initial set of 15 mindfulness and 15 distraction coping strategies on a scale from 1 to 4 (very low degree to very high degree) for clarity, usefulness, and tone. They also provided comments about the content.

RESULTS

Participants found the initial distraction messages slightly clearer than mindfulness (mean 3.5, SD 0.4 and mean 3.4, SD 0.4, respectively), both were comparable in tone (mean 3.2, SD 0.5 and mean 3.2, SD 0.4, respectively), and mindfulness messages were more useful than distraction (mean 3.0, SD 0.5 and mean 2.8, SD 0.6, respectively). Of the 30 messages, 29 received a rating of very low or low (<2) on any domain by >3 participants or received a comment suggesting a change. We revised all these messages based on this feedback, and the participants rated the revised messages approximately 2 weeks later. Participants earned US $10 for completing the first and US $20 for the second survey. The ratings improved on usefulness (especially the distraction items) with very little change in clarity and tone. The top 10 messages of each coping type (mindfulness and distraction) were identified by overall average rating (collapsed across all 3 dimensions: all rated >3.0). The final items were comparable in clarity (distraction mean 3.6, SD 0.4; mindfulness mean 3.6, SD 0.4), tone (distraction mean 3.4, SD 0.4; mindfulness mean 3.4, SD 0.4), and usefulness (distraction mean 3.1, SD 0.5; mindfulness mean 3.2, SD 0.5).

CONCLUSIONS

The inclusion of end users in the formative process of developing these messages was valuable and resulted in improvements to the content of the messages. The majority of the messages were changed in some way including the removal of potentially triggering language. These messages were subsequently used in an ecological momentary intervention.

The inner membrane protein YhiM is necessary for Escherichia coli growth at high temperatures and low osmolarity

To survive, Escherichia coli must be able to survive in rapidly changing environmental conditions including changes in temperature and osmolarity. We have studied the role of the inner membrane protein YhiM in changing environmental conditions. Our data indicate that YhiM is required for normal growth at 37 and 41 °C but not 21 °C. YhiM-deficient cells grown at high temperatures spend more time in lag phase and stop growing at lower cell densities in comparison with their wild-type counterparts. They also have growth defects in low NaCl medium at 37 °C and do not grow at all at 41 °C. The effects of low NaCl can be rescued by addition of KCl or sucrose to the low salt medium. Finally, YhiM-deficient cells fail to grow in dilute medium at 41 °C. These data suggest that YhiM may be important in protecting the cells from changes in temperature and osmolarity.

Women With Gestational Diabetes Mellitus Randomized to a Higher-Complex Carbohydrate/Low-Fat Diet Manifest Lower Adipose Tissue Insulin Resistance, Inflammation, Glucose, and Free Fatty Acids: A Pilot Study

OBJECTIVE

Diet therapy in gestational diabetes mellitus (GDM) has focused on carbohydrate restriction but is poorly substantiated. In this pilot randomized clinical trial, we challenged the conventional low-carbohydrate/higher-fat (LC/CONV) diet, hypothesizing that a higher-complex carbohydrate/lower-fat (CHOICE) diet would improve maternal insulin resistance (IR), adipose tissue (AT) lipolysis, and infant adiposity.

RESEARCH DESIGN AND METHODS

At 31 weeks, 12 diet-controlled overweight/obese women with GDM were randomized to an isocaloric LC/CONV (40% carbohydrate/45% fat/15% protein; n = 6) or CHOICE (60%/25%/15%; n = 6) diet. All meals were provided. AT was biopsied at 37 weeks.

RESULTS

After ∼7 weeks, fasting glucose (P = 0.03) and free fatty acids (P = 0.06) decreased on CHOICE, whereas fasting glucose increased on LC/CONV (P = 0.03). Insulin suppression of AT lipolysis was improved on CHOICE versus LC/CONV (56 vs. 31%, P = 0.005), consistent with improved IR. AT expression of multiple proinflammatory genes was lower on CHOICE (P < 0.01). Infant adiposity trended lower with CHOICE (10.1 ± 1.4 vs. 12.6 ± 2%, respectively).

CONCLUSIONS

A CHOICE diet may improve maternal IR and infant adiposity, challenging recommendations for a LC/CONV diet.

When do we transfuse cryoprecipitate?

BACKGROUND

The 2001 National Health and Medical Research Council/Australasian Society of Blood Transfusion Clinical Practice Guidelines for cryoprecipitate are being updated, and cryoprecipitate has been incorporated into new Patient Blood Management modules.

AIMS

This clinical audit sought to clarify current cryoprecipitate use in Victoria, Tasmania and the Australian Capital Territory; assess adherence to guidelines; and gain insights into deviations from recommended practice. This information can be utilised in updating guidelines to make them more relevant, to identify areas for clinician education and to form a baseline of practice prior to release of the 2011 guidelines.

METHODS

Participating institutions were invited to audit up to 30 consecutive episodes of cryoprecipitate transfusion over an 11-month period in 2008. The audits were conducted using a standardised pro forma and involved review of patient records. These were collated electronically using algorithms to determine alignment versus non-alignment with guidelines.

RESULTS

Cryoprecipitate is used in a variety of situations with surgery accounting for the highest volume. Twenty-six per cent (26%) of transfusions were aligned with 2001 guidelines rising to 61% with a modified fibrinogen trigger. Fibrinogen levels did not appear to dictate all clinical decisions regarding cryoprecipitate use perhaps owing to the acuity of many cases. Additional bleeding risk together with low fibrinogen levels (e.g. thrombocytopenic patients) may contribute to empiric cryoprecipitate use.

CONCLUSIONS

These results highlight discrepancies between guidelines and practice, providing rationale for the update of the guidelines that is currently underway. Cryoprecipitate has attendant risks, and it is appropriate that transfusion be restricted to situations with good evidence or sound principles to underpin use.

A higher-complex carbohydrate diet in gestational diabetes mellitus achieves glucose targets and lowers postprandial lipids: a randomized crossover study

OBJECTIVE

The conventional diet approach to gestational diabetes mellitus (GDM) advocates carbohydrate restriction, resulting in higher fat (HF), also a substrate for fetal fat accretion and associated with maternal insulin resistance. Consequently, there is no consensus about the ideal GDM diet. We hypothesized that, compared with a conventional, lower-carbohydrate/HF diet (40% carbohydrate/45% fat/15% protein), consumption of a higher-complex carbohydrate (HCC)/lower-fat (LF) Choosing Healthy Options in Carbohydrate Energy (CHOICE) diet (60/25/15%) would result in 24-h glucose area under the curve (AUC) profiles within therapeutic targets and lower postprandial lipids.

RESEARCH DESIGN AND METHODS

Using a randomized, crossover design, we provided 16 GDM women (BMI 34 ± 1 kg/m2) with two 3-day isocaloric diets at 31 ± 0.5 weeks (washout between diets) and performed continuous glucose monitoring. On day 4 of each diet, we determined postprandial (5 h) glucose, insulin, triglycerides (TGs), and free fatty acids (FFAs) following a controlled breakfast meal.

RESULTS

There were no between-diet differences for fasting or mean nocturnal glucose, but 24-h AUC was slightly higher (∼6%) on the HCC/LF CHOICE diet (P = 0.02). The continuous glucose monitoring system (CGMS) revealed modestly higher 1- and 2-h postprandial glucose on CHOICE (1 h, 115 ± 2 vs. 107 ± 3 mg/dL, P ≤ 0.01; 2 h, 106 ± 3 vs. 97 ± 3 mg/dL, P = 0.001) but well below current targets. After breakfast, 5-h glucose and insulin AUCs were slightly higher (P < 0.05), TG AUC was no different, but the FFA AUC was significantly lower (∼19%; P ≤ 0.01) on the CHOICE diet.

CONCLUSIONS

This highly controlled study randomizing isocaloric diets and using a CGMS is the first to show that liberalizing complex carbohydrates and reducing fat still achieved glycemia below current treatment targets and lower postprandial FFAs. This diet strategy may have important implications for preventing macrosomia.

The impact of ingested potato type II inhibitors on the production of the major serine proteases in the gut of Helicoverpa armigera

The flowers of the ornamental tobacco produce high levels of a series of 6 kDa serine protease inhibitors (NaPIs) that are effective inhibitors of trypsins and chymotrypsins from lepidopteran species. These inhibitors have a negative impact on the growth and development of lepidopteran larvae and have a potential role in plant protection. Here we investigate the effect of NaPIs on the activity and levels of serine proteases in the gut of Helicoverpa armigera larvae and explore the adaptive mechanisms larvae employ to overcome the negative effects of NaPIs in the diet. Polyclonal antibodies were raised against a Helicoverpa punctigera trypsin that is a target for NaPIs and two H. punctigera chymotrypsins; one that is resistant and one that is susceptible to inhibition by NaPIs. The antibodies were used to optimize procedures for extraction of proteases for immunoblot analysis and to assess the effect of NaPIs on the relative levels of the proteases in the gut and frass. We discovered that consumption of NaPIs did not lead to over-production of trypsins or chymotrypsins but did result in excessive loss of proteases to the frass.

Persistent complement-dependent anti-AnWj in a lymphoproliferative disorder: a case study and review

AnWj is a high-incidence antigen present on the red blood cells (RBCs) of greater than 99 percent of the general population. A 58-year-old man underwent autologous hematopoietic stem cell transplantation (HSCT) for stage IVa mantle cell lymphoma. This procedure was complicated by failure to engraft, necessitating ongoing support with blood components. After a 2-month period of uneventful transfusion support, the patient experienced increasingly severe reactions with fever and evidence of intravascular hemolysis, including hemoglobinuria. Testing revealed a complement-dependent anti-AnWj. Phenotyping confirmed the AnWj- phenotype. Anti-AnWj was persistent despite immunosuppression, including treatment with allogeneic HSCT. Of interest, the pathogenesis of the downregulation of the graft AnWj in this patient is unclear.

Seawater Mg/Ca controls polymorph mineralogy of microbial CaCO3: a potential proxy for calcite-aragonite seas in Precambrian time

A previously published hydrothermal brine-river water mixing model driven by ocean crust production suggests that the molar Mg/Ca ratio of seawater (mMg/Ca(sw)) has varied significantly (approximately 1.0-5.2) over Precambrian time, resulting in six intervals of aragonite-favouring seas (mMg/Ca(sw) > 2) and five intervals of calcite-favouring seas (mMg/Ca(sw) < 2) since the Late Archaean. To evaluate the viability of microbial carbonates as mineralogical proxy for Precambrian calcite-aragonite seas, calcifying microbial marine biofilms were cultured in experimental seawaters formulated over the range of Mg/Ca ratios believed to have characterized Precambrian seawater. Biofilms cultured in experimental aragonite seawater (mMg/Ca(sw) = 5.2) precipitated primarily aragonite with lesser amounts of high-Mg calcite (mMg/Ca(calcite) = 0.16), while biofilms cultured in experimental calcite seawater (mMg/Ca(sw) = 1.5) precipitated exclusively lower magnesian calcite (mMg/Ca(calcite) = 0.06). Furthermore, Mg/Ca(calcite )varied proportionally with Mg/Ca(sw). This nearly abiotic mineralogical response of the biofilm CaCO3 to altered Mg/Ca(sw) is consistent with the assertion that biofilm calcification proceeds more through the elevation of , via metabolic removal of CO2 and/or H+, than through the elevation of Ca2+, which would alter the Mg/Ca ratio of the biofilm's calcifying fluid causing its pattern of CaCO3 polymorph precipitation (aragonite vs. calcite; Mg-incorporation in calcite) to deviate from that of abiotic calcification. If previous assertions are correct that the physicochemical properties of Precambrian seawater were such that Mg/Ca(sw) was the primary variable influencing CaCO3 polymorph mineralogy, then the observed response of the biofilms' CaCO3 polymorph mineralogy to variations in Mg/Ca(sw), combined with the ubiquity of such microbial carbonates in Precambrian strata, suggests that the original polymorph mineralogy and Mg/Ca(calcite )of well-preserved microbial carbonates may be an archive of calcite-aragonite seas throughout Precambrian time. These results invite a systematic evaluation of microbial carbonate primary mineralogy to empirically constrain Precambrian seawater Mg/Ca.

Risk of malignancy in resected cystic tumors of the pancreas < or =3 cm in size: is it safe to observe asymptomatic patients? A multi-institutional report

Recent international consensus guidelines propose that cystic pancreatic tumors less than 3 cm in size in asymptomatic patients with no radiographic features concerning for malignancy are safe to observe; however, there is little published data to support this recommendation. The purpose of this study was to determine the prevalence of malignancy in this group of patients using pancreatic resection databases from five high-volume pancreatic centers to assess the appropriateness of these guidelines. All pancreatic resections performed for cystic neoplasms < or =3 cm in size were evaluated over the time period of 1998-2006. One hundred sixty-six cases were identified, and the clinical, radiographic, and pathological data were reviewed. The correlation with age, gender, and symptoms (abdominal pain, nausea and vomiting, jaundice, presence of pancreatitis, unexplained weight loss, and anorexia), radiographic features suggestive of malignancy by either computed tomography, magnetic resonance imaging, or endoscopic ultrasound (presence of solid component, lymphadenopathy, or dilated main pancreatic duct or common bile duct), and the presence of malignancy was assessed using univariate and multivariate analysis. Among the 166 pancreatic resections for cystic pancreatic tumors < or =3 cm, 135 cases were benign [38 serous cystadenomas, 35 mucinous cystic neoplasms, 60 intraductal papillary mucinous neoplasms (IPMN), 1 cystic papillary tumor, and 1 cystic islet cell tumor], whereas 31 cases were malignant (14 mucinous cystic adenocarcinomas and 13 invasive carcinomas and 4 in situ carcinomas arising in the setting of IPMN). A greater incidence of cystic neoplasms was seen in female patients (99/166, 60%). Gender was a predictor of malignant pathology, with male patients having a higher incidence of malignancy (19/67, 28%) compared to female patients (12/99, 12%; p < 0.02). Older age was associated with malignancy (mean age 67 years in patients with malignant disease vs 62 years in patients with benign lesions (p < 0.05). A majority of the patients with malignancy were symptomatic (28/31, 90%). Symptoms that correlated with malignancy included jaundice (p < 0.001), weight loss (p < 0.003), and anorexia (p < 0.05). Radiographic features that correlated with malignancy were presence of a solid component (p < 0.0001), main pancreatic duct dilation (p = 0.002), common bile duct dilation (p < 0.001), and lymphadenopathy (p < 0.002). Twenty-seven of 31(87%) patients with malignant lesions had at least one radiographic feature concerning for malignancy. Forty-five patients (27%) were identified as having asymptomatic cystic neoplasms. All but three (6.6%) of the patients in this group had benign disease. Of the patients that had no symptoms and no radiographic features, 1 out of 30 (3.3%) had malignancy (carcinoma in situ arising in a side branch IPMN). Malignancy in cystic neoplasms < or =3 cm in size was associated with older age, male gender, presence of symptoms (jaundice, weight loss, and anorexia), and presence of concerning radiographic features (solid component, main pancreatic duct dilation, common bile duct dilation, and lymphadenopathy). Among asymptomatic patients that displayed no discernable radiographic features suggestive of malignancy who underwent resection, the incidence of occult malignancy was 3.3%. This study suggests that a group of patients with small cystic pancreatic neoplasms who have low risk of malignancy can be identified, and selective resection of these lesions may be appropriate.

Development of a solar-powered microbial fuel cell

AIMS

To understand factors that impact solar-powered electricity generation by Rhodobacter sphaeroides in a single-chamber microbial fuel cell (MFC).

METHODS AND RESULTS

The MFC used submerged platinum-coated carbon paper anodes and cathodes of the same material, in contact with atmospheric oxygen. Power was measured by monitoring voltage drop across an external resistance. Biohydrogen production and in situ hydrogen oxidation were identified as the main mechanisms for electron transfer to the MFC circuit. The nitrogen source affected MFC performance, with glutamate and nitrate-enhancing power production over ammonium.

CONCLUSIONS

Power generation depended on the nature of the nitrogen source and on the availability of light. With light, the maximum point power density was 790 mW m(-2) (2.9 W m(-3)). In the dark, power output was less than 0.5 mW m(-2) (0.008 W m(-3)). Also, sustainable electrochemical activity was possible in cultures that did not receive a nitrogen source.

SIGNIFICANCE AND IMPACT OF THE STUDY

We show conditions at which solar energy can serve as an alternative energy source for MFC operation. Power densities obtained with these one-chamber solar-driven MFC were comparable with densities reported in nonphotosynthetic MFC and sustainable for longer times than with previous work on two-chamber systems using photosynthetic bacteria.

Reducing sediment and phosphorus in tributary waters with alum and polyacrylamide

The Salton Sea is the largest inland water body in California, covering an area of 980 km(2). Inflow to the Salton Sea (1.6 km(3) yr(-1)) is predominately nutrient-rich agricultural wastewater, which has led to eutrophication. Because internal phosphorus release from the bottom sediments is comparatively low and external phosphorus loading to the Salton Sea is high, reduction of tributary phosphorus is expected to reduce algal blooms, increase dissolved oxygen, and reduce odors. Removing both dissolved phosphorus and phosphorus-laden sediment from agricultural drainage water (ADW) should decrease eutrophication. Both alum and polyacrylamide (PAM) are commonly used in wastewater treatment to remove phosphorus and sediment and were tested for use in tributary waters. Laboratory jar tests determined PAM effectiveness (2 mg L(-1)) for turbidity reduction as cationic > anionic = nonionic. Although cationic PAM was the most effective at reducing turbidity at higher speeds, there was no observed difference between the neutral and anionic PAMs at velocity gradients of 18 to 45 s(-1). Alum (4 mg L(-1) Al) reduced turbidity in low energy systems (velocity gradients < 10 s(-1)) by 95% and was necessary to reduce soluble phosphorus, which comprises 47 to 100% of the total P concentration in the tributaries. When PAM was added with alum, the anionic PAM became ineffective in aiding flocculation. The nonionic PAM (2 mg L(-1)) + alum (4 mg L(-1) Al) is recommended to reduce suspended solids in higher energy systems and reduce soluble P by 93%.

Defensins--components of the innate immune system in plants

Plant defensins are small (c.a. 5 kDa), basic, cysteine-rich proteins with antimicrobial activities. They are ubiquitous in plants and form part of the innate immunity arsenal. Plant defensins are encoded by small multigene families and are expressed in various plant tissues, but are best characterized in seeds. They are typically produced as preproteins, however, a small subset are produced as larger precursors with C-terminal prodomains. To date, the three-dimensional solution structures of seven seed- and two floral-derived defensins have been elucidated by (1)H-NMR spectroscopy. Despite limited amino acid sequence identities, these defensins have comparable global folds with features that are characteristic of the cysteine-stabilized alphabeta (CSalphabeta) motif. Interestingly, their structures are remarkably similar to those of insect defensins and scorpion toxins. Functionally, these proteins exhibit a diverse array of biological activities, although they all serve a common function as defenders of their hosts. This review describes the distribution, biosynthesis, structure, function and mode of action of plant defensins and reflects on their potential in agribiotechnological applications.

Removal of nano and microparticles by granular filter media coated with nanoporous aluminium oxide

Conventional filtration was designed to achieve high levels of particle and pathogen removal. Previous studies have examined the possibility of modifying filtration media to improve their ability to remove microorganisms and viruses. Although these studies have evaluated filter media coatings for this purpose, none have evaluated nanoscale particle suspensions as coating materials. The overall goal of this paper is to describe the preliminary test results of nanoporous aluminium oxide coated media that can be used to enhance filtration of nano and microparticles. Filtration tests were carried out using columns packed with uncoated and coated forms of granular anthracite or granular activated carbon. A positive correlation between isoelectric pH of filter media and particle removal was observed. The modified filter media with a higher isoelectric pH facilitated better removal of bacteriophage MS2 and 3 microm latex microspheres, possibly due to increased favorable electrostatic interactions.

An innovative photocatalytic technology in the treatment of river water containing humic substances

This study addresses the application of a photoelectrocatalytic (PEC) system with separated hole and electron reactions to treat humic acid (HA) from river water. A TiO2 electrode, coated by the sol-gel method, is used for that purpose. The degradation of humic acid in the river water was followed with respect to time using parameters of UV254, color and total organic carbon (TOC). For comparison purposes the photocatalytic (PC) removal of HA was also studied on the same photoanode. The obtained results showed that the PEC system was much more effective than the PC method. The effect of other important reaction variables, such as external potential, oxygen and UV intensity on HA degradation were also investigated. For all the external applied potential conditions and UV intensity range over 90% removal of UV254 and color were obtained with the PEC system while TOC removal was between 58-80%.

Evaluation of Kd underestimation using solid phase microextraction

Many important environmental pollutants are strongly adsorbing hydrophobic compounds. Because of their potential to adsorb to dissolved organic matter (DOM), their partition coefficient Kd may be underestimated by the conventional approach due to incomplete phase separation. In this study, solid-phase microextraction (SPME) was compared with liquid-liquid partition (LLP) for measuring Kd of bifenthrin and permethrin isomers on sediments. Due to its selective detection of the freely dissolved concentration, SPME gave Kd values 0.6-4.4-fold greater than those obtained by LLP in creek and field sediments and 3.6-21.7-fold greater in nursery runoff sediments. Underestimation by the conventional method was attributed to adsorption to DOM that was not excluded from the aqueous phase by centrifugation. The degree of underestimation was dependent on the source and amount of DOM and may be generally significant for compounds that have DOM adsorption coefficient (KDOM) > 10(4). This study provides evidence that the existing Kd values for many hydrophobic pollutants may be underestimated, and SPME may be a viable, efficacious tool for evaluating the underestimation.

Nursing research in home health care: endangered species?

An information revolution is occurring in home health care documentation processes and systems. The federally mandated Outcomes and Assessment Information Set (OASIS) for patient assessment and the use of electronic patient medical records will significantly affect the conduct of nursing research in home health care. The purposes of this article are to inform potential home care nurse researchers about the standardization of patient information as exemplified by OASIS and electronic patient medical records and recommend strategies to accommodate these changes. The potential for meaningful, scholarly studies in home care has never been greater, but researchers must address new challenges and adapt investigations accordingly.

Combined endoscopic mucosal resection and photodynamic therapy for esophageal neoplasia within Barrett's esophagus

BACKGROUND

Endoscopic mucosal resection (EMR) and photodynamic therapy have been proposed as treatments for early stage cancers. EMR is limited by its focal nature whereas photodynamic therapy is dependent on precise staging. The combination of EMR and photodynamic therapy were studied in the treatment of superficial cancer in patients with Barrett's esophagus.

METHODS

Seventeen consecutive nonsurgical patients with superficial cancers underwent EMR followed by photodynamic therapy with a porphyrin photosensitizer. Photoradiation was performed at 630 nm for a total dose of 200 J/cm of diffuser.

RESULTS

Seventeen patients (15 men; mean age 69 +/- 13 years) underwent EMR. The mean diameter of mucosal resection was 1 cm. The margins were involved by cancer in 3 cases. EMR improved staging in 8 patients (47%). Sixteen (94%) patients remained in remission (median follow-up 13 months). Complications included minor bleeding after EMR in 1 patient (6%), stricture in 5 (30%), cutaneous phototoxicity in 2 (12%), and supraventricular tachycardia in 1 patient (6%).

CONCLUSIONS

Combined EMR and photodynamic therapy appears to be an effective and safe therapy for superficial esophageal cancer within Barrett's esophagus. This combination improves cancer staging, removes the superficial cancer, and eliminates remaining mucosa at risk for cancer development.

Hydrolysis of phosphotriesters: determination of transition states in parallel reactions by heavy-atom isotope effects

The remote label method was used to measure primary and secondary (18)O isotope effects in the alkaline hydrolysis of O,O-diethylphosphorylcholine iodide (DEPC) and the primary (18)O effect in the alkaline hydrolysis of O,O-diethyl-m-nitrobenzyl phosphate (DEmNBP). Both the leaving group of interest (choline or m-nitrobenzyl alcohol) and ethanol can be ejected during hydrolysis due to the similarity of their pK values. The heavy-atom isotope effects were measured by isotope ratio mass spectrometry. Parallel reaction and incomplete labeling corrections were made for both systems. DEPC has a primary (18)O isotope effect of 1.041 +/- 0.003 and a secondary (18)O isotope effect of 1.033 +/- 0.002. The primary (18)O isotope effect for DEmNBP was 1.052 +/- 0.003. These large effects suggest a highly associative transition state in which the nucleophile approaches very close to the phosphorus atom to eject the leaving group. The large values are also indicative of a large compression, or general movement, on the reaction coordinate.

Solution structures by 1H NMR of the novel cyclic trypsin inhibitor SFTI-1 from sunflower seeds and an acyclic permutant

SFTI-1 is a recently discovered cyclic peptide trypsin inhibitor from sunflower seeds comprising 14 amino acid residues. It is the most potent known Bowman-Birk inhibitor and the only naturally occurring cyclic one. The solution structure of SFTI-1 has been determined by 1H-NMR spectroscopy and compared with a synthetic acyclic permutant. The solution structures of both are remarkably similar. The lowest energy structures from each family of 20 structures of cyclic and acyclic SFTI-1 have an rmsd over the backbone and heavy atoms of 0.29 A and 0.66 A, respectively. The structures consist of two short antiparallel beta-strands joined by an extended loop containing the active site at one end. Cyclic SFTI-1 also has a hairpin turn completing the cycle. Both molecules contain particularly stable arrangements of cross-linking hydrogen bonds between the beta-strands and a single disulfide bridge, making them rigid and well defined in solution. These stable arrangements allow both the cyclic and acyclic variants of SFTI-1 to inhibit trypsin with very high potencies (0.5 nM and 12.1 nM, respectively). The cyclic nature of SFTI-1 appears to have evolved to provide higher trypsin inhibition as well as higher stability. The solution structures are similar to the crystal structure of the cyclic inhibitor in complex with trypsin. The lack of a major conformational change upon binding suggests that the structure of SFTI-1 is rigid and already pre-organized for maximal binding due to minimization of entropic losses compared to a more flexible ligand. These properties make SFTI-1 an ideal platform for the design of small peptidic pharmaceuticals or pesticides.

Biochemical characterization of cartilage affected by osteochondritis dissecans in the humeral head of dogs

OBJECTIVE

To determine glycosaminoglycan (GAG) concentration and immunohistochemical staining characteristics of type-I, -II, and -X collagen from cartilage affected by osteochondritis dissecans (OCD) in dogs.

ANIMALS

31 dogs with OCD and 11 clinically normal purpose-bred dogs.

PROCEDURE

Cartilage samples were evaluated microscopically, and GAG content was determined. Immunohistochemical staining was performed for type-I, -II, and -X collagen. Sections were subjectively evaluated for location and intensity of staining.

RESULTS

Cartilage affected by OCD had a variety of pathologic changes and significantly lower GAG concentrations than did normal cartilage. Normal cartilage had no detectable type-I collagen. For dogs < 9 months of age, cartilage affected by OCD had significantly more type-I collagen but significantly less type-X collagen than did control cartilage. For dogs > 12 months of age, cartilage affected by OCD contained significantly more type-I collagen than did control cartilage. There was a significant negative correlation between immunoreactivity of type-I collagen and that of type-II and -X collagen. A significant positive correlation was found between immunoreactivity of type-II and -X collagen.

CONCLUSIONS AND CLINICAL RELEVANCE

Cartilage affected by OCD contains less GAG, more type-I collagen, and less type-X collagen, compared with normal cartilage. A direct correlation between these changes and the etiopathogenesis of OCD was not established.

Extent of high-grade dysplasia in Barrett's esophagus correlates with risk of adenocarcinoma

BACKGROUND & AIMS

The identification of any high-grade dysplasia (HGD) in Barrett's esophagus has been considered to be an indication for esophagectomy because of the increased risk of cancer. The aim of this study was to determine if a limited extent of HGD has the same potential for cancer as diffuse HGD.

METHODS

A retrospective cohort study was performed to assess the risk of developing adenocarcinoma in relationship to the extent of HGD found on endoscopic surveillance. The extent of HGD was defined as focal if cytologic and/or architectural changes of HGD were limited to a single focus of 5 or fewer crypts and diffuse if more than 5 crypts were involved in a single biopsy specimen or if HGD involved more than one biopsy fragment. The relative risk of cancer was assessed using a Cox proportional hazard model, and cancer-free survival was determined using survival curves.

RESULTS

Sixty-seven patients with diffuse HGD and 33 with focal HGD satisfied selection criteria. Cancer-free survival rates at 1 and 3 years were 93% and 86% for focal HGD compared with 62% and 44% for diffuse HGD (P < 0.001). On univariate analysis, extent of HGD (relative risk, 5.36; 95% confidence interval, 1.84-15.56), nodularity on endoscopy (relative risk, 3.98; 95% confidence interval, 1.97-8.04), and lack of acid suppression (relative risk, 2.48; 95% confidence interval, 1.16-5.28) were associated with an increased risk of esophageal adenocarcinoma. Diffuse HGD had a 3.7-fold increase in the risk of esophageal cancer compared with focal HGD (P = 0.02) on multivariate analysis.

CONCLUSIONS

Patients with focal HGD are less likely to have cancer during the first year after diagnosis or on subsequent follow-up compared with diffuse HGD.

Contribution of intraoperative enteroscopy in the management of obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding remains a significant diagnostic challenge. Our aims were (1) to determine the efficacy of intraoperative enteroscopy (IOE) in identifying lesions responsible for obscure gastrointestinal bleeding and (2) to determine the outcome of patients after treatment of these lesions. We retrospectively reviewed all patients who underwent IOE for obscure gastrointestinal bleeding from 1992 to 1998. Patients were divided into those with overt and those with occult gastrointestinal bleeding. Follow-up was complete in 67 patients (96%), with a median of 32 months (range 1 to 91 months). Seventy patients (52 overt and 18 occult) underwent IOE after extensive preoperative evaluation. Median duration of bleeding was 12 months, requiring a median of 14 blood transfusions. Risk factors for bleeding were identified in 46 patients (61%). A lesion was identified and treated in 52 patients (74%)-39 in the overt group and 13 in the occult group. Lesions identified were vascular (54%), ulcerations (31%), tumors (11%), and small bowel diverticula (4%). Overall, 35 patients (52%) were found to have one or more lesions at IOE that were treated surgically and had no further bleeding. IOE, through a mid-small bowel enterotomy, has low morbidity and is effective in that it identified a treatable lesion in 74% of patients, which led to cure of bleeding in 52%.

Doing more with less and less with more

The "devil is in the details" of any policy response. What forms such changes may take, and what research informs them, are critical to the profession as a whole and to practitioners on a daily basis. Research partnerships between home care agencies and university professors may provide rigorous, systematic, and validated findings necessary for meaningful solutions (Plotkin & Roche, 2000). The evidence of a dialogue between nursing researchers, home healthcare practitioners, and policymakers anticipating impacts on practice of changing fiscal and information-gathering requirements is scant. Such issues are in need a priority discussion by agencies, and collaborative investigative efforts between all involved.

Recent advances in external skeletal fixation

While the use of external skeletal fixation was once associated with substantial postoperative morbidity, clinical and experimental studies have led to technological advances and modifications in application techniques that have greatly improved the results obtained with this treatment modality. The past decade saw numerous advances in external skeletal fixator implants, components and instrumentation, including improvements in fixation pin design, and the development of new linear external skeletal fixation systems and economical circular external skeletal fixation systems specifically engineered for use in dogs and cats. In addition, a greater understanding of fixator biomechanics and the pathobiology of the bone-fixation pin interface have improved fixator application practices. This article reviews many of the more significant recent advances in external skeletal fixation.

The solution structure of C1-T1, a two-domain proteinase inhibitor derived from a circular precursor protein from Nicotiana alata

A two-domain portion of the proteinase inhibitor precursor from Nicotiana alata (NaProPI) has been expressed and its structure determined by NMR spectroscopy. NaProPI contains six almost identical 53 amino acid repeats that fold into six highly similar domains; however, the sequence repeats do not coincide with the structural domains. Five of the structural domains comprise the C-terminal portion of one repeat and the N-terminal portion of the next. The sixth domain contains the C-terminal portion of the sixth repeat and the N-terminal portion of the first repeat. Disulphide bonds link these C and N-terminal fragments to generate the clasped-bracelet fold of NaProPI. The three-dimensional structure of NaProPI is not known, but it is conceivable that adjacent domains in NaProPI interact to generate the circular "bracelet" with the N and C termini in close enough proximity to facilitate formation of the disulphide bonds that form the "clasp". The expressed protein, examined in the current study, comprises residues 25-135 of NaProPI and encompasses the first two contiguous structural domains, namely the chymotrypsin inhibitor C1 and the trypsin inhibitor T1, joined by a five-residue linker, and is referred to as C1-T1. The tertiary structure of each domain in C1-T1 is identical to that found in the isolated inhibitors. However, no nuclear Overhauser effect contacts are observed between the two domains and the five-residue linker adopts an extended conformation. The absence of interactions between the domains indicates that adjacent domains do not specifically interact to drive the circularisation of NaProPI. These results are in agreement with recent data which describe similar PI precursors from other members of the Solanaceae having two, three, or four repeats. The lack of strong interdomain association is likely to be important for the function of individual inhibitors by ensuring that there is no masking of reactive sites upon release from the precursor.

Theory and laboratory study of a tall passive chamber for measuring gas fluxes at soil surface

A tall passive flux chamber with a height significantly greater than its horizontal dimensions is proposed for measuring fluxes of volatile organic compounds (VOCs) at the soil surface. The main feature of this tall chamber is the presence of a vertical concentration gradient of the target gas in the chamber. The emission and transport behavior of the target gas in the soil-chamber system are analyzed using the diffusion theory. A mathematical model is developed to estimate the flux from the soil into the tall chamber, providing the target gas establishes a detectable vertical concentration gradient in the chamber. To obtain the data required for calculating flux, only two gas concentrations (C1 and C2) at two heights (h1 and h2) within the chamber need to be measured at the end of a short chamber placement time (tp). To evaluate the applicability of the tall chamber for measuring flux, several laboratory tests have been conducted, using CH2Cl2 and CH3Br as the target gases. The results indicate that the proposed tall chamber has promising potential as a method for measuring fluxes of VOCs at the soil surface.

Feline osteosarcoma: 145 cases (1990-1995)

Feline osteosarcoma (OSA) is a rare tumor in cats. Ninety (62%) of feline OSAs detailed in this study arose from the skeleton, and 55 (38%) arose from extraskeletal sites. Fifty OSAs originated in the appendicular skeleton, and 40 OSAs originated in the axial skeleton. Extraskeletal OSA sites included subcutaneous sites (n=44), with an apparent prevalence for sites commonly used for vaccination. Other locations included ocular/orbital (n=4), oral (n=3), intestinal/omental (n=3), and mammary sites (n=1). Survival data was available for 74 cases. When considered as a group, cats with either appendicular (mean, 11.8 mos) or extraskeletal (mean, 12.67 mos) OSA survived longer than those with axial (mean, 6.07 mos) OSA. Regardless of the type of feline OSA, aggressive surgical excision with or without ancillary therapy appeared to be the most effective form of treatment.

Persistent genetic abnormalities in Barrett's esophagus after photodynamic therapy

BACKGROUND & AIMS

Photodynamic therapy (PDT) is a technique for nonsurgical treatment of patients with dysplasia in Barrett's esophagus. The primary endpoint for PDT has been resolution of dysplasia. We studied the effect of PDT at the genetic level.

METHODS

Archival material from 3 patients who had initial improvement in dysplasia after PDT but occurrence of high-grade dysplasia during follow-up was used. Biopsy specimens were analyzed for increased proliferation, aneuploidy, p53 protein overexpression, p53 mutations, and p16 promoter hypermethylation.

RESULTS

Patients developed high-grade dysplasia 16, 28, and 37 months after PDT. In all cases, one or more genetic markers were positive after PDT treatment, whereas histology was downstaged consistently after therapy. Increasing genetic abnormalities were noted by the end of follow-up.

CONCLUSIONS

Genetic abnormalities may persist after PDT despite phenotypical improvement of dysplasia. These patients may progress to high-grade dysplasia or develop adenocarcinoma. Histologic improvement in dysplasia is an inadequate endpoint for PDT in patients with Barrett's esophagus.

Endoscopic ultrasound is highly accurate and directs management in patients with neuroendocrine tumors of the pancreas

Preoperative localization of pancreatic neuroendocrine tumors with traditional imaging fails in 40-60% of patients. Endoscopic ultrasound (EUS) is highly sensitive in the detection of these tumors. Previous reports included relatively few patients or required the collaboration of multiple centers. We report the results of EUS evaluation of 82 patients with pancreatic neuroendocrine tumors.

METHODS

We prospectively used EUS early in the diagnostic evaluation of patients with biochemical or clinical evidence of neuroendocrine tumors. Patients had surgical confirmation of tumor localization or clinical follow-up of >1 yr.

RESULTS

Eighty-two patients underwent 91 examinations (cases). Thirty patients had multiple endocrine neoplasia syndrome type 1. One hundred pancreatic tumors were visualized by EUS in 54 different patients. The remaining 28 patients had no pancreatic tumor or an extrapancreatic tumor. Surgical/pathological confirmation was obtained in 75 patients. The mean tumor diameter was 1.51 cm and 71% of the tumors were < or =2.0 cm in diameter. Of the 54 explorations with surgical confirmation of a pancreatic tumor, EUS correctly localized the tumor in 50 patients (93%). Twenty-nine insulinomas, 18 gastrinomas, as well as one glucagonoma, one carcinoid tumor, and one somatostatinoma were localized. The most common site for tumor localization was the pancreatic head (46 patients). Most tumors were hypoechoic, homogenous, and had distinct margins. EUS of the pancreas was correctly negative in 20 of 21 patients (specificity, 95%). EUS was more accurate than angiography with or without stimulation testing (secretin for gastrinoma, calcium for insulinoma), transcutaneous ultrasound, and CT in those patients undergoing further imaging procedures. EUS was not reliable in localizing extrapancreatic tumors.

CONCLUSIONS

In this series, the largest single center experience reported to date, EUS had an overall sensitivity and accuracy of 93% for pancreatic neuroendocrine tumors. Our results support the use of EUS as a primary diagnostic modality in the evaluation and management of patients with neuroendocrine tumors of the pancreas.

A continuity of care integrated literature review, Part 2: Methodological issues

PURPOSE

In Part 2 of this two-part series, research designs, methods, and measurement of continuity of care are explored.

DESIGN

Qualitative, integrated literature review of a sample of 38 continuity of care nursing research article published 1990-1995.

METHODS

Ganong's (1987) stages of the integrative literature research review process were followed. A data collection tool was designed and pilot tested, and rules for data analysis and interpretation were established. Research articles were systematically analyzed and reported using descriptive analysis.

FINDINGS

Results showed few nursing models, primarily convenience sampling and nonexperimental cross-sectional study designs, varied data collection methods, and inadequate instrumentation. Measurement criteria were diverse and influenced by the perspectives of the measurer.

CONCLUSIONS

Continuity of patient care was identified as a construct comprised of many related and tangential concepts in need of more sophisticated review. Recommendations for researchers are discussed.

Integrated literature review of continuity of care: Part 1, Conceptual issues

PURPOSE

Continuity of patient care is a fundamental tenet of professional nursing, yet comprehension of the concept and related issues remains elusive. The purpose of this study was to explore issues associated with definitions, related concepts, and research methods of continuity of care through systematic literature-based study. In Part 1 of this two-part series, definitions and related concepts, factors, and variables associated with continuity of care were explored.

DESIGN

Qualitative, integrated literature review of a sample of 38 nursing research articles about continuity of care, 1990-1995.

METHODS

Ganong's (1987) stages of an integrative research review guided this study. A data collection tool was developed and pilot tested, and rules for data analysis and interpretation were established. Research articles were systematically analyzed and reported using descriptive analysis.

FINDINGS AND CONCLUSIONS

No consensus was found in the literature about the conceptual definition of continuity of care. Continuity of patient care is a multifactorial concept affected by environmental influences, communication, patient, professional, and system factors.

Magnetoelastic sensors in combination with nanometer-scale honeycombed thin film ceramic TiO2 for remote query measurement of humidity

Ribbonlike magnetoelastic sensors can be considered the magnetic analog of an acoustic bell; in response to an externally applied magnetic field impulse the sensors emit magnetic flux with a characteristic resonant frequency. The magnetic flux can be detected external to the test area using a pick-up coil, enabling query remote monitoring of the sensor. The characteristic resonant frequency of a magnetoelastic sensor changes in response to mass loads. [L.D. Landau and E. M. Lifshitz, Theory of Elasticity, 3rd ed. (Pergamon, New York, 1986). p. 100].Therefore, remote query chemical sensors can be fabricated by combining the magnetoelastic sensors with a mass changing, chemically responsive layer. In this work magnetoelastic sensors are coated with humidity-sensitive thin films of ceramic, nanodimensionally porous TiO2 to make remote query humidity sensors.

Talking about patients: communication and continuity of care

Continuity of patient care is a tenet of professional nursing practice regardless of setting. Communication between providers about patients is fundamental to continuity. As the role of hospitals in health care is constrained, care is now commonly delivered to patients during an episode of illness by multiple agencies. Continuity of care now assumes full communication between providers about patients' conditions and needs. Research provides evidence about the dynamics of patient care communication: more lean (background and medical) than rich (nursing care and psychosocial) data are communicated; structured, written formats transmit more information than informal channels of communication; and organizational and patient characteristics would appear to affect communication about patients. Knowledge about the communication dynamics of patient care may assist providers in designing strategies to attain the basic goals of continuity of care.

Validity of diagnostic ultrasound as a measure of delayed onset muscle soreness

STUDY DESIGN

Repeated measures were taken to evaluate delayed onset muscle soreness (DOMS) following eccentric bicep contractions of the nondominant arm at 140% of 1 repetition maximum (RM) while the dominant arm served as control.

OBJECTIVES

To explore the usefulness of a noninvasive method to assess delayed onset muscle soreness.

BACKGROUND

Although many methods have been proposed to assess DOMS, most are somewhat subjective or require a blood sample. This study compared the assessment of DOMS following eccentric exercise using common assessment techniques with diagnostic ultrasound (US).

METHODS AND MEASURES

Forty nonimpaired women (18-40 years) used a Cybex isotonic biceps curl machine to eccentrically lower, using their nondominant arm, 140% of their dominant arm 1 RM to induce muscle soreness. Four assessment methods, (1) goniometry assessing spontaneous muscle shortening (SMS); (2) subjective muscle soreness ratings (MSRs); (3) serum creatine kinase (CK); and (4) diagnostic US scans of muscle cross-sectional area (CSA), were conducted at 5 different assessment times: (1) pre-eccentric exercise; (2) postexercise; (3) 24 hours postexercise; (4) 48 hours postexercise; and (5) 72 hours postexercise.

RESULTS

Significant differences existed across assessment times for 3 of the 4 assessment techniques, CK, SMS, and MSR.

CONCLUSIONS

Previously published methodologies used to assess DOMS (CK, SMS, and MSR) were able to provide consistent and expected results relative to the onset and progression of soreness with a high degree of relatedness (r = 0.48-0.84). However, it appeared that the ability to assess muscle soreness by diagnostic US, as evidenced by intramuscular swelling, was limited. Thus, the technique was not sensitive enough to detect any statistically significant changes in muscle CSA.

A rural perspective on home care communication about elderly patients after hospital discharge

Little is known about home health agencies (HHA) and their integration in the continuum of care in rural areas. The aims of this study are to describe the amount and type of patient-related data transferred by discharging hospitals to rural HHAs and to explore the influence of selected organizational factors on that communication process using a previously tested model of interorganizational communication. In this study, 446 closed-case, elderly patient records at three rural HHAs were reviewed using the Referral Data Inventory. Rural HHAs receive about half of the literature-recommended referral data, characterized primarily by background data, some medical data, and almost no psychosocial or nursing-care data. Referrals transmitted by telephone and written data were superior to referrals transferred by a telephone call only. Hospital-affiliated HHAs received significantly greater amounts and richer types of referral data than did free-standing HHAs. Findings suggest that cost-saving measures in the referral process need investigation.

Identification of a novel four-domain member of the proteinase inhibitor II family from the stigmas of Nicotiana alata

Proteinase inhibitors (PIs) of the potato type II family have been identified in a number of solanaceous species. Most family members have two PI domains which are specific for either chymotrypsin or trypsin. More recently family members have been described with three or six repeated PI domains. Here we describe a novel four-domain family member produced in the stigmas and leaves of the ornamental tobacco, Nicotiana alata, which has high sequence identity with a six-domain member from the same species. Both proteins are produced as precursors that enter the secretory pathway and are subsequently processed into a series of 6 kDa Pis. The four- and six-domain precursor proteins were isolated from immature stigmas and characterised by mass spectrometry which revealed that both proteins had been trimmed at the N-terminus, at a position corresponding to the predicted signal peptide cleavage site. Furthermore, no post-translational modifications were apparent.

Unplanned hospital readmissions: a home care perspective

BACKGROUND

The extensive literature concerning hospital readmissions is grounded in a medical or hospital perspective, and fails to address hospital readmissions during home care.

OBJECTIVES

To describe clients who have unplanned returns to an inpatient setting during the first 100 days of home care service delivery.

METHOD

Using the Hospital Readmission Inventory (HRI), an audit tool with previously established validity and reliability, 916 medical records for clients from 11 midwestern home care agencies were reviewed retrospectively.

RESULTS

Typically, clients were referred for their first home care admission after a 9-day hospital length of stay for a cardiovascular, respiratory, or neoplastic disorder. After an average 18-day length home care stay, clients were readmitted to the hospital, usually due to the development of a new problem, or due to deterioration in health status related to the primary or to a secondary medical diagnosis. Significant respiratory, cardiovascular or GI symptoms were generally present at hospital readmission. Typically, readmitted clients were 75 year old married females, who had been able to care for themselves at home. At hospital readmission, home care nurses judged these clients to be moderately ill, and likely in need of acute care.

CONCLUSIONS

Chronic illness appears to be the best indicator for hospital readmission. The crucial time period for hospital readmission during home care is the first 2-3 weeks following hospital discharge. Intensive study of home care service arrangements utilized by readmitted patients, as well as agency variations, are needed. Study findings concerning patients readmitted from home care point to similarities with rehospitalized patients generally. Findings may assist home care clinicians in targeting high risk patients who could benefit from interventions aimed at minimizing unplanned returns to the hospital.

Identification and characterization of a prevacuolar compartment in stigmas of nicotiana alata

The stigmas of the ornamental tobacco plant Nicotiana alata accumulate large quantities of a series of 6-kD proteinase inhibitors (PIs) in the central vacuole that are derived from a 40-kD precursor protein, Na-PI. The sorting information that directs Na-PI to the vacuole is likely to reside in a C-terminal propeptide domain of 25 amino acids that forms an amphipathic alpha helix. Using cell fractionation techniques, we have examined transit of Na-PI through the endomembrane system and have identified a prevacuolar compartment that contains Na-PI with an intact targeting signal. In contrast, the targeting signal is not present on the predominant form of Na-PI in the vacuole. The prevacuolar compartment is marked by the presence of homologs of both the t-SNARE, PEP12p, and the putative vacuolar sorting receptor BP-80. Cross-linking and affinity precipitation studies revealed that Na-PI associates with BP-80 within this compartment, providing in vivo evidence for the function of BP-80 as a sorting receptor for a protein with a C-terminal vacuolar targeting signal.

Service delivery challenges of nursing research in home health care

For nurse researchers interested in patient care and delivery systems, home health care is an area of increasing focus. Compared to institutional sites, however, there are challenges in conducting research in home health care that are a function of the organizational and operational environment. In addition to the unique environment, current regulatory and legislative changes also are having an impact on home health care nurses and agencies. Finally, home health care is an area that has not historically been involved with research of any kind. This article presents an overview of selected challenges of research in home health agencies and recommendations for nurse researchers.

Structure of a putative ancestral protein encoded by a single sequence repeat from a multidomain proteinase inhibitor gene from Nicotiana alata

BACKGROUND

The ornamental tobacco Nicotiana alata produces a series of proteinase inhibitors (PIs) that are derived from a 43 kDa precursor protein, NaProPI. NaProPI contains six highly homologous repeats that fold to generate six separate structural domains, each corresponding to one of the native PIs. An unusual feature of NaProPI is that the structural domains lie across adjacent repeats and that the sixth PI domain is generated from fragments of the first and sixth repeats. Although the homology of the repeats suggests that they may have arisen from gene duplication, the observed folding does not appear to support this. This study of the solution structure of a single NaProPI repeat (aPI1) forms a basis for unravelling the mechanism by which this protein may have evolved.

RESULTS

The three-dimensional structure of aPI1 closely resembles the triple-stranded antiparallel beta sheet observed in each of the native PIs. The five-residue sequence Glu-Glu-Lys-Lys-Asn, which forms the linker between the six structural domains in NaProPI, exists as a disordered loop in aPI1. The presence of this loop in aPI1 results in a loss of the characteristically flat and disc-like topography of the native inhibitors.

CONCLUSIONS

A single repeat from NaProPI is capable of folding into a compact globular domain that displays native-like PI activity. Consequently, it is possible that a similar single-domain inhibitor represents the ancestral protein from which NaProPI evolved.

A novel two-chain proteinase inhibitor generated by circularization of a multidomain precursor protein

Female reproductive tissues of the ornamental tobacco amass high levels of serine proteinase inhibitors (PIs) for protection against pests and pathogens. These PIs are produced from a precursor protein composed of six repeats each with a protease reactive site. Here we show that proteolytic processing of the precursor generates five single-chain PIs and a remarkable two-chain inhibitor formed by disulfide-bond linkage of N- and C-terminal peptide fragments. Surprisingly, PI precursors adopt this circular structure regardless of the number of inhibitor domains, suggesting this bracelet-like conformation is characteristic of the widespread potato inhibitor II (Pot II) protein family.

Communication: an outcome of case management

Case management is a healthcare delivery model emphasizing coordination and networking of patient care services across multidisciplinary providers and various care settings. This requires effective communication to overcome traditional barriers to information exchange. This study investigates communication as an outcome of case management. The classic communication model of sender-message-channel-receiver is used as a conceptual framework. Using a closed medical record review, the amount and type of referral information exchanged between a hospital using a case management model to coordinate care and a home health agency accepting the case-managed patient is described. In addition, the influence of selected organizational and medical condition factors on communication is explored.

Home health care referrals following hospital discharge: communication in health services delivery

Interinstitutional communication in the delivery of health services is fundamental to continuity of patient care. The purpose of this investigation was to describe the information transferred in the formal home care referral of elderly clients by hospitals and to describe selected organizational and medical condition characteristics that may affect referral content. Results indicated that approximately half of the information recommended by the literature was actually transmitted in the referral form. This information was composed primarily of background and medical data with some nursing care and almost no psychosocial data. More data were transferred when standardized written forms were used, when smaller hospitals provided the information, and when the home health agency was affiliated with the hospital.

Postpartum home visits: infant outcomes

Early postpartum discharge of mothers and infants has increased as health care providers and payers attempt to control health care cost. Questions regarding patient safety have been raised. Literature supports the safety of early discharge when providers adhere to strict discharge guidelines and when clients comply with home follow-up. Previous studies calculated hospital readmission rates, but few examined other outcomes or characteristics. The purposes of this descriptive study were to examine outcome data for infant participants in a postpartum home visit program and to explore factors that may influence hospital readmissions for infants. Using an audit tool with established reliability and validity, a convenience sample of 199 infant medical records was reviewed for demographic information, characteristics, and outcomes. The hospital readmission rate for all infants within 3 weeks of discharge was comparable to other studies; however, the rate for only early discharge infants was higher than the rate reported in other studies. The study of postdelivery outcomes for infants provides additional insight into the issue of early discharge and may reflect the significance of postpartum follow-up care and education.