Performance of the ACMG-AMP criteria in a large familial renal glucosuria cohort with identified SLC5A2 sequence variants

Familial Renal Glucosuria (FRG) is a co-dominantly inherited trait characterized by orthoglycaemic glucosuria. From 2003 to 2015 we have reported several cohorts validating SLC5A2 (16p11.2), encoding SGLT2 (Na+/glucose cotransporter family member 2), as the gene responsible for FRG. The aim of this work was to validate the variants identified in our extended FRG cohort of published, as well more recent unreported cases, according to the ACMG-AMP 2015 criteria. Forty-six variants were evaluated, including 16 novel alleles first described in this study. All are rare, ultra-rare or absent from population databases and most are missense changes. According to the ACMG-AMP standards, only 74% of the variants were classified as P/LP. The lack of descriptions of unrelated patients with similar variants or failing to test additional affected family members, averted a conclusion for pathogenicity in the alleles that scored VUS, highlighting the importance of both family testing and variant reporting. Finally, the cryo-EM structure of the hSGLT2-MAP17 complex in the empagliflozin-bound state improved the ACMG-AMP pathogenicity score by identifying critical/functional protein domains.

Anorexia nervosa admissions during the COVID-19 pandemic: results from a Department of Psychiatry in northern Portugal

Introduction

Emerging evidence suggests that the COVID-19 pandemic had a negative impact on mental health. In particular, patients with Anorexia nervosa (AN) may have faced increased symptom severity.

Objectives

To compare the clinical characteristics of inpatients with AN admitted amidst the COVID-19 pandemic versus the two previous years.

Methods

Retrospective observational study of inpatients admitted between January 2018 and December 2020 in a psychiatry inpatient unit of a tertiary hospital.

Results

There were 11 admissions of patients with AN in 2020 (8 from March onwards), a 22% increase relative to 2019, which in turn saw a 28% increase in admissions relative to 2018. Most patients had an AN diagnosis previous to the pandemic. The majority were undergoing outpatient treatment for over a year. Two patients were admitted within a month of outpatient treatment. There was an increase in admissions through the emergency service in 2020. The most frequent diagnostic was AN binge-eating/purging type in 2020 and 2019, whereas in 2018 the AN restrictive type was dominant. Mean BMI at admission and average length of stay were similar across the three years. Readmission in a 12-month period was 54,5% in 2020 (22,2% in 2019 and 42,9% in 2018).

Conclusions

Despite the widespread impression of a negative impact of the pandemic on AN patients, in our study the clinical characteristics of AN patients admitted in 2020 were mostly similar to the two previous years. Readmissions were higher in 2020, therefore future analysis of data from 2021 might be more enlightening.

Disclosure

No significant relationships.

First year of implementation of a drug consumption room in Lisbon: the client’s profile

Issue

Drug consumption rooms (DCR) are in place for more than three decades in Europe and have been proven to be effective as a public health response. However, their implementation remains slow and controversial in many countries. In Portugal, despite being legal since 2001, the first DCR only came into reality in 2019 by the initiative of the City Council of Lisbon.

Description of the Problem

These Programs are aimed at high risk users with a very fragile social and health situation and for that reason usually they adopt a integrate model of care, offering other services behind supervised consumption: basic healthcare, social support, rapid testing and referral to other services. In context of the first year of implementation of a mobile DCR in Lisbon, we intend to investigate if the program was able to reach those at higher risk. Service data collected between April and December 2019 was used to define the client's profile.

Results

The data collected by the program indicates that the vast majority of registered users are men, over 40 years old and homeless. Most users have already been tested for HIV and viral hepatitis in their lifetime, however, there are still barriers in accessing and utilizing specialized care. We also observed high risk practices: injecting in public spaces, groin injection and high rates of benzodiazepine injection.

Lessons

The mobile DCR in Lisbon was able to reach those users at greater risk, both by the pattern of consumption, and by the social and health situation in which they find themselves.

Key message

DCR combined with other harm reduction responses and health services can contribute to improve the health of a very marginalized group of users.

Characteristics of Patients and Treatment Recommendations from a Multidisciplinary Spinal Tumor Program

Objective: We describe characteristics of patient and treatment recommendations from a spinal tumor board at one institution, including representation from palliative care.

Background: The impact of prospective multidisciplinary input for patients with spinal tumors is poorly understood despite their increasing complexity.

Methods: We retrospectively reviewed 622 cases sequentially discussed at a weekly spinal tumor board, and abstracted patient and treatment information from the medical record and meeting minutes.

Results: From April 2017 to February 2019, 622 cases representing 438 unique patients were discussed. The median age was 62 years (range 21–92). Most patients had spinal tumors originating from metastases (91.78%), including breast (14.3%), nonsmall cell lung cancer (13.4%), prostate (10.9%), and renal cell cancer (8.8%), and the remainder had primary central nervous system (4.3%) or benign tumors (3.9%). Sixty-five percent of patients were alive at last follow-up. Conventional external beam radiotherapy was the most common treatment recommendation (33.8%) followed by surgery (26.2%), stereotactic body radiation therapy (17.8%), imaging follow-up (16.6%), and vertebroplasty (15.9%). Palliative care was the primary treatment recommended for 4.5%, and no therapy recommended for 4.0%. Treatment recommendation involved two modalities for 29% of cases, and three in 1.3% of cases. In four cases, biopsy to confirm pathology changed management due to unexpected findings of osteomyelitis, hematopoiesis, or new diagnosis of plasmacytoma.

Conclusions: Multidisciplinary input is integral to the optimal care of spinal tumor patients. The high risk of death highlights the need to prioritize modalities that optimize quality of life in the context of a patient's individual prognosis.

Factors affecting mortality in major trauma patients in Trinidad and Tobago – A view from the developing world

Introduction

There are few data on major trauma in the developing world. This study investigated the characteristics and outcomes of seriously injured patients in Trinidad and Tobago, using Trauma and Injury Severity Score (TRISS) methodology. We also aimed to assess the predictive accuracy of the TRISS model in patients in Trinidad and Tobago.

Methods

Retrospective data from major trauma patients attending the Emergency Department of a tertiary hospital in Trinidad between 2010 and 2014 were analysed. Patients ≥18 years having an Injury Severity Score >15 were included. The impact of age, gender, comorbidities, mechanisms and patterns of injury on mortality was investigated. Using TRISS methodology, predicted mortality was calculated and compared to actual mortality.

Results

Of 323 patients analysed, 284 were male and 24 were aged ≥65 years. The commonest injury mechanisms in younger people were motor vehicle accidents (34.1%) and stabbings (30.8%) compared to falls (66.7%) and motor vehicle accidents (20.8%) in people aged ≥65 years. The commonest areas injured were the chest in younger patients (81.9%) and the head and neck in patients aged ≥65 years (58.3%). Women’s mortality rates were similar to men (RR 1.8; 95% CI 0.7–4.9). Mortality was higher with age ≥65 years (RR 7.0; 95% CI 3.1–15.9), blunt trauma (RR 7.6; 95% CI 1.8–32.4) and Charlson Comorbidity Index of 1 or more (RR 3.2; 95% CI 1.3–8.0). The TRISS model performed well at lower ISS scores and was excellent at predicting survival (discrimination statistic 0.94).

Conclusion

Multiple factors influence mortality in major trauma patients in Trinidad and Tobago, including age, co-morbidities and injury mechanism. TRISS methodology accurately predicted survival in this population but was better at predicting mortality in patients with lower Injury Severity Score.

Cybersecurity risk analysis in healthcare institutions

Introduction The growing digitization of businesses and its increasing dependence on Internet infrastructure has boosted the concerns related to data privacy and confidentiality. Healthcare institutions have been challenged with specific issues, namely the sensitivity of data, the specificity of networked equipment and the average information technology skills held by of healthcare professionals in Portugal.

Objectives To understand the relationship level established by healthcare professionals with the information security by assessing attitudes and behaviours in cybersecurity; to identify risks and actions that may be taken to enhance the healthcare professional’s cybersecurity awareness.

Methodology The study consists in translating, adjusting and applying two previously validated and published Likert-type response scales to assess health professionals' cybersecurity attitudes and behaviours in the Portuguese health environment. This is an observational, quantitative, cross-sectional and descriptive study in cybersecurity attitudes and behaviours in a healthcare institution in Portugal.

Results The sample was composed by 56 professionals, 71% women and 29% men, divided in four professional groups, where a mean (±SD) of 31.59 (±14.211) points was achieved for the cybersecurity risky behaviour (RScB) scale and 66.41 (±6,26) points for the cybersecurity and cybercrime in business attitudes scale (ATC-IB).

Conclusions There was no-significant statistical differences between the sociodemographic factors and the scores obtained on both scales. However, the points of the scales for the different domains evidences a statistical difference between ages, genders and professional groups by items, which are therefore important points for the development of future studies. The results showed a relationship between acquired behaviours and the attitudes of involvement with work and organizational commitment, establishing a bridge for the quantification in awareness.

The Relationship Between Self-Esteem, Emotional Intelligence, and Empathy Among Students From Six Health Professional Programs

Theory: Psychosocial skills such as communication, empathy, and emotional intelligence are now considered key attributes of health professionals. Self-esteem is another important construct that is less well studied. Self-esteem is important because low levels have been linked to depression, suicide, and eating disorders. Given that health professional students experience high levels of stress and are at increased risk for similar psychopathology, self-esteem may be an important variable in student well-being and performance after graduation. Hypotheses: This study sought to explore self-esteem during students' 1st year of training hypothesizing that several would demonstrate low self-esteem. It is also hypothesized that emotional intelligence and empathy would be associated with self-esteem. Method: A cross-sectional survey was conducted, and data were gathered from dental, medical, nursing, optometry, pharmacy and veterinary students. Self-report questionnaires assessing self-esteem, emotional intelligence, and empathy were completed and demographic information was collected. Scores were calculated and differences between groups analyzed with analysis of variance and chi-square testing. Pearson's correlation was used to assess associations between the constructs. Results: The mean self-esteem score was 26.2 ± 2.3 but 21% of the sample evidenced low self-esteem. There was no difference in the proportion of students demonstrating low self-esteem among programs. Gender did not have a significant effect on self-esteem scores, though ethnicity did. Emotional intelligence scores were higher among male individuals than among female. Emotional intelligence and empathy showed a small association with self-esteem. Conclusions: A significant proportion of health professional students suffer from low self-esteem during their 1st year of study. Such students may be more susceptible to the stresses associated with study and the development of psychopathology. More research needs to be conducted to explore the relationships between self-esteem, emotional intelligence, and empathy with a view to strengthening training in these areas and managing the challenges faced by health professional students.

The National Alcohol Survey of Households in Trinidad and Tobago (NASHTT): willingness to support changes in policy, laws and regulations

Background

Over 60% of households (HHs) in Trinidad and Tobago (T&T) consume alcohol. These HHs were more likely to report illnesses, relationship problems, and behavioral problems with children. This study set out to determine what proportion of HHs were willing to support changes in specific policies, laws and regulations in a national alcohol campaign.

Methods

A cross-sectional convenience sample of HHs were surveyed from a random sample of enumeration districts (ED) in T&T. An interviewer-applied, field pre-tested de novo questionnaire had 5 domains and was developed over 1 1/2 years after an extensive literature review and consultation. Many of the WHO ‘best buys’ recommendations were included.

Results

One thousand six hundred ninety-five HHs (from 53 ED) responded from a total of 1837 HHs approached (response rate 92%). In a national campaign the following proportions of HHs would support: setting the legal age for drinking at 21 years (82.4%); restricting or banning alcohol advertising on TV and other media (73.1% and 54.4% respectively); banning all alcohol advertising at sports and cultural events (64.8%); banning radio stations playing songs with reference to alcohol use (71.3%); holding sellers of alcohol responsible for the amount of alcohol sold (79.5%); advocating that proof of age to be shown by persons buying alcohol (87.4%); placing more prominent warning labels on products displaying alcohol content (87.2%); placing more prominent warning labels on products showing harmful effects (88.5%); increasing taxes on alcohol sales (87.7%). Less than 50% of HH supported restrictions in density of outlets and reduction in opening times for alcohol outlets.

Conclusions

Many HHs in T&T are willing to support changes in policies around alcohol, including many of the policies shown by the WHO to be effective in reducing the harmful consumption of alcohol.

Pediatric Renal Transplantation: Evaluation of Long-Term Outcomes and Comparison to Adult Population

BACKGROUND

In Europe, pediatric transplantation accounts for only about 4% of all kidney transplantations performed. The aim of our work is to evaluate the evolution of pediatric renal transplantation in our department over time, but also to compare this special population with the adult one.

METHODS

We evaluated all pediatric renal transplantations performed in our department between January 1981 and December 2016. We performed the analysis of clinical, analytical, and surgical factors to look for predictive factors of graft loss or decrease of survival. In addition, we performed a comparative study of pediatric and adult populations and an evaluation of the evolution of pediatric renal transplantation in our department over time.

RESULTS

We evaluated 101 renal transplantations performed in patients younger than 18 years. Pediatric transplantations corresponded to 3.4% of all renal transplantations performed in our department. The rate of living donors was 12%. Donors of grafts for the pediatric population were significantly younger than in the adult population. The increase in donor age was associated with lower renal graft survival rates. Acute rejections were more frequent in the pediatric population. Eleven pediatric recipients (10.9%) died in the follow-up period. Renal graft survival in the pediatric population was 94.8%, 77.4%, and 66.5% at 1, 5, and 10 years, respectively. There was no significant difference in graft survival in the pediatric and adult population. The pediatric overall survival rate at 1, 5 and 10 years was 97.9%, 96.8%, and 91.9%, respectively.

CONCLUSION

Pediatric renal transplantation presents results identical to those identified in adults.

GRAM marks the spot for STIM. Commentary on "GRAM domain proteins specialize functionally distinct ER-PM contact sites in human cells"

GRAM domain proteins were reported as novel ER-PM tethers defining specific membrane contact sites (MCS) subdomains. GRAMD2a pre-marks the sites occupied by STIM1 at MCS and its ablation impairs STIM1 translocation, but not store-operated Ca²⁺ entry. We discuss these apparently counterintuitive findings in the context of STIM/ORAI signaling at MCS.

Assessing the validity of the Triage Risk Screening Tool in a third world setting

Background Social risk is rarely evaluated in older emergency department (ED) patients, although its identification can reduce re-attendance. Objectives This study assessed the diagnostic accuracy of the Triage Risk Screening Tool (TRST) in the ED of a developing country. Methods The diagnostic accuracy of the TRST to detect elderly adults in need of social service intervention was compared with routine clinical evaluation, using comprehensive evaluation by an experienced social worker as the "gold standard". The inter-rater reliability of the TRST was assessed on a separate cohort of patients prior to the main study. Results The sensitivity of the TRST was 94.7% versus 55.6% for physician assessment. The TRST had good inter-rater reliability (Cohen's kappa = .882), and physicians found it easy to use. Conclusion The TRST provides a rapid means of assessing risk in older ED patients. This study confirmed the validity of this screening tool in a third world setting.

Falls in older people: comparing older and younger fallers in a developing country

Purpose

While falls are common in older people, causing significant mortality and morbidity, this phenomenon has not been extensively studied in the Caribbean. This study aimed to compare falls in older and younger people in this setting.

Methods

We conducted a prospective observational study of older trauma patients in Trinidad, comparing older and younger patients sustaining falls.

Results

1432 adult trauma patients were included (1141 aged 18–64 years and 291 aged 65 years and older). Older fallers were more likely to be female (66.7 vs 47.2%; p < 0.001), suffer from multiple pre-existing diseases (24.7 vs 2.4%; p < 0.001) and take multiple medications (16.1 vs 0.8%; p < 0.001). They also sustained more severe injuries and presented with higher acuity than younger fallers. Admission rates were higher among older fallers (29.9 vs 13.1%; p < 0.001).

Conclusions

In our study, older patients who fell were a distinct group from younger falls victims, with unique demographic, clinical and injury related characteristics. Their increased risk of injury within the home, coupled with their propensity for more severe injuries made them a high risk patient group. More research is needed to better understand this patient group and plan specific preventive interventions.

Electronic supplementary material

The online version of this article (doi:10.1007/s00068-017-0818-2) contains supplementary material, which is available to authorized users.

National Alcohol Survey of households in Trinidad and Tobago (NASHTT): Alcohol use in households

BACKGROUND

To determine the patterns of alcohol use among households in Trinidad and Tobago (T&T) and to estimate the association between alcohol use and negative psychological, social, or physical events experienced by the household.

METHODS

A convenience sample of 1837 households across T&T. We identified bivariate correlates of alcohol use, and heavy episodic drinking using chi-square and t-test analyses and used multivariable logistic regression to estimate adjusted associations between household alcohol use and experiences within the past 12 months adjusted for sociodemographic covariates.

RESULTS

One thousand five hundred two households had complete data for all variables (82% response rate). Nearly two thirds (64%) of households included alcohol users; 57% of household that consumed alcohol also reported heavy episodic drinking. Households that reported alcohol consumption were significantly more likely to report illnesses within the households, relationship problems, and behavioral and antisocial problems with children. Among households where a member was employed, those who consumed alcohol were nearly twice as likely (OR = 1.98; 95% confidence interval (CI) 1.03, 3.82) to have a household member call in sick to work and 2.9 times as likely (OR = 2.9; CI 1.19, 7.04) to have a household member suffer work related problems compared with households who reported not consuming alcohol.

CONCLUSIONS

Approximately two thirds of households in T&T reported using alcohol. These households were more likely to report psychological, physical, and social problems. These findings would support efforts to enforce current policies, laws, and regulations as well as new strategies to reduce the impact of harmful alcohol consumption on households in T&T.

Are older fallers different? Comparing older fallers and non-fallers in a developing country

Objectives

Falls are common in older people, causing significant mortality and morbidity, but little is known about this phenomenon in developing countries. This study aimed to investigate falls in older people in the developing world, comparing fallers with other trauma patients.

Methods

We conducted a prospective observational study of older trauma patients in Trinidad over a four-month period, comparing falls victims with other trauma patients, in relation to their demographic, pre-morbid and injury characteristics.

Results

A total of 439 older trauma patients (aged ≥65 years) were included. Fallers were older (median age 75 years (interquartile range 65–89 years) vs. 70 years (interquartile range 65–79 years) in non-fallers). Overall, 65.2% of fallers were female, compared to 43.7% of non-fallers. Fallers were more likely to suffer from multiple pre-existing diseases, with 29.8% having ≥3 comordibities, compared to 9.7% of non-fallers. Fallers were also more likely to be on multiple medications: 7.1% were on five medications, compared to no non-fallers. Fallers also sustained more severe injuries and presented with higher acuity than non-fallers. Admission and referral rates were higher among fallers compared to other trauma patients (59.9% vs. 30.4%).

Conclusions

Older patients who fall are a distinct group from other older trauma patients, with unique demographic, clinical and injury-related characteristics. This information is useful in planning preventive and management strategies for these patients.

Pilot scale nanofiltration treatment of olive mill wastewater: a technical and economical evaluation

The treatment of large volumes of olive mill wastewater is presently a challenge. This study reports the technical and economical feasibility of a sequential treatment of olive mill wastewater comprising a dissolved air flotation pre-treatment and nanofiltration. Different pilot nanofiltration assays were conducted in a concentration mode up to different volume reduction factors (29, 45, 58, and 81). Data attained demonstrated that nanofiltration can be operated at considerably high volume reduction factors and still be effective towards the removal of several components. A flux decline of approximately 50% was observed at the highest volume reduction factor, mainly due to increase of the osmotic pressure. Considerably high rejections were obtained across all experiments for total suspended solids (83 to >99%), total organic carbon (64 to 99%), chemical oxygen demand (53 to 77%), and oil and grease (67 to >82%). Treated water was in compliance with European legal limits for discharge regarding total suspended solids and oil and grease. The potential recovery of phenolic compounds was evaluated and found not relevant. It was demonstrated that nanofiltration is economically feasible, involving operation costs of approximately 2.56-3.08 €/m³, depending on the working plan schedule and volume reduction factor, and requiring a footprint of approximately 52 m² to treat 1000 m³ of olive mill wastewater.

The antidepressant fluoxetine induces necrosis by energy depletion and mitochondrial calcium overload

Selective Serotonin Reuptake Inhibitor antidepressants, such as fluoxetine (Prozac), have been shown to induce cell death in cancer cells, paving the way for their potential use as cancer therapy. These compounds are able to increase cytosolic calcium concentration ([Ca2+]cyt), but the involved mechanisms and their physiological consequences are still not well understood. Here, we show that fluoxetine induces an increase in [Ca2+]cyt by emptying the endoplasmic reticulum (ER) through the translocon, an ER Ca2+ leakage structure. Our data also show that fluoxetine inhibits oxygen consumption and lowers mitochondrial ATP. This latter is essential for Ca2+ reuptake into the ER, and we postulated therefore that the fluoxetine-induced decrease in mitochondrial ATP production results in the emptying of the ER, leading to capacitative calcium entry. Furthermore, Ca2+ quickly accumulated in the mitochondria, leading to mitochondrial Ca2+ overload and cell death. We found that fluoxetine could induce an early necrosis in human peripheral blood lymphocytes and Jurkat cells, and could also induce late apoptosis, especially in the tumor cell line. These results shed light on fluoxetine-induced cell death and its potential use in cancer treatment.

Antiproton Flux, Antiproton-to-Proton Flux Ratio, and Properties of Elementary Particle Fluxes in Primary Cosmic Rays Measured with the Alpha Magnetic Spectrometer on the International Space Station

A precision measurement by AMS of the antiproton flux and the antiproton-to-proton flux ratio in primary cosmic rays in the absolute rigidity range from 1 to 450 GV is presented based on 3.49×10^{5} antiproton events and 2.42×10^{9} proton events. The fluxes and flux ratios of charged elementary particles in cosmic rays are also presented. In the absolute rigidity range ∼60 to ∼500  GV, the antiproton p[over ¯], proton p, and positron e^{+} fluxes are found to have nearly identical rigidity dependence and the electron e^{-} flux exhibits a different rigidity dependence. Below 60 GV, the (p[over ¯]/p), (p[over ¯]/e^{+}), and (p/e^{+}) flux ratios each reaches a maximum. From ∼60 to ∼500  GV, the (p[over ¯]/p), (p[over ¯]/e^{+}), and (p/e^{+}) flux ratios show no rigidity dependence. These are new observations of the properties of elementary particles in the cosmos.

The role of STIM and ORAI proteins in phagocytic immune cells

Phagocytic cells, such as neutrophils, macrophages, and dendritic cells, migrate to sites of infection or damage and are integral to innate immunity through two main mechanisms. The first is to directly neutralize foreign agents and damaged or infected cells by secreting toxic substances or ingesting them through phagocytosis. The second is to alert the adaptive immune system through the secretion of cytokines and the presentation of the ingested materials as antigens, inducing T cell maturation into helper, cytotoxic, or regulatory phenotypes. While calcium signaling has been implicated in numerous phagocyte functions, including differentiation, maturation, migration, secretion, and phagocytosis, the molecular components that mediate these Ca(2+) signals have been elusive. The discovery of the STIM and ORAI proteins has allowed researchers to begin clarifying the mechanisms and physiological impact of store-operated Ca(2+) entry, the major pathway for generating calcium signals in innate immune cells. Here, we review evidence from cell lines and mouse models linking STIM and ORAI proteins to the control of specific innate immune functions of neutrophils, macrophages, and dendritic cells.

Uridine monophosphate, folic acid and vitamin B12 in patients with symptomatic peripheral entrapment neuropathies

BACKGROUND

Carpal tunnel syndrome is the most common type of peripheral entrapment neuropathy.

PATIENTS & METHODS

We performed an exploratory, open-label, multicenter, observational study of 48 patients with peripheral entrapment neuropathy. Patients received a daily capsule of uridine monophosphate, folic acid + vitamin B12 for 2 months and were evaluated using the Pain DETECT questionnaire.

RESULTS

The global score for pain decreased from 17.3 ± 5.9 at baseline to 10.3 ± 6.1 at the final evaluation (p < 0.001). Concomitant analgesic and anti-inflammatory treatment was stopped or the dose reduced in 77.4% of patients.

CONCLUSION

Uridine monophosphate + folic acid + vitamin B12 reduced total pain score, intensity and characterization of pain and associated symptoms. These results should be tested in a well-designed, adequately powered randomized controlled trial.

Measuring Phagosome pH by Ratiometric Fluorescence Microscopy

Phagocytosis is a fundamental process through which innate immune cells engulf bacteria, apoptotic cells or other foreign particles in order to kill or neutralize the ingested material, or to present it as antigens and initiate adaptive immune responses. The pH of phagosomes is a critical parameter regulating fission or fusion with endomembranes and activation of proteolytic enzymes, events that allow the phagocytic vacuole to mature into a degradative organelle. In addition, translocation of H(+) is required for the production of high levels of reactive oxygen species (ROS), which are essential for efficient killing and signaling to other host tissues. Many intracellular pathogens subvert phagocytic killing by limiting phagosomal acidification, highlighting the importance of pH in phagosome biology. Here we describe a ratiometric method for measuring phagosomal pH in neutrophils using fluorescein isothiocyanate (FITC)-labeled zymosan as phagocytic targets, and live-cell imaging. The assay is based on the fluorescence properties of FITC, which is quenched by acidic pH when excited at 490 nm but not when excited at 440 nm, allowing quantification of a pH-dependent ratio, rather than absolute fluorescence, of a single dye. A detailed protocol for performing in situ dye calibration and conversion of ratio to real pH values is also provided. Single-dye ratiometric methods are generally considered superior to single wavelength or dual-dye pseudo-ratiometric protocols, as they are less sensitive to perturbations such as bleaching, focus changes, laser variations, and uneven labeling, which distort the measured signal. This method can be easily modified to measure pH in other phagocytic cell types, and zymosan can be replaced by any other amine-containing particle, from inert beads to living microorganisms. Finally, this method can be adapted to make use of other fluorescent probes sensitive to different pH ranges or other phagosomal activities, making it a generalized protocol for the functional imaging of phagosomes.

Precision Measurement of the Helium Flux in Primary Cosmic Rays of Rigidities 1.9 GV to 3 TV with the Alpha Magnetic Spectrometer on the International Space Station

Knowledge of the precise rigidity dependence of the helium flux is important in understanding the origin, acceleration, and propagation of cosmic rays. A precise measurement of the helium flux in primary cosmic rays with rigidity (momentum/charge) from 1.9 GV to 3 TV based on 50 million events is presented and compared to the proton flux. The detailed variation with rigidity of the helium flux spectral index is presented for the first time. The spectral index progressively hardens at rigidities larger than 100 GV. The rigidity dependence of the helium flux spectral index is similar to that of the proton spectral index though the magnitudes are different. Remarkably, the spectral index of the proton to helium flux ratio increases with rigidity up to 45 GV and then becomes constant; the flux ratio above 45 GV is well described by a single power law.

Junctate boosts phagocytosis by recruiting endoplasmic reticulum Ca2+ stores near phagosomes

Local intracellular Ca(2+) elevations increase the efficiency of phagocytosis, a process that is essential for innate and adaptive immunity. These local Ca(2+) elevations are generated in part by the store-operated Ca(2+) entry (SOCE) sensor STIM1, which recruits endoplasmic reticulum (ER) cisternae to phagosomes and opens phagosomal Ca(2+) channels at ER-phagosome junctions. However, residual ER-phagosome contacts and periphagosomal Ca(2+) hotspots remain in Stim1(-/-) cells. Here, we tested whether junctate (also called ASPH isoform 8), a molecule that targets STIM1 to ER-plasma-membrane contacts upon Ca(2+)-store depletion, cooperates with STIM1 at phagosome junctions. Junctate expression in Stim1(-/-) and Stim1(-/-); Stim2(-/-) phagocytic fibroblasts increased phagocytosis and periphagosomal Ca(2+) elevations, yet with only a minimal impact on global SOCE. These Ca(2+) hotspots were only marginally reduced by the SOCE channel blocker lanthanum chloride (La(3+)) but were abrogated by inositol trisphosphate receptor inhibitors 2-APB and xestospongin-C, revealing that unlike STIM1-mediated hotspots, junctate-mediated Ca(2+) originates predominantly from periphagosomal Ca(2+) stores. Accordingly, junctate accumulates near phagosomes and elongates ER-phagosome junctions in Stim1(-/-) cells. Thus, junctate mediates an alternative mechanism for generating localized Ca(2+) elevations within cells, promoting Ca(2+) release from internal stores recruited to phagosomes, thereby boosting phagocytosis.

Social support in older people: lessons from a developing country

PURPOSE

The purpose of this study was to determine the level of social support in older people presenting to the Emergency Department of a tertiary hospital in Trinidad.

METHODS

This was a prospective observational study, assessing social support in patients ≥65 years presenting to the Emergency Department, using the Sarason Social Support Questionnaire.

RESULTS

One hundred sixty-two respondents aged 65 years and older were included. Respondents reported a median Social Support Questionnaire Score (SSQS) of 4.83 and number (SSQN) of 1.67, which did not differ significantly between genders and ethnic groups. Patients who presented via ambulance had a significantly lower SSQS (4.33 vs. 5.16) and SSQN (1.33 vs. 1.92) than those who arrived by their own transport. Respondents reported far greater median family scores (1.33) than non-family scores (0.00).

CONCLUSIONS

This study contributes to the understanding of social support for older people in developing countries. The dependence on family support in developing countries may prove challenging in the long term as family structures in these countries change with economic pressures. More extensive research is needed into the phenomenon of social support for older people in developing countries, particularly with the impending expansion of this age group in these countries.

Precision Measurement of the Proton Flux in Primary Cosmic Rays from Rigidity 1 GV to 1.8 TV with the Alpha Magnetic Spectrometer on the International Space Station

A precise measurement of the proton flux in primary cosmic rays with rigidity (momentum/charge) from 1 GV to 1.8 TV is presented based on 300 million events. Knowledge of the rigidity dependence of the proton flux is important in understanding the origin, acceleration, and propagation of cosmic rays. We present the detailed variation with rigidity of the flux spectral index for the first time. The spectral index progressively hardens at high rigidities.

STIM1L traps and gates Orai1 channels without remodeling the cortical ER

STIM proteins populate and expand cortical endoplasmic reticulum (ER) sheets to mediate store-operated Ca²⁺ entry (SOCE) by trapping and gating Orai channels in ER-plasma membrane clusters. A longer splice variant, STIM1L, forms permanent ER-plasma membrane clusters and mediates rapid Ca²⁺ influx in muscle. Here, we used electron microscopy, total internal reflection fluorescence (TIRF) microscopy and Ca²⁺ imaging to establish the trafficking and signaling properties of the two STIM1 isoforms in Stim1^−/−/Stim2^−/− fibroblasts. Unlike STIM1, STIM1L was poorly recruited into ER-plasma membrane clusters and did not mediate store-dependent expansion of cortical ER cisternae. Removal of the STIM1 lysine-rich tail prevented store-dependent cluster enlargement, whereas inhibition of cytosolic Ca²⁺ elevations or removal of the STIM1L actin-binding domain had no impact on cluster expansion. Finally, STIM1L restored robust but not accelerated SOCE and clustered with Orai1 channels more slowly than STIM1 following store depletion. These results indicate that STIM1L does not mediate rapid SOCE but can trap and gate Orai1 channels efficiently without remodeling cortical ER cisternae. The ability of STIM proteins to induce cortical ER formation is dispensable for SOCE and requires the lysine-rich tail of STIM1 involved in binding to phosphoinositides.

Precision Measurement of the (e^{+}+e^{-}) Flux in Primary Cosmic Rays from 0.5 GeV to 1 TeV with the Alpha Magnetic Spectrometer on the International Space Station

We present a measurement of the cosmic ray (e^{+}+e^{-}) flux in the range 0.5 GeV to 1 TeV based on the analysis of 10.6 million (e^{+}+e^{-}) events collected by AMS. The statistics and the resolution of AMS provide a precision measurement of the flux. The flux is smooth and reveals new and distinct information. Above 30.2 GeV, the flux can be described by a single power law with a spectral index γ=-3.170±0.008(stat+syst)±0.008(energy scale).

Energy drinks and other dietary supplement use among adolescents attending secondary schools in Trinidad and Tobago

OBJECTIVE

The objective of the present study was to determine the knowledge and practices among Trinidad and Tobago school-attending adolescents towards energy drinks (ED), alcohol combined with energy drinks (AwED), weight-altering supplements (WAS) and vitamin/mineral supplements (VMS) and their experience of adverse effects associated with such use.

DESIGN

A cross-sectional, proportionate, stratified sampling strategy was adopted using a self-administered, de novo questionnaire.

SETTING

Secondary schools throughout Trinidad and Tobago.

SUBJECTS

Students aged 15-19 years.

RESULTS

Five hundred and sixty-one students participated, an 84% response rate; 43·0% were male, 40·5% East Indian and 34·1% mixed race. VMS, ED, WAS and anabolic steroids were used by 52·4%, 44·0%, 8·9% and 1·4% of students, respectively, with 51·6% of ED users using AwED. Predictors of use of AwED were males and students who played sport for their school (OR = 1·9; 95% CI 1·2, 3·2 and OR = 2·6; 95% CI 1·4, 4·7, respectively). Predictors of ED use were males and attendees of government secondary schools (OR = 1·7; 95% CI 1·1, 2·4 and OR = 1·7; 95% CI 1·2, 2·4, respectively). Side-effects, mainly palpitations, headaches and sleep disturbances, were reported in 20·7% of dietary supplement users.

CONCLUSIONS

Many adolescent students in Trinidad and Tobago use dietary supplements, including ED and AwED, and about one-fifth of users experience side-effects. Identification of students at risk for ED, AwED and WAS use and education of students about the dangers of using dietary supplements need to be instituted to prevent potential adverse events.

An exploration of changes in cognitive and emotional empathy among medical students in the Caribbean

OBJECTIVE

This study explored the empathy profile of students across five years of medical training. In addition the study examined whether the Jefferson Scale for Physician Empathy correlated with a measure of cognitive empathy, the Reading the Mind in the Eyes Test and a measure of affective empathy, the Toronto Empathy Questionnaire.

METHODS

The study was a comparative cross-sectional design at one Caribbean medical school. Students were contacted in class, participation was voluntary and empathy was assessed using all three instruments Descriptive statistics were calculated and differences between groups evaluated using non-parametric tests.

RESULTS

Overall 669 students participated (response rate, 67%). There was a significant correlation between the Jefferson Scale of Physician Empathy and the Toronto Empathy Questionnaire (ρ = 0.48), both scales indicating a decline in medical student empathy scores over time. There was, however, little correlation between scores from the Reading the Mind in the Eyes Test and the Jefferson Scale of Physician Empathy. Female students demonstrated significantly higher scores on all three measures.

CONCLUSIONS

Medical students' lower empathy scores during their final years of training appear to be due to a change in the affective component of empathy. These findings may reflect an adaptive neurobiological response to the stressors associated with encountering new clinical situations. Attention should be paid not only to providing empathy training for students but also to teaching strategies for improved cognitive processing capacity when they are encountering new and challenging circumstances.

Electron and positron fluxes in primary cosmic rays measured with the alpha magnetic spectrometer on the international space station

Precision measurements by the Alpha Magnetic Spectrometer on the International Space Station of the primary cosmic-ray electron flux in the range 0.5 to 700 GeV and the positron flux in the range 0.5 to 500 GeV are presented. The electron flux and the positron flux each require a description beyond a single power-law spectrum. Both the electron flux and the positron flux change their behavior at ∼30  GeV but the fluxes are significantly different in their magnitude and energy dependence. Between 20 and 200 GeV the positron spectral index is significantly harder than the electron spectral index. The determination of the differing behavior of the spectral indices versus energy is a new observation and provides important information on the origins of cosmic-ray electrons and positrons.

High statistics measurement of the positron fraction in primary cosmic rays of 0.5-500 GeV with the alpha magnetic spectrometer on the international space station

A precision measurement by AMS of the positron fraction in primary cosmic rays in the energy range from 0.5 to 500 GeV based on 10.9 million positron and electron events is presented. This measurement extends the energy range of our previous observation and increases its precision. The new results show, for the first time, that above ∼200  GeV the positron fraction no longer exhibits an increase with energy.

Redox regulation of store-operated Ca2+ entry

SIGNIFICANCE

Store-operated Ca2+ entry (SOCE) is a ubiquitous Ca2+ signaling mechanism triggered by Ca2+ depletion of the endoplasmic reticulum (ER) and by a variety of cellular stresses. Reactive oxygen species (ROS) are often concomitantly produced in response to these stresses, however, the relationship between redox signaling and SOCE is not completely understood. Various cardiovascular, neurological, and immune diseases are associated with alterations in both Ca2+ signaling and ROS production, and thus understanding this relationship has therapeutic implications.

RECENT ADVANCES

Several reactive cysteine modifications in stromal interaction molecule (STIM) and Orai proteins comprising the core SOCE machinery were recently shown to modulate SOCE in a redox-dependent manner. Moreover, STIM1 and Orai1 expression levels may reciprocally regulate and be affected by responses to oxidative stress. ER proteins involved in oxidative protein folding have gained increased recognition as important sources of ROS, and the recent discovery of their accumulation in contact sites between the ER and mitochondria provides a further link between ROS production and intracellular Ca2+ handling.

CRITICAL ISSUES AND FUTURE DIRECTIONS

Future research should aim to establish the complete set of SOCE controlling molecules, to determine their redox-sensitive residues, and to understand how intracellular Ca2+ stores dynamically respond to different types of stress. Mapping the precise nature and functional consequence of key redox-sensitive components of the pre- and post-translational control of SOCE machinery and of proteins regulating ER calcium content will be pivotal in advancing our understanding of the complex cross-talk between redox and Ca2+ signaling.

Stenotrophomonas maltophilia: rare cause of meningitis

Stenotrophomonas maltophilia is a Gram-negative bacillus, which is an extremely rare cause of meningitis. To our knowledge, there are only five previous pediatrics cases. Here, we describe the case of a 4-year-old boy who developed meningitis associated with this organism, after several neurosurgical procedures and previous treatment with a broad-spectrum antibiotic. He was treated successfully with a combination of trimethoprim-sulfamethoxazole, ceftazidime and levofloxacin. Stenotrophomonas maltophilia should be considered as a potential cause of meningitis, especially among severely debilitated or immunosuppressed patients. Antimicrobial therapy is complicated by the high resistance of the organism to multiple antibiotics.

High-throughput chemical screening identifies AG-490 as a stimulator of aquaporin 2 membrane expression and urine concentration

A reduction or loss of plasma membrane aquaporin 2 (AQP2) in kidney principal cells due to defective vasopressin (VP) signaling through the VP receptor causes excessive urine production, i.e., diabetes insipidus. The amount of AQP2 on the plasma membrane is regulated by a balance of exocytosis and endocytosis and is the rate limiting step for water reabsorption in the collecting duct. We describe here a systematic approach using high-throughput screening (HTS) followed by in vitro and in vivo assays to discover novel compounds that enhance vasopressin-independent AQP2 membrane expression. We performed initial chemical library screening with a high-throughput exocytosis fluorescence assay using LLC-PK1 cells expressing soluble secreted yellow fluorescent protein and AQP2. Thirty-six candidate exocytosis enhancers were identified. These compounds were then rescreened in AQP2-expressing cells to determine their ability to increase AQP2 membrane accumulation. Effective drugs were then applied to kidney slices in vitro. Three compounds, AG-490, β-lapachone, and HA14-1 increased AQP2 membrane accumulation in LLC-PK1 cells, and both AG-490 and β-lapachone were also effective in MDCK cells and principal cells in rat kidney slices. Finally, one compound, AG-490 (an EGF receptor and JAK-2 kinase inhibitor), decreased urine volume and increased urine osmolality significantly in the first 2-4 h after a single injection into VP-deficient Brattleboro rats. In conclusion, we have developed a systematic procedure for identifying new compounds that modulate AQP2 trafficking using initial HTS followed by in vitro assays in cells and kidney slices, and concluding with in vivo testing in an animal model.

Hv1 proton channels differentially regulate the pH of neutrophil and macrophage phagosomes by sustaining the production of phagosomal ROS that inhibit the delivery of vacuolar ATPases

Production of ROS and maintenance of an appropriate pH within the lumen of neutrophil and macrophage phagosomes are important for an effective immune response. Hv1 proton channels sustain ROS production at the plasma membrane, but their role in phagosomes is not known. Here, we tested whether Hv1 channels regulate the pH_p and sustain phagosomal ROS production in neutrophils and macrophages. The presence of Hv1 channels on phagosomes of human neutrophils and mouse macrophages was confirmed by Western blot and immunostaining. Phagosomal ROS production, measured with OxyBurst-coupled targets, was reduced in neutrophils and macrophages isolated from Hv1-deficient mice. Ratiometric imaging of FITC-coupled targets showed that phagosomes acidified more slowly in Hv1-deficient macrophages and transiently alkalinized when the V-ATPase was inhibited. In WT neutrophils, 97% of phagosomes remained neutral 30 min after particle ingestion, whereas 37% of Hv1-deficient phagosomes were alkaline (pH>8.3) and 14% acidic (pH<6.3). The subpopulation of acidic phagosomes was eliminated by V-ATPase inhibition, whereas NOX inhibition caused a rapid acidification, independently of Hv1 expression. Finally, V-ATPase accumulation on phagosomes was inversely correlated to intraphagosomal ROS production in neutrophils. These data indicate that Hvcn1 ablation deregulates neutrophil pH_p, leading to alkalinization in phagosomes with residual ROS production or to the early accumulation of V-ATPase on phagosomes that fail to mount an oxidative response. Hv1 channels therefore differentially regulate the pH_p in neutrophils and macrophages, sustaining rapid acidification in macrophage phagosomes and maintaining a neutral pH in neutrophil phagosomes.

Effects of cyclosporine and sirolimus on insulin-stimulated glucose transport and glucose tolerance in a rat model

Cyclosporine (CsA) and sirolimus (SRL) have been associated with undesirable side effects, including posttransplantation diabetes and hyperlipidemia, but the molecular mechanisms underlying these effects remain to be elucidated. Animal studies focusing on clinically relevant doses are advised. This study sought to compare the metabolic effects on isolated rat adipocytes treated with either CsA or SRL ex vivo and after long-term in vivo treatment in Wistar rats. We assessed the ex vivo effects of CsA (0.5-30 μmol/L) and SRL (1-250 μmol/L) on insulin-stimulated (14)C-glucose uptake in epididymal adipocytes (n = 6-9). In parallel, rats (n = 12) were treated with either vehicle, CsA (5 mg/kg/d) or SRL (1 mg/kg/d) for either 3 or 9 weeks. At the end of the treatment, glucose tolerance test (GTT) and insulin-stimulated (14)C-glucose uptake as well as biochemical parameters were analyzed. A significant reduction in the insulin-stimulated glucose uptake over basal was observed among isolated adipocytes, whether exposed ex vivo or in vivo to CsA or SRL treatment. Furthermore, the SRL group showed significantly lighter fat pads and smaller adipocytes at 3 weeks with a smaller gain in body weight throughout the study compared with either the vehicle or CsA cohorts. Glucose intolerance was observed after a GTT, at the end of the treatment with either drug. Additionally, at 9 weeks serum triglycerides were increased by CsA compared with vehicle or SRL treatment. Interestingly, although SRL-treated animals presented higher fed and fasted insulin levels compared with either group, suggesting insulin resistance, the CsA group presented lower fed and fasted insulin values, suggesting a defect in insulin secretion at 9 weeks. These results suggested that either ex vivo treatment of fat cells or in vivo treatment of rats with CsA or SRL impaired insulin-stimulated glucose uptake by adipocytes. Both drugs caused glucose intolerance, which altogether could be responsible for the development of posttransplantation diabetes.

Renal transplantation with donors older than 70 years: does age matter?

PURPOSE

The need for organs for renal transplantation has encouraged the use of grafts from increasingly older donors. Studies of transplantation results with donors older than 70 years are sparse. The main purpose of this study is to compare the results of transplantation with donors older and younger than 70 years old.

METHODS

This retrospective study included 1233 consecutive deceased-donor renal transplantations performed between January 1, 2001, and December 31, 2011. We compared outcomes of grafts from donors older than 70 years (group ≥ 70; n = 82) versus donors younger than 70 years (group < 70; n = 1151).

RESULTS

Univariate analysis of pretransplantation data showed statistically significant differences (P < .05) among the following variables for the group < 70 and group ≥ 70, respectively: recipient age (46 ± 13 versus 61 ± 5 years), donor age (44 ± 16 versus 73 ± 3 years), donor male gender (69.4% versus 47.6%), use of antibody induction immunosuppression (51.7% versus 70.7%), and HLA compatibilities (2.4 versus 2). The group ≥ 70 showed increased postoperative minor complications: bleeding (8.5% versus 3.4%; P = .017), lymphocele formation (3.7% versus 0.5%; P = .011), and incisional hernia (2.4% versus 0.2%; P < .001). Regarding transplantation results, we observed that mean serum creatinine was significantly lower among group < 70, at 1, 3, 6, 12, 24, and 60 months after transplantation (P < .05). Cumulative graft survival at 1, 3, and 4 years was 90%, 85%, and 83% in the group < 70 versus 87%, 79%, and 72% in the group ≥ 70. In the subgroup of recipients younger than 60 years, we did not verify statistically significant differences in allograft survival between group ≥ 70 and group < 70. Using Cox regression for survival analysis, we verified that donor age was not an independent risk factor for graft failure.

CONCLUSIONS

The group of patients who received kidneys from donors younger than 70 years achieved better transplantation outcomes. Nevertheless, kidneys from older donors represent an excellent alternative for older recipients.

Regulation of the NADPH oxidase and associated ion fluxes during phagocytosis

The production of reactive oxygen species (ROS) within immune cell phagosomes is critical for antimicrobial activity and for correct antigen processing, and influences signaling pathways that direct host responses to infection and inflammation. Because excess oxidants can cause tissue damage and oxidative stress, phagocytes must precisely control both the location and timing of NADPH oxidase activity. How differential regulation is achieved at phagosomes is not well understood. Recent studies have revealed that the PI(3)P phosphoinositide plays an important role in locally boosting phagosomal NADPH oxidase activity through its binding to the p40(phox) NADPH oxidase subunit. Furthermore, phox subunit dynamics at phagosomes may regulate the timing of the oxidative burst. Novel elements regulating catalytic core trafficking include Rab27 and SNAP-23. In addition to trafficking events, the activity of the electrogenic oxidase is also governed by ionic fluxes, which are constrained at phagosomes owing to low intraphagosomal volume and dynamic display of channels, transporters, and pumps. New insights on the interdependence of phagosomal pH and ROS have been recently elucidated, and chloride channels important for microbicidal functions, including CFTR, and CLIC family channels, have been identified. Finally, periphagosomal calcium microdomains and calcium-dependent S100A8/9 protein recruitment may help fine-tune spatiotemporal regulation of NADPH oxidase activation for an effective immune response.

Attitudes and practices regarding resuscitation in emergency departments in Trinidad and Tobago

BACKGROUND

Ethical issues with regard to resuscitation are increasingly important. Understanding how emergency physicians deal with these problems is essential for the development of policies for resuscitative care.

OBJECTIVES

To identify the knowledge, opinions and practices of emergency physicians employed full time in public hospitals in Trinidad and Tobago, with respect to cardiopulmonary resuscitation. To compare the differences in responses between physicians in training and those who were not. In addition, to compare these responses with those expressed in a similar study in the USA in 2007.

METHODS

All emergency physicians (120) who fulfilled the eligibility criteria for the study were asked to record anonymous responses to survey questions about ethical issues regarding resuscitation.

RESULTS

Of the 98 respondents, most (79.6%) had been practising emergency medicine for ≤5 years and about 38% had had some training in emergency medicine. Most respondents agreed that survival rates for cardiopulmonary resuscitation (CPR) were poor. However, 41.2% of respondents had performed CPR >10 times in the past 3 years despite expected futility. More participants in the US study than in the local study thought that the existence of an advance directive was important in making decisions about CPR and that legal concerns should not, but do, affect CPR decisions in practice.

CONCLUSIONS

Local emergency physicians are as affected by legal and ethical CPR issues as are US emergency physicians. Education programmes and policies that deal with these concerns would better assist the emergency physician in dealing with them.

An unexpected temporary suppression of lactation after a local corticosteroid injection for tenosynovitis

INTRODUCTION

Intra-lesional glucocorticosteroid (GCS) injections are used widely for painful musculoskeletal conditions in general practice.

CASE

A 26 year old female, was given an intra-lesional injection of 24 mg methyl prednisolone acetate (MPA) with 15 mg lidocaine for treatment of DeQuervain's tenosynovitis. She was six weeks postpartum and predominantly breast feeding. Lactation was suppressed at approximately 30 h post injection and this persisted for a period of approximately 36 h before spontaneous resumption of milk production. Lactation returned to normal 90 h after the injection.

DISCUSSION

Studies done in lactating animals have shown that injected GCS have led to a reduction of milk production, but there is limited data on these injections in lactating humans. The dose of GCS administered and the site of the GCS injection appear to contribute to this phenomenon. Very large doses of GCS have caused suppression of lactation in humans as opposed to low doses of GCS. Injections of GCS into areas of the body subjected to high activity level like the knee or wrist could lead to greater systemic absorption of GCS than GSC administered to body sites with lower physical activity like the shoulder.

CONCLUSION

Local injection of MPA reversibly suppressed lactation in a young woman for a period of 24-48 h. Doctors using injectable GCS in lactating women should apprise patients of this possibility. Mothers can take precautions like expressing and storing enough breast milk to cover this period prior to receiving these injections.