Evaluation of Pharmacy Resident-Driven Medication Reconciliation on Patients at High Risk of Hospital Readmission.

Purpose: Pharmacists play a key role in preventing medication errors during transitions of care and preventing hospital readmissions through medication reconciliation (MR) programs. This study retrospectively evaluated the implementation of a standardized pharmacy residentdriven MR program for patients at high risk for readmission as defined by the Hospital Readmissions Reduction Program (HRRP). Methods: This was a single-center, retrospective cross sectional study of a pharmacy resident-driven MR program including patients at high risk of readmission defined by HRRP. The primary objective was to determine the number of inpatient regimen interventions identified during the MR. Secondary objectives include severity of interventions, number of medication discrepancies identified, types of interventions and discrepancies identified, and all-cause hospital readmission rates within 30 days of discharge.. Results: Fifty-three high-risk patients were included in the study. Pharmacy intervention recommendations were accepted by prescribers for nine patients (9/53; 17.0%) with a total of 13 accepted inpatient regimen interventions. The two most commonly identified medication classes for interventions were anticonvulsants (3/13; 23.1%) and antidepressants (6/13; 46.2%). Discrepancies on the admission MR were identified for 46 (46/53; 86.8%) patients with a median of three discrepancies per patient (interquartile range 2-4). The most common type of discrepancy was an incorrect or unnecessary drug. The 30-day all-cause readmission rate was 35.8% (19/53) for the total patient Conclusion: A pharmacy-resident driven MR program provided value in clarifying prior to admission medications and may help prevent drugrelated adverse events.

Resistant Starch Bagels Reduce Fasting and Postprandial Insulin in Adults at Risk of Type 2 Diabetes.

BACKGROUND: Type 2 diabetes (T2D) incidence continues to rise. Although increasing dietary fiber intake is an established strategy for improved glycemic control, most adults consume insufficient amounts. Fiber-enhanced functional foods can increase fiber intake, and there is particular interest in resistant starch (RS) as a high-fiber ingredient. Studies show that high-amylose maize resistant starch, type 2 (HAM-RS2) improves acute and chronic glycemic responses, but more studies are needed in individuals at high risk of T2D with RS delivered in commonly consumed foods. OBJECTIVE: The objective of this study was to examine the chronic effects of consuming bagels high in HAM-RS2 on fasting and postprandial glycemic markers in adults at increased risk of T2D. METHODS: With the use of a randomized, double-blind crossover design, 24 men and women with a mean ± SE age of 55.3 ± 1.59 y and body mass index (in kg/m2) of 30.2 ± 0.57 consumed 1 bagel containing 25 g HAM-RS2/d or 1 control wheat bagel/d for 56 d each, separated by a 4-wk washout. Fasting and postprandial oral-glucose-tolerance test (OGTT) glucose and insulin were measured on study days 1 and 57 of each bagel treatment. RESULTS: The RS bagel treatment resulted in significantly lower fasting (22.1%, P = 0.04), 2-h (23.3%, P < 0.008), and 3-h (18.9%, P = 0.05) insulin incremental areas under the curve and fasting insulin resistance (homeostasis model assessment of insulin resistance; 23.1%, P = 0.04) than did the control bagel treatment. Fasting and postprandial OGTT glucose concentrations did not differ between the RS and control bagel treatments on study days 1 or 57. CONCLUSIONS: These data suggest that consumption of a high-HAM-RS2 bagel improves glycemic efficiency by reducing the amount of insulin required to manage postprandial glucose while improving fasting insulin sensitivity in adults at increased risk of T2D. This research provides support for a feasible dietary strategy for T2D risk reduction. This trial was registered at clinicaltrials.gov as NCT02129946.

Alanine scanning of the S6 segment reveals a unique and cAMP-sensitive association between the pore and voltage-dependent opening in HCN channels.

Hyperpolarization-activated cyclic nucleotide-modulated (HCN) channels resemble Shaker K+ channels in structure and function. In both, changes in membrane voltage produce directionally similar movement of positively charged residues in the voltage sensor to alter the pore structure at the intracellular side and gate ion flow. However, HCNs open when hyperpolarized, whereas Shaker opens when depolarized. Thus, electromechanical coupling between the voltage sensor and gate is opposite. A key determinant of this coupling is the intrinsic stability of the pore. In Shaker, an alanine/valine scan of residues across the pore, by single point mutation, showed that most mutations made the channel easier to open and steepened the response of the channel to changes in voltage. Because most mutations likely destabilize protein packing, the Shaker pore is most stable when closed, and the voltage sensor works to open it. In HCN channels, the pore energetics and vector of work by the voltage sensor are unknown. Accordingly, we performed a 22-residue alanine/valine scan of the distal pore of the HCN2 isoform and show that the effects of mutations on channel opening and on the steepness of the response of the channel to voltage are mixed and smaller than those in Shaker. These data imply that the stabilities of the open and closed pore are similar, the voltage sensor must apply force to close the pore, and the interactions between the pore and voltage sensor are weak. Moreover, cAMP binding to the channel heightens the effects of the mutations, indicating stronger interactions between the pore and voltage sensor, and tips the energetic balance toward a more stable open state.

Regulation of cell surface expression of functional pacemaker channels by a motif in the B-helix of the cyclic nucleotide-binding domain.

Previous studies have suggested that a portion of the cyclic nucleotide-binding domain (CNBD) of the hyperpolarization-activated cyclic nucleotide-gated channel 2 (HCN2) "pacemaker" channel, composed of the A- and B-helices and the interceding beta-barrel, confers two functions: inhibition of channel opening in response to hyperpolarization and promotion of cell surface expression. The sequence determinants required for each of these functions are unknown. In addition, the mechanism underlying plasma membrane targeting by this subdomain has been limitedly explored. Here we identify a four-amino acid motif (EEYP) in the B-helix that strongly promotes channel export from the endoplasmic reticulum (ER) and cell surface expression but does not contribute to the inhibition of channel opening. This motif augments a step in the trafficking pathway and/or the efficiency of correct folding and assembly.

Tropospheric O(3) compromises net primary production in young stands of trembling aspen, paper birch and sugar maple in response to elevated atmospheric CO(2).

Concentrations of atmospheric CO(2) and tropospheric ozone (O(3)) are rising concurrently in the atmosphere, with potentially antagonistic effects on forest net primary production (NPP) and implications for terrestrial carbon sequestration. Using free-air CO(2) enrichment (FACE) technology, we exposed north-temperate forest communities to concentrations of CO(2) and O(3) predicted for the year 2050 for the first 7 yr of stand development. Site-specific allometric equations were applied to annual nondestructive growth measurements to estimate above- and below-ground biomass and NPP for each year of the experiment. Relative to the control, elevated CO(2) increased total biomass 25, 45 and 60% in the aspen, aspen-birch and aspen-maple communities, respectively. Tropospheric O(3) caused 23, 13 and 14% reductions in total biomass relative to the control in the respective communities. Combined fumigation resulted in total biomass response of -7.8, +8.4 and +24.3% relative to the control in the aspen, aspen-birch and aspen-sugar maple communities, respectively. These results indicate that exposure to even moderate levels of O(3) significantly reduce the capacity of NPP to respond to elevated CO(2) in some forests.

Research note: Can decreased transpiration limit plant nitrogen acquisition in elevated CO2?

N acquisition often lags behind accelerated C gain in plants exposed to CO2-enriched atmospheres. To help resolve the causes of this lag, we considered its possible link with stomatal closure, a common first-order response to elevated CO2 that can decrease transpiration. Specifically, we tested the hypothesis that declines in transpiration, and hence mass flow of soil solution, can decrease delivery of mobile N to the root and thereby limit plant N acquisition. We altered transpiration by manipulating relative humidity (RH) and atmospheric [CO2]. During a 7-d period, we grew potted cottonwood (Populus deltoides Bartr.) trees in humidified (76% RH) and non-humidified (43% RH) glasshouses ventilated with either CO2-enriched or non-enriched air (~1000 vs ~380µmol mol-1). We monitored effects of elevated humidity and/or CO2 on stomatal conductance, whole-plant transpiration, plant biomass gain, and N accumulation. To facilitate the latter, NO3- enriched in 15N (5 atom%) was added to all pots at the outset of the experiment. Transpiration and 15N accumulation decreased when either CO2 or humidity were elevated. The disparity between N accumulation and accelerated C gain in elevated CO2 led to a 19% decrease in shoot N concentration relative to ambient CO2. Across all treatments, 15N gain was positively correlated with root mass (P<0.0001), and a significant portion of the remaining variation (44%) was positively related to transpiration per unit root mass. At a given humidity, transpiration per unit leaf area was positively related to stomatal conductance. Thus, declines in plant N concentration and/or content under CO2 enrichment may be attributable in part to associated decreases in stomatal conductance and transpiration.

CO2 and light effects on deciduous trees: growth, foliar chemistry, and insect performance.

This study examined the effects of CO2 and light availability on sapling growth and foliar chemistry, and consequences for insect performance. Quaking aspen (Populus tremuloides Michx.), paper birch (Betula papyrifera Marsh.), and sugar maple (Acer saccharum Marsh.) were grown in controlled environment greenhouses under ambient or elevated CO2 (38.7 and 69.6 Pa), and low or high light availability (375 and 855 µmol m-2 s-1). Because CO2 and light are both required for carbon assimilation, the levels of these two resources are expected to have strong interactive effects on tree growth and secondary metabolism. Results from this study support that prediction, indicating that the relative effect of rising atmospheric CO2 concentrations on the growth and secondary metabolism of deciduous trees may be dependent on light environment. Trees in ambient CO2-low light environments had substantial levels of phytochemicals despite low growth rates; the concept of basal secondary metabolism is proposed to explain allocation to secondary metabolites under growth-limiting conditions. Differences between CO2 and light effects on the responses of growth and secondary metabolite levels suggest that relative allocation is not dependent solely on the amount of carbon assimilated. The relative growth rates and indices of feeding efficiency for gypsy moth (Lymantria dispar L.) larvae fed foliage from the experimental treatments showed no significant interactive effects of light and CO2, although some main effects and many host species interactions were significant. Gypsy moth performance was negatively correlated with CO2- and light-induced increases in the phenolic glycoside content of aspen foliage. Insects were not strongly affected, however, by treatment differences in the nutritional and secondary chemical components of birch and maple.

Photosynthetic responses of Miconia species to canopy openings in a lowland tropical rainforest.

We examined the photosynthetic acclimation of three tropical species of Miconia to canopy openings in a Costa Rican rainforest. The response of photosynthesis to canopy opening was very similar in Miconia affinis, M. gracilis, and M. nervosa, despite differences in growth form (trees and shrubs) and local distributions of plants (understory and gap). Four months after the canopy was opened by a treefall, photosynthetic capacity in all three species had approximately doubled from closed canopy levels. There were no obvious signs of high light damage after treefall but acclimation to the gap environment was not immediate. Two weeks after treefall, Amax, stomatal conductance, apprarent quantum efficiency, and dark respiration rates had not changed significantly from understory values. The production of new leaves appears to be an important component of light acclimation in these species. The only variables to differ significantly among species were stomatal conductance at Amax and the light level at which assimilation was saturated. M. affinis had a higher stomatal conductance which may reduce its water use efficiency in gap environments. Photosynthesis in the more shade-tolerant M. gracilis saturated at lower light levels than in the other two species. Individual plant light environments were assessed after treefall with canopy photography but they explained only a small fraction of plant variation in most measures of photosynthesis and growth. In conclusion, we speculate that species differences in local distribution and in light requirements for reproduction may be more strongly related to species differences in carbon allocation than in carbon assimilation.