Autophagy is required for self-incompatible pollen rejection in two transgenic Arabidopsis thaliana accessions

Successful reproduction in the Brassicaceae is mediated by a complex series of interactions between the pollen and the pistil, and some species have an additional layer of regulation with the self-incompatibility trait. While the initial activation of the self-incompatibility pathway by the pollen S-locus protein 11/S locus cysteine-rich protein and the stigma S Receptor Kinase is well characterized, the downstream mechanisms causing self-pollen rejection are still not fully understood. In previous studies, we detected the presence of autophagic bodies with self-incompatible (SI) pollinations in Arabidopsis lyrata and transgenic Arabidopsis thaliana lines, but whether autophagy was essential for self-pollen rejection was unknown. Here, we investigated the requirement of autophagy in this response by crossing mutations in the essential AUTOPHAGY7 (ATG7) and ATG5 genes into two different transgenic SI A. thaliana lines in the Col-0 and C24 accessions. By using these previously characterized transgenic lines that express A. lyrata and Arabidopsis halleri self-incompatibility genes, we demonstrated that disrupting autophagy weakened their SI responses in the stigma. When the atg7 or atg5 mutations were present, an increased number of SI pollen was found to hydrate and form pollen tubes that successfully fertilized the SI pistils. Additionally, we confirmed the presence of GFP-ATG8a-labeled autophagosomes in the stigmatic papillae following SI pollinations. Together, these findings support the requirement of autophagy in the self-incompatibility response and add to the growing understanding of the intracellular mechanisms employed in the transgenic A. thaliana stigmas to reject self-pollen.

Introducing Lifestyle Medicine Within the Mayo Clinic Alix School of Medicine in Arizona

Purpose: High-value care is becoming increasingly important as the United States shifts toward a more sustainable health care system. Lifestyle medicine (LM) may be the highest-value model of care. Surprisingly, however, it is taught in a minority of medical schools. In this article, we describe a pilot project of introducing a brief LM course taught within the Mayo Clinic Alix School of Medicine in Arizona. The main purpose of the course was to introduce the students to LM as a specialty practice and to provide students with foundational knowledge of the pillars of LM. Results: Students reported improved personal health habits and increased confidence in LM competencies.

“Real-World” Application of Thrombolysis in Cardiac Arrest

Background:

Current guidelines recommend consideration of thrombosis as a reversible cause of cardiac arrest. The use of thrombolytic therapy during cardiac arrest, however, is controversial.

Objective:

We sought to characterize the use of thrombolytic therapy during cardiac arrest and to evaluate the rate of return of spontaneous circulation (ROSC) in a “real-word” setting.

Methods:

A single-center, retrospective, cohort study of adult patients who received alteplase during cardiac arrest between 2010 and 2015 were performed at a tertiary academic medical center.

Results:

Twenty-six patients were identified. Patients were predominantly male (65%) and Caucasian (89%) and were a median age of 64 years. Five patients had a history of preexisting venous thromboembolism, and eight patients were receiving systemic anticoagulation. Pulmonary embolism was confirmed prior to the administration of alteplase in 5 patients. The median dose of alteplase administered was 100 mg. ROSC was achieved in 65% of patients, 2 of whom survived to hospital discharge. Both surviving patients experienced a bleeding event.

Conclusion:

In a single center’s experience, thrombolytic therapy is used infrequently for the management of cardiac arrest. Thrombolysis during cardiac arrest should be considered on a case-by-case basis and should be utilized only when there is a high suspicion for pulmonary embolism as the cause of arrest and when thrombolytic therapy is readily available.

Prediction of outcome in newly diagnosed myeloma: a meta-analysis of the molecular profiles of 1905 trial patients

Robust establishment of survival in multiple myeloma (MM) and its relationship to recurrent genetic aberrations is required as outcomes are variable despite apparent similar staging. We assayed copy number alterations (CNA) and translocations in 1036 patients from the NCRI Myeloma XI trial and linked these to overall survival (OS) and progression-free survival. Through a meta-anlysis of these data with data from MRC Myeloma IX trial, totalling 1905 newly diagnosed MM patients (NDMM), we confirm the association of t(4;14), t(14;16), t(14;20), del(17p) and gain(1q21) with poor prognosis with hazard ratios (HRs) for OS of 1.60 (P=4.77 × 10^-7), 1.74 (P=0.0005), 1.90 (P=0.0089), 2.10 (P=8.86 × 10^-14) and 1.68 (P=2.18 × 10^-14), respectively. Patients with 'double-hit' defined by co-occurrence of at least two adverse lesions have an especially poor prognosis with HRs for OS of 2.67 (P=8.13 × 10^-27) for all patients and 3.19 (P=1.23 × 10^-18) for intensively treated patients. Using comprehensive CNA and translocation profiling in Myeloma XI we also demonstrate a strong association between t(4;14) and BIRC2/BIRC3 deletion (P=8.7 × 10^-15), including homozygous deletion. Finally, we define distinct sub-groups of hyperdiploid MM, with either gain(1q21) and CCND2 overexpression (P<0.0001) or gain(11q25) and CCND1 overexpression (P<0.0001). Profiling multiple genetic lesions can identify MM patients likely to relapse early allowing stratification of treatment.

Impact of Pharmacist Intervention to Increase Compliance With Guideline-Directed Statin Therapy During an Acute Coronary Syndrome Hospitalization

Background: Despite evidence on poor adherence to guideline-directed statin therapy (GDST) following an acute coronary syndrome (ACS), little information has been published on pharmacist-led statin pilot programs for secondary prevention. Objective: We sought to evaluate the impact of a pharmacist intervention (PI) on GDST during an ACS hospitalization. Methods: A historical control (HC) group consisting of 125 ACS hospitalizations was retrospectively identified, with prospective data of 113 patients captured over 6 months in the PI group. The primary outcome of GDST was defined according to 2013 clinical guidelines and evaluated in all 238 qualifying patients. Secondary outcomes included number of interventions and use of logistic regression to investigate the relationship of ACS subtype with statin dose. Results: On admission, GDST was ordered in 62.5% of the HC and 75.9% of the PI group. At discharge, the PI group had a higher rate of GDST relative to HC among all patients (86.7 % vs 77.4%, P = 0.06), and after exclusion of contraindications (84.8% vs 74.5%; P = 0.1), 10 patients required PI, accounting for an increase in GDST of 5.3%. Statin dose selection did not differ by ACS subtype (odds ratio = 0.79; 95% CI = 0.0.29-2.17; P = 0.18). Conclusion: PI did not significantly increase GDST. Increased compliance rates measured were primarily driven by higher baseline adherence and guideline incorporation over time.

Current use of guidelines, protocols, and care pathways for symptom management in hospice

Evidence-based guidelines or care pathways for symptom management could provide a means to reduce symptom distress in dying patients. We surveyed directors of nursing from hospices affiliated with the Population-based Palliative Care Research Network (PoPCRN) regarding their hospices’ current use of and attitudes toward written symptom management materials. A majority (53/78, 68 percent) of participating hospices reported use of written materials, such as guidelines, protocols, or care pathways, for one or more symptoms. Materials were based on multiple sources and varied from simple medication orders to more comprehensive, multicategory symptom management resources. Regardless of the composition, these materials were perceived as helpful. Given this favorable view, variations in the use and content of written materials may signify an opportunity to decrease symptom distress in hospice through the implementation of evidence-based symptom management resources.

Structure-property relationships in non-epitaxial chalcogenide heterostructures: the role of interface density on charge exchange

A homologous series of quasi-2D ([PbSe]1+δ)m(TiSe2)m nanolayered heterostructures are prepared via self-assembly of designed precursors with 1 ≤m≤ 4 and their structures and properties investigated. All heterostructures have the same global composition but vary in their interface density. X-ray diffraction and electron microscopy studies show that the structures consist of rock salt structured PbSe layers alternating with TiSe2 layers, and that grain size increases with m. The compounds are all metallic with upturns in resistivity at low temperature suggesting electron localization, with room temperature resistivity of 1-3 10(-5)Ω m, negative Hall coefficients and Seebeck coefficients between -50 and -100 μV K(-1). A decrease in the mobile carrier concentration with temperature is observed for all m and the rate increases with increasing low-dimensionality. Decreasing the interface density also decreases the average carrier concentration while increasing the electron mobility. The Seebeck coefficients systematically increase in magnitude as m is increased, but the net effect to the power factor is small due to a compensating increase in resistivity. The observed transport behavior is not described by the simple rigid band models with charge transfer between constituents used previously. Charge exchange between constituents stabilizes the intergrowth, but also introduces mobile carriers and interfacial band bending that must play a role in the transport behavior of the heterostructures. As chemical potentials equilibrate in high m heterostructures there is a decrease in total coulombic stabilization as there are fewer interfaces, so m = 1 is likely to be most stable. This rationalizes why the structurally similar misfit layer compounds with m = 1 are often the only intergrowths that can be prepared. Charge transfer and band bending at interfaces should occur in other heterostructures with similar type II broken-gap band alignments and are important considerations regarding both their stability and transport properties.

Management of Outbreaks of Methicillin-ResistantStaphylococcus aureusInfection in the Neonatal Intensive Care Unit: A Consensus Statement

Objective.

In 2002, the Chicago Department of Public Health (CDPH; Chicago, Illinois) convened the Chicago-Area Neonatal MRSA Working Group (CANMWG) to discuss and compare approaches aimed at control of methicillin-resistantStaphylococcus aureus(MRSA) in neonatal intensive care units (NICUs). To better understand these issues on a regional level, the CDPH and the Evanston Department of Health and Human Services (EDHHS; Evanston, Illinois) began an investigation.

Design.

Survey to collect demographic, clinical, microbiologic, and epidemiologic data on individual cases and clusters of MRSA infection; an additional survey collected data on infection control practices.

Setting.

Level III NICUs at Chicago-area hospitals.

Participants.

Neonates and healthcare workers associated with the level III NICUs.

Methods.

From June 2001 through September 2002, the participating hospitals reported all clusters of MRSA infection in their respective level III NICUs to the CDPH and the EDHHS.

Results.

Thirteen clusters of MRSA infection were detected in level III NICUs, and 149 MRSA-positive infants were reported. Infection control surveys showed that hospitals took different approaches for controlling MRSA colonization and infection in NICUs.

Conclusion.

The CANMWG developed recommendations for the prevention and control of MRSA colonization and infection in the NICU and agreed that recommendations should expand to include future data generated by further studies. Continuing partnerships between hospital infection control personnel and public health professionals will be crucial in honing appropriate guidelines for effective approaches to the management and control of MRSA colonization and infection in NICUs.

Genetic factors influencing the risk of multiple myeloma bone disease

A major complication of multiple myeloma (MM) is the development of osteolytic lesions, fractures and bone pain. To identify genetic variants influencing the development of MM bone disease (MBD), we analyzed MM patients of European ancestry (totaling 3774), which had been radiologically surveyed for MBD. Each patient had been genotyped for ~6 00 000 single-nucleotide polymorphisms with genotypes for six million common variants imputed using 1000 Genomes Project and UK10K as reference. We identified a locus at 8q24.12 for MBD (rs4407910, OPG/TNFRSF11B, odds ratio=1.38, P=4.09 × 10(-9)) and a promising association at 19q13.43 (rs74676832, odds ratio=1.97, P=9.33 × 10(-7)). Our findings demonstrate that germline variation influences MBD and highlights the importance of RANK/RANKL/OPG pathway in MBD development. These findings will contribute to the development of future strategies for prevention of MBD in the early precancerous phases of MM.

Physician response to implementation of genotype-tailored antiplatelet therapy

Physician responses to genomic information are vital to the success of precision medicine initiatives. We prospectively studied a pharmacogenomics implementation program for the propensity of clinicians to select antiplatelet therapy based on CYP2C19 loss-of-function variants in stented patients. Among 2,676 patients, 514 (19.2%) were found to have a CYP2C19 variant affecting clopidogrel metabolism. For the majority (93.6%) of the cohort, cardiologists received active and direct notification of CYP2C19 status. Over 12 months, 57.6% of poor metabolizers and 33.2% of intermediate metabolizers received alternatives to clopidogrel. CYP2C19 variant status was the most influential factor impacting the prescribing decision (hazard ratio [HR] in poor metabolizers 8.1, 95% confidence interval [CI] [5.4, 12.2] and HR 5.0, 95% CI [4.0, 6.3] in intermediate metabolizers), followed by patient age and type of stent implanted. We conclude that cardiologists tailored antiplatelet therapy for a minority of patients with a CYP2C19 variant and considered both genomic and nongenomic risks in their clinical decision-making.

Easy to remember, difficult to forget: the development of fear regulation

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Adolescent humans and rodents show diminished cued-fear extinction.

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Early-life stress in humans and rodents persistently alters fear regulation.

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BDNF Val66Met genotype diminishes cued-fear extinction learning.

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Age and BDNF genotype may impact the efficacy of exposure-based therapies.

Fear extinction learning is a highly adaptive process that involves the integrity of frontolimbic circuitry. Its disruption has been associated with emotional dysregulation in stress and anxiety disorders. In this article we consider how age, genetics and experiences shape our capacity to regulate fear in cross-species studies. Evidence for adolescent-specific diminished fear extinction learning is presented in the context of immature frontolimbic circuitry. We also present evidence for less neural plasticity in fear regulation as a function of early-life stress and by genotype, focusing on the common brain derived neurotrophin factor (BDNF) Val66Met polymorphism. Finally, we discuss this work in the context of exposure-based behavioral therapies for the treatment of anxiety and stress disorders that are based on principles of fear extinction. We conclude by speculating on how such therapies may be optimized for the individual based on the patient's age, genetic profile and personal history to move from standard treatment of care to personalized and precision medicine.

Chilling and frost tolerance in Miscanthus and Saccharum genotypes bred for cool temperate climates

Miscanthus hybrids are leading candidates for bioenergy feedstocks in mid to high latitudes of North America and Eurasia, due to high productivity associated with the C4 photosynthetic pathway and their tolerance of cooler conditions. However, as C4 plants, they may lack tolerance of chilling conditions (0-10 °C) and frost, particularly when compared with candidate C3 crops at high latitudes. In higher latitudes, cold tolerance is particularly important if the feedstock is to utilize fully the long, early-season days of May and June. Here, leaf gas exchange and fluorescence are used to assess chilling tolerance of photosynthesis in five Miscanthus hybrids bred for cold tolerance, a complex Saccharum hybrid (energycane), and an upland sugarcane variety with some chilling tolerance. The chilling treatment consisted of transferring warm-grown plants (25/20 °C day/night growth temperatures) to chilling (12/5 °C) conditions for 1 week, followed by assessing recovery after return to warm temperatures. Chilling tolerance was also evaluated in outdoor, spring-grown Miscanthus genotypes before and after a cold front that was punctuated by a frost event. Miscanthus×giganteus was found to be the most chilling-tolerant genotype based on its ability to maintain a high net CO2 assimilation rate (A) during chilling, and recover A to a greater degree following a return to warm conditions. This was associated with increasing its capacity for short-term dark-reversible photoprotective processes (ΦREG) and the proportion of open photosystem II reaction centres (qL) while minimizing photoinactivation (ΦNF). Similarly, in the field, M.×giganteus exhibited a significantly greater A and pre-dawn F v/F m after the cold front compared with the other chilling-sensitive Miscanthus hybrids.

Translocations at 8q24 juxtapose MYC with genes that harbor superenhancers resulting in overexpression and poor prognosis in myeloma patients

Secondary MYC translocations in myeloma have been shown to be important in the pathogenesis and progression of disease. Here, we have used a DNA capture and massively parallel sequencing approach to identify the partner chromosomes in 104 presentation myeloma samples. 8q24 breakpoints were identified in 21 (20%) samples with partner loci including IGH, IGK and IGL, which juxtapose the immunoglobulin (Ig) enhancers next to MYC in 8/23 samples. The remaining samples had partner loci including XBP1, FAM46C, CCND1 and KRAS, which are important in B-cell maturation or myeloma pathogenesis. Analysis of the region surrounding the breakpoints indicated the presence of superenhancers on the partner chromosomes and gene expression analysis showed increased expression of MYC in these samples. Patients with MYC translocations had a decreased progression-free and overall survival. We postulate that translocation breakpoints near MYC result in colocalization of the gene with superenhancers from loci, which are important in the development of the cell type in which they occur. In the case of myeloma these are the Ig loci and those important for plasma cell development and myeloma pathogenesis, resulting in increased expression of MYC and an aggressive disease phenotype.

Inherited genetic susceptibility to multiple myeloma

Although the familial clustering of multiple myeloma (MM) supports the role of inherited susceptibility, only recently has direct evidence for genetic predisposition been demonstrated. A meta-analysis of two genome-wide association (GWA) studies has identified single-nucleotide polymorphisms (SNPs) localising to a number of genomic regions that are robustly associated with MM risk. In this review, we provide an overview of the evidence supporting a genetic contribution to the predisposition to MM and MGUS (monoclonal gammopathy of unknown significance), and the insight this gives into the biological basis of disease aetiology. We also highlight the promise of future approaches to identify further specific risk factors and their potential clinical utility.

Initial events during the evolution of C4 photosynthesis in C3 species of Flaveria

The evolution of C4 photosynthesis in many taxa involves the establishment of a two-celled photorespiratory CO2 pump, termed C2 photosynthesis. How C3 species evolved C2 metabolism is critical to understanding the initial phases of C4 plant evolution. To evaluate early events in C4 evolution, we compared leaf anatomy, ultrastructure, and gas-exchange responses of closely related C3 and C2 species of Flaveria, a model genus for C4 evolution. We hypothesized that Flaveria pringlei and Flaveria robusta, two C3 species that are most closely related to the C2 Flaveria species, would show rudimentary characteristics of C2 physiology. Compared with less-related C3 species, bundle sheath (BS) cells of F. pringlei and F. robusta had more mitochondria and chloroplasts, larger mitochondria, and proportionally more of these organelles located along the inner cell periphery. These patterns were similar, although generally less in magnitude, than those observed in the C2 species Flaveria angustifolia and Flaveria sonorensis. In F. pringlei and F. robusta, the CO2 compensation point of photosynthesis was slightly lower than in the less-related C3 species, indicating an increase in photosynthetic efficiency. This could occur because of enhanced refixation of photorespired CO2 by the centripetally positioned organelles in the BS cells. If the phylogenetic positions of F. pringlei and F. robusta reflect ancestral states, these results support a hypothesis that increased numbers of centripetally located organelles initiated a metabolic scavenging of photorespired CO2 within the BS. This could have facilitated the formation of a glycine shuttle between mesophyll and BS cells that characterizes C2 photosynthesis.

A School-Located Vaccination Adolescent Pilot Initiative in Chicago: Lessons Learned

BACKGROUND

Many adolescents underutilize preventive services and are underimmunized.

METHODS

To promote medical homes and increase immunization rates, we conceptualized and implemented a 3-year, 8-school pilot school-located vaccination collaborative program. We sought community, parent, and school nurse input the year prior to implementation. We selected schools with predominantly Medicaid-enrolled or Medicaid-eligible students to receive Vaccines For Children stock vaccines. Nurses employed by a mass immunizer delivered these vaccines at participating schools 3 times a year.

RESULTS

Over 3 years, we delivered approximately 1800 vaccines at schools. School administrators, health centers, and neighboring private physicians generally welcomed the program. Parents did not express overt concerns about school-located vaccination. School nurses were not able to participate because of multiple school assignments. Obtaining parental consent via backpack mail was an inefficient process, and classroom incentives did not increase consent form return rate. The influenza vaccine had the most prolific uptake. The optimal time for administering vaccines was during regular school hours.

CONCLUSIONS

Although school-located vaccination for adolescents is feasible, this is a paradigm shift for community members and thus accompanies challenges in implementation. High principal or school personnel turnover led to a consequent lack of institutional memory. It was difficult to communicate directly with parents. Because we were uncertain about the proportion of parents who received consent forms, we are exploring Internet-based and back-to-school registration options for making the consent form distribution and return process more rigorous. Securing an immunization champion at each school helped the immunization processes. Identifying a financially sustainable school-located vaccination model is critical for national expansion of school-located vaccination.

Factors associated with timely initiation of antiretroviral therapy in two HIV clinics in Lilongwe, Malawi

The World Health Organization (WHO) estimates that only 30% of eligible, HIV-infected individuals start antiretroviral therapy (ART). This study seeks to explore the geographic and individual factors associated with starting ART on time. This retrospective study includes 15,734 HIV-positive adults initiating ART at two HIV clinics in Lilongwe, Malawi. The outcome was starting ART within two weeks of meeting ART eligibility as defined by the Malawi ART guidelines. Euclidean distance from patient neighbourhood to their clinic was calculated using Google Earth. Logistic regression models assessed factors influencing starting ART on time. Of 15,734 adults initiating ART, 8178 were from Lighthouse (LH) and 7556 were from Martin Preuss Center (MPC). Combined, 68.7% started treatment on time. Patients who were eligible for ART based on a CD4 cell count <250 cells/mm(3) versus WHO stage were less likely to begin ART on time at both LH (odds ratio [OR] 0.16; 95% CI 0.13-0.19) and MPC (OR 0.24; 95% CI 0.21-0.28). Likelihood of starting on time decreased with each kilometer further from clinic location among LH patients (OR 0.97; 95% CI 0.94-0.99); distance was not significant at MPC. In conclusion, predictors differed by clinic. Distance to clinic and type of eligibility for ART significantly influence starting ART on time.

Comparison of Potential-Time Waveforms for the Detection of Biogenic Amines in Complex Mixtures following Their Separation by Liquid Chromatography

Pulsed amperometric detection (PAD), integrated voltammetric detection (IVD), and integrated square-wave detection (ISWD) at gold electrodes are compared for the flow injection detection of 1,3-diaminopropane in a liquid chromatograph (LC). These detection methods are especially significant for alkylamines and amino acids because (i) the majority of these compounds do not naturally possess chromophoric or fluorophoric functional groups and (ii) their amperometric detection at constant potential at Au electrodes fails because the electrode activity is severely attenuated by the formation of an inert surface oxide (AuO). The anodic response mechanisms for detection of amines require concomitant formation of AuO; therefore, a large background signal is observed with conventional PAD. In comparison, the background is much smaller for IVD and ISWD because the anodic charge for oxide formation (positive scan/step) is compensated by the cathodic charge for oxide reduction (negative scan/step). The limits of detection (S/N = 3) for 1,3-diaminopropane by LC-PAD, LC-IVD and LC-ISWD are about 3 × 10(2) pg (4 pmol), 5 × 10(1) pg (0.7 pmol), and 3 × 10(1) pg (0.5 pmol), respectively, for 25-μL injections. Results are also shown to demonstrate ISWD for detection of nine biogenic amines following their chromatographic separation.

Effect of patient- and medication-related factors on inpatient medication reconciliation errors

BACKGROUND

Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge.

OBJECTIVE

To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list.

DESIGN, PARTICIPANTS

We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study.

MAIN MEASURES

Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors.

KEY RESULTS

On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11).

CONCLUSIONS

Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy

BACKGROUND

High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered.

METHODS

A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics.

RESULTS

Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2224 exposed to warfarin, 8383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period-and the heparinlenoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent.

CONCLUSIONS

Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy.

The occurrence of C(2) photosynthesis in Euphorbia subgenus Chamaesyce (Euphorbiaceae)

This study investigated whether Euphorbia subgenus Chamaesyce subsection Acutae contains C(3)-C(4) intermediate species utilizing C(2) photosynthesis, the process where photorespired CO(2) is concentrated into bundle sheath cells. Euphorbia species in subgenus Chamaesyce are generally C(4), but three species in subsection Acutae (E. acuta, E. angusta, and E. johnstonii) have C(3) isotopic ratios. Phylogenetically, subsection Acutae branches between basal C(3) clades within Euphorbia and the C(4) clade in subgenus Chamaesyce. Euphorbia angusta is C(3), as indicated by a photosynthetic CO(2) compensation point (Г) of 69 μmol mol(-1) at 30 °C, a lack of Kranz anatomy, and the occurrence of glycine decarboxylase in mesophyll tissues. Euphorbia acuta utilizes C(2) photosynthesis, as indicated by a Г of 33 μmol mol(-1) at 30 °C, Kranz-like anatomy with mitochondria restricted to the centripetal (inner) wall of the bundle sheath cells, and localization of glycine decarboxlyase to bundle sheath mitochondria. Low activities of PEP carboxylase, NADP malic enzyme, and NAD malic enzyme demonstrated no C(4) cycle activity occurs in E. acuta thereby classifying it as a Type I C(3)-C(4) intermediate. Kranz-like anatomy in E. johnstonii indicates it also utilizes C(2) photosynthesis. Given the phylogenetically intermediate position of E. acuta and E. johnstonii, these results support the hypothesis that C(2) photosynthesis is an evolutionary intermediate condition between C(3) and C(4) photosynthesis.

Pediatric antiretroviral therapy

The rate of perinatal HIV transmission has decreased significantly in developed countries. However, worldwide, it remains the main source of HIV infection within the pediatric population. Recent advances as a result of findings from clinical trials, viral resistance testing and the advent of new drugs have increased the options for initial treatment regimens. This article provides an overview of antiretroviral therapy in treatment-naive children, including recent pediatric data and updated guidelines from the NIH. It also provides information on new drugs approved for the pediatric age group, dosage information, drug resistance testing and monitoring suggestions for children and adolescents receiving antiretroviral therapy. Special issues pertaining to adherence, disclosure and contraception are also highlighted.

Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study

BACKGROUND

Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens, suboptimal discharge instructions, and prolonged time to follow-up. Pharmacist-based interventions may be effective in promoting the safe and effective use of medications, especially among high-risk patients such as those with low health literacy.

METHODS AND RESULTS

The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study is a randomized controlled trial conducted at 2 academic centers-Vanderbilt University Hospital and Brigham and Women's Hospital. Patients admitted with acute coronary syndrome or acute decompensated heart failure were randomly assigned to usual care or intervention. The intervention consisted of pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and tailored telephone follow-up after discharge. The primary outcome is the occurrence of serious medication errors in the first 30 days after hospital discharge. Secondary outcomes are health care utilization, disease-specific quality of life, and cost-effectiveness. Enrollment was completed September 2009. A total of 862 patients were enrolled, and 430 patients were randomly assigned to receive the intervention. Analyses will determine whether the intervention was effective in reducing serious medication errors, particularly in patients with low health literacy.

CONCLUSIONS

The PILL-CVD study was designed to reduce serious medication errors after hospitalization through a pharmacist-based intervention. The intervention, if effective, will inform health care facilities on the use of pharmacist-assisted medication reconciliation, inpatient counseling, low-literacy adherence aids, and patient follow-up after discharge. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00632021.

Judgment of action capabilities in children at risk for developmental coordination disorder

PURPOSE

To evaluate the ability to accurately perceive the limits of action capabilities in children at risk for developmental coordination disorder (DCD).

METHODS

In Study 1, 9 to 12-year-old children (mean = 10.6 years, SD = 1.09) were identified as at risk for DCD and the accuracy of their perceptual judgments was compared with the judgments of a group of typically developing children (TDC). Two judgment tasks were used: Maximum vertical reach and maximum sitting height. Study 2 tested the hypothesis that a significant correlation would be found between a specific movement task and a related judgment task. Participants were randomly selected (n = 24) 10 and 11-year-old children (mean = 10.5 years, SD = 0.51).

RESULTS

Magnitude of judgment error (absolute error) on all tasks was significantly (p < 0.05) greater in the DCD group than in the TDC group. Study 2 revealed a significant (p < 0.05) correlation between the movement task and the related perceptual task (r = 0.70).

CONCLUSION

Compared to a typically developing group, children at risk for DCD made less accurate judgments of the limits of their action capabilities. The accuracy of a perceptual judgment was found to correlate with a related movement skill.

Children at risk for developmental coordination disorder: judgement of changes in action capabilities

In three separate manipulations, a group of children at risk for developmental coordination disorder (DCD; five males, seven females; mean age 11y 6mo [SD 6.8mo] who were at or below the 15th centile on the Movement ABC) and a group of typically developing children (TDC; seven males, five females; mean age 11y 3mo [SD 6.8mo]) judged the limit of their standing horizontal reach (HRmax) under two conditions in which actual HRmax differed. The manipulations were: (1) one-hand versus two-hand reach; and (2) standard versus short effective foot-length; and (3) rigid versus compliant support surface. For the foot-length and support surface manipulations (but not for the hand manipulation), children correctly judged that their actual HRmax differed in the two conditions (p<.05). On all three manipulations, TDC made significantly larger adjustments in their judgements than did children at risk for DCD (p<0.05). The TDC group adjusted their judgements in the appropriate direction on all three manipulations, whereas the DCD group adjusted in the appropriate direction for the foot-length manipulation only. The results suggest that children at risk for DCD are less adept at detecting changes in the limits of their action capabilities.

HIV-1 vaccine induced immune responses in newborns of HIV-1 infected mothers

OBJECTIVE

Breast milk transmission continues to account for a large proportion of cases of mother-to-child transmission of HIV-1 worldwide. An effective HIV-1 vaccine coupled with either passive immunization or short-term antiretroviral prophylaxis represents a potential strategy to prevent breast milk transmission. This study evaluated the safety and immunogenicity of ALVAC HIV-1 vaccine with and without a subunit envelope boost in infants born to HIV-1-infected women.

DESIGN

: Placebo-controlled, double-blinded study.

METHODS

Infants born to HIV-1-infected mothers in the US were immunized with a prime-boost regimen using a canarypox virus HIV-1 vaccine (vCP1452) and a recombinant glycoprotein subunit vaccine (rgp120). Infants (n = 30) were randomized to receive: vCP1452 alone, vCP1452 + rgp120, or corresponding placebos.

RESULTS

Local reactions were mild or moderate and no significant systemic toxicities occurred. Subjects receiving both vaccines had gp120-specific binding serum antibodies that were distinguishable from maternal antibody. Repeated gp160-specific lymphoproliferative responses were observed in 75%. Neutralizing activity to HIV-1 homologous to the vaccine strain was observed in 50% of the vCP1452 + rgp120 subjects who had lost maternal antibody by week 24. In some infants HIV-1-specific proliferative and antibody responses persisted until week 104. HIV-1-specific cytotoxic T lymphocyte responses were detected in two subjects in each treatment group; the frequency of HIV-1 specific cytotoxic T lymphocyte responses did not differ between vaccine and placebo recipients.

CONCLUSION

The demonstration of vaccine-induced immune responses in early infancy supports further study of HIV-1 vaccination as a strategy to reduce breast milk transmission.

Safety and Immunogenicity of an HIV‐1 Recombinant Canarypox Vaccine in Newborns and Infants of HIV‐1–Infected Women

Pediatric AIDS Clinical Trials Group protocol 326 is a study of 2 formulations of recombinant canarypox ALVAC vaccine (vCP205) against human immunodeficiency virus type 1 (HIV-1). HIV-1-exposed infants were randomized to receive 1 of 2 formulations of vCP205 or placebo at birth and 4, 8, and 12 weeks. The vaccines were safe. Lymphoproliferative responses were detected at > or =2 time points in 44%-56% of vaccinees and none of the placebo recipients. A cytotoxic T lymphocyte response on at least 1 occasion was detected in 62.5% of infants in cohort 1 (10(6.08) median tissue culture dose [TCID(50)] vaccine formulation) and 44% of infants in cohort 2 (10(6.33) TCID(50) vaccine formulation). Rare mucosal immunoglobulin A responses and no measurable vaccine-elicited serum antibodies were detected. In children, vCP205 appeared to be safe and immunogenic.

NifU and NifS are required for the maturation of nitrogenase and cannot replace the function of isc-gene products in Azotobacter vinelandii

In recent years, it has become evident that [Fe-S] proteins, such as hydrogenase, nitrogenase and aconitase, require a complex machinery to assemble and insert their associated [Fe-S] clusters. So far, three different types of [Fe-S] cluster biosynthetic systems have been identified and these have been designated nif, isc and suf. In the present work, we show that the nif-specific [Fe-S] cluster biosynthetic system from Azotobacter vinelandii, which is required for nitrogenase maturation, cannot functionally replace the isc [Fe-S] cluster system used for the maturation of other [Fe-S] proteins, such as aconitase. The results indicate that, in certain cases, [Fe-S] cluster biosynthetic machineries have evolved to perform only specialized functions.

Effectiveness of Screening Aqueous Contrast Swallow in Detecting Clinically Significant Anastomotic Leaks after Esophagectomy

BACKGROUND

Aqueous contrast swallow study is recommended as a screening procedure for the evaluation of esophageal anastomotic integrity following esophagectomy. The aim of this study was to assess the accuracy of water-soluble contrast swallow screening as a predictor of clinically significant anastomotic leak in patients with esophagectomy.

PATIENTS AND METHODS

The records of 505 consecutive patients undergoing esophagectomy in Mayo Clinic from January 1991 through December 1995 were retrospectively reviewed. 464 (92%) patients had water-soluble contrast swallows performed in the early postoperative period (median postoperative day 7, range 4-11 days).

RESULTS

A total of 39 radiological leaks were obtained but only 17 of these had clinical signs of anastomotic leakage. Furthermore, 25 patients who had normal swallow study developed a clinical anastomotic leak. There were therefore 22 (4.7%) false positive and 25 (5.4%) false negative results giving values for the specificity, sensitivity and false negative error rate of the radiological examination of 94.7, 40.4, and 59.5% respectively. Aspiration of the contrast agent was noted on fluoroscopy in 30 (6.5%) patients. Only 2 (0.4%) patients developed aqueous contrast agent-caused aspiration pneumonia. There was no procedure-related mortality.

CONCLUSION

While radiological assessment of esophageal anastomoses in the early postoperative period using aqueous contrast agents appears to be a relatively safe procedure, the poor sensitivity and high false negative error rate of this technique, when performed on postoperative day 7 and in a series with clinical anastomotic leak rate of 9%, is insufficient for it to be worthwhile as a screening procedure.

Sudden Infant Death Syndrome and prenatal maternal smoking: rising attributed risk in the Back to Sleep era

BACKGROUND

Parental smoking and prone sleep positioning are recognized causal features of Sudden Infant Death. This study quantifies the relationship between prenatal smoking and infant death over the time period of the Back to Sleep campaign in the United States, which encouraged parents to use a supine sleeping position for infants.

METHODS

This retrospective cohort study utilized the Colorado Birth Registry. All singleton, normal birth weight infants born from 1989 to 1998 were identified and linked to the Colorado Infant Death registry. Multivariable logistic regression was used to analyze the relationship between outcomes of interest and prenatal maternal cigarette use. Potential confounders analyzed included infant gender, gestational age, and birth year as well as maternal marital status, ethnicity, pregnancy interval, age, education, and alcohol use.

RESULTS

We analyzed 488,918 birth records after excluding 5835 records with missing smoking status. Smokers were more likely to be single, non-Hispanic, less educated, and to report alcohol use while pregnant (p < 0.001). The study included 598 SIDS cases of which 172 occurred in smoke-exposed infants. Smoke exposed infants were 1.9 times (95% CI 1.6 to 2.3) more likely to die of SIDS. The attributed risk associating smoking and SIDS increased during the study period from approximately 50% to 80%. During the entire study period 59% (101/172) of SIDS deaths in smoke-exposed infants were attributed to maternal smoking.

CONCLUSIONS

Due to a decreased overall rate of SIDS likely due to changing infant sleep position, the attributed risk associating maternal smoking and SIDS has increased following the Back to Sleep campaign. Mothers should be informed of the 2-fold increased rate of SIDS associated with maternal cigarette consumption.

Barriers to effective symptom management in hospice

The barriers to effective symptom management in hospice are not well described. We surveyed nurses of hospices affiliated with the Population-based Palliative Care Research Network (PoPCRN) to identify barriers to the effective management of common symptoms in terminally ill patients. 867/1710 (51%) nurses from 67 hospices in 25 U.S. States returned surveys. Of 32 symptoms, nurses reported agitation (45%), pain (40%), and dyspnea (34%) as the 'most difficult to manage.' The most common perceived barriers to effective symptom management were inability of family care providers to implement or maintain recommended treatments (38%), patients or families not wanting recommended treatments (38%), and competing demands from other distressing symptoms (37%). Patterns of barriers varied by symptom. These nurses endorsed multiple barriers contributing to unrelieved symptom distress in patients receiving hospice care. Interventions to improve symptom management in hospice may need to account for these differing barrier patterns.

Key Articles and Guidelines Relative to Treatment of Patients with Acute Coronary Syndromes

Patients with cardiovascular disease who have acute coronary syndromes (ACS) are at risk of significant morbidity and mortality. Also, treatment of these patients in the early-phase setting has a significant financial impact on the health care system. With the existence of numerous pharmacologic agents, abundance of major clinical trials, and several nationally recognized clinical guidelines, compiling the needed reference material to make evidence-based decisions on the care of patients with ACS can be difficult for clinicians. To assist clinicians in this endeavor, we complied pertinent articles and guidelines that have shaped the current treatment of patients with ACS. Owing to the rapidly evolving body of evidence in the management of ACS, this compilation will require periodic updating.

Solidification of stainless steel slag by accelerated carbonation

On exposure to carbon dioxide (CO2) at a pressure of 3 bars, compacts formed from pressed ground slag, and 12.5 weight percent water, were found to react with approximately 18% of their own weight of CO2. The reaction product formed was calcium carbonate causing the slag to self-cement. Unconfined compressive strengths of 9MPa were recorded in carbonated compacts whereas strengths of < 1 MPa were recorded in non-carbonated slag compacts. As molten stainless steel slag containing dicalcium silicate (C2S) cools it can undergo several phase transitions. The final transformation from the beta-polymorph to gamma-C2S is accompanied by a volume change that causes the slag to self-pulverise or 'dust'. As a consequence of this the fine grained portion of the slag contains more of this phase whilst the coarser particles of the slag contain more of the calcium magnesium silicates that contribute the bulk of the waste. The fine fraction (< 125 microm) of the slag when ground is found to react to the same extent as the ground bulk slag and produces compacts with equivalent strength. A coarser fraction (4-8 mm) when ground to a similar grading does not react as extensively and produces a weaker product. Additions of ordinary Portland cement (OPC) at 5 and 10 percent by weight did not alter the degree of reaction during carbonation of the bulk slag or ground fine fraction, however the strength of the 4-8 mm fraction was increased by this change.

Acid neutralisation capacity of accelerated carbonated stainless steel slag

The acid neutralisation capacity test is widely used to assess the long-term performance of waste materials prior to disposal. Samples of fixed mass are exposed to increasing additions of nitric add in sealed containers and the resultant pH is plotted as a titration curve. In this work, the add neutralisation capacity test was used in the assessment of an accelerated carbonated stainless steel slag. Difficulties arose in applying the test procedure to this material. This was largely because of the raised pressure from significant volumes of released carbon dioxide trapped in the sealed sample containers, causing an alteration to leachate pH values. Consequently, the add neutralisation capacity test was modified to enable testing of samples in equilibrium with the atmosphere. No adverse effects on the results from testing of a carbonate free material were recorded.

Would you be surprised if this patient died?: Preliminary exploration of first and second year residents' approach to care decisions in critically ill patients

BACKGROUND: How physicians approach decision-making when caring for critically ill patients is poorly understood. This study aims to explore how residents think about prognosis and approach care decisions when caring for seriously ill, hospitalized patients. METHODS: Qualitative study where we conducted structured discussions with first and second year internal medicine residents (n = 8) caring for critically ill patients during Medical Intensive Care Unit Ethics and Discharge Planning Rounds. Residents were asked to respond to questions beginning with "Would you be surprised if this patient died?" RESULTS: An equal number of residents responded that they would (n = 4) or would not (n = 4) be surprised if their patient died. Reasons for being surprised included the rapid onset of an acute illness, reversible disease, improving clinical course and the patient's prior survival under similar circumstances. Residents reported no surprise with worsening clinical course. Based on the realization that their patient might die, residents cited potential changes in management that included clarifying treatment goals, improving communication with families, spending more time with patients and ordering fewer laboratory tests. Perceived or implied barriers to changes in management included limited time, competing clinical priorities, "not knowing" a patient, limited knowledge and experience, presence of diagnostic or prognostic uncertainty and unclear treatment goals. CONCLUSIONS: These junior-level residents appear to rely on clinical course, among other factors, when assessing prognosis and the possibility for death in severely ill patients. Further investigation is needed to understand how these factors impact decision-making and whether perceived barriers to changes in patient management influence approaches to care.

Inhibition of the MHC class II antigen presentation pathway by human cytomegalovirus

Human cytomegalovirus (HCMV) causes serious disease in immunocompromised individuals. Normally, anti-HCMV immune response controls virus replication following reactivation from latency. However, HCMV, like other large herpesviruses, encodes immune evasion proteins that allow the virus to replicate, for a time or in specific tissues, and produce viral progeny in the face of robust host immunity. HCMV glycoproteins US2, US3, US6 and US11 all inhibit different stages of the MHC class I antigen presentation pathway and can reduce recognition by CD8+ T lymphocytes. Here, we discuss two novel inhibitors of the MHC class II antigen presentation pathway, HCMV glycoproteins US2 and US3. Both US2 and US3 can inhibit presentation of exogenous protein antigens to CD4+ T lymphocytes in in vitro assays. US2 causes degradation of MHC class II molecules: HLA-DR-alpha and HLA-DM-alpha, as well as class I heavy chain (HC), but does not affect DR-beta or DM-beta chains. Mutant forms of US2 have been constructed that can bind to DR-alpha and class I HC but do not cause their degradation, separating the binding step from other processes that precede degradation. We also found evidence that US2-induced degradation of class I and II proteins involves a cellular component, other than Sec61, that is limiting in quantity. Unlike US2, US3 binds newly synthesized class II alpha/beta complexes, reducing the association with the invariant chain (Ii) and causing mislocalization of class II complexes in cells. US3 expression reduces accumulation of class II complexes in peptide-loading compartments and loading of peptides. Since US2 and US3 are expressed solely within HCMV-infected cells, it appears that these viral proteins have evolved to inhibit presentation of endogenous, intracellular viral antigens to anti-HCMV CD4+ T cells. This is different from how the MHC class II pathway is normally viewed, as a pathway for presentation of exogenous, extracellular proteins. The existence of these proteins indicates the importance of class II-mediated presentation of endogenous antigens in signalling virus infection to CD4+ T cells.

Herpes simplex virus with highly reduced gD levels can efficiently enter and spread between human keratinocytes

The rapid spread of herpes simplex virus type 1 (HSV-1) in mucosal epithelia and neuronal tissue depends primarily on the ability of the virus to navigate within polarized cells and the tissues they constitute. To understand HSV entry and the spread of virus across cell junctions, we have previously characterized a human keratinocyte cell line, HaCaT. These cells appear to reflect cells infected in vivo more accurately than many of the cultured cells used to propagate HSV. HSV mutants lacking gE/gI are highly compromised in spread within epithelial and neuronal tissues and also show defects in cell-to-cell spread in HaCaT cells, but not in other, nonpolarized cells. HSV gD is normally considered absolutely essential for entry and cell-to-cell spread, both in cultured cells and in vivo. Here, an HSV-1 gD mutant virus, F-US6kan, was found to efficiently enter HaCaT cells and normal human keratinocytes and could spread from cell to cell without gD provided by complementing cells. By contrast, entry and spread into other cells, especially highly transformed cells commonly used to propagate HSV, were extremely inefficient. Further analyses of F-US6kan indicated that this mutant expressed extraordinarily low (1/500 wild-type) levels of gD. Neutralizing anti-gD monoclonal antibodies inhibited entry of F-US6kan, suggesting F-US6kan utilized this small amount of gD to enter cells. HaCaT cells expressed high levels of an HSV gD receptor, HveC, and entry of F-US6kan into HaCaT cells could also be inhibited with antibodies specific for HveC. Interestingly, anti-HveC antibodies were not fully able to inhibit entry of wild-type HSV-1 into HaCaT cells. These results help to uncover important properties of HSV and human keratinocytes. HSV, with exceedingly low levels of a crucial receptor-binding glycoprotein, can enter cells expressing high levels of receptor. In this case, surplus gD may be useful to avoid neutralization by anti-gD antibodies.