Patterns of Comorbidities and Prescribing and Dispensing of Non-steroidal Anti-inflammatory Drugs (NSAIDs) Among Patients with Osteoarthritis in the USA: Real-World Study.

BACKGROUND: Osteoarthritis (OA) is a major cause of chronic pain. Non-steroidal anti-inflammatory drugs (NSAIDs) are analgesics commonly used for musculoskeletal pain; however, NSAIDs can increase the risk of certain adverse events, such as gastrointestinal bleeding, edema, heart failure, and hypertension. OBJECTIVE: The objective of this study was to characterize existing comorbidities among patients with OA. For patients with OA with and without a coexisting medical condition of interest (CMCOI), we estimated the prevalence of prescribing and dispensing NSAIDs pre-OA and post-OA diagnosis. METHODS: Data from three large administrative claims databases were used to construct an OA retrospective cohort. Databases leveraged were IBM MarketScan Medicare Supplemental Database (MDCR), IBM MarketScan Commercial Database (CCAE), and Optum's de-identified Clinformatics® Data Mart Database (Optum CDM). The OA study population was defined to be those patients who had an OA diagnosis from an inpatient or outpatient visit with at least 365 days of prior observation time in the database during January 2000 through May 2021. Asthma, cardiovascular disorders, renal impairment, and gastrointestinal bleeding risks were the CMCOI of interest. Patients with OA were then classified as having or not having evidence of a CMCOI. For both groups, NSAID dispensing patterns pre-OA and post-OA diagnosis were identified. Descriptive analysis was performed within the Observational Health Data Sciences and Informatics framework. RESULTS: In each database, the proportion of the OA population with at least one CMCOI was nearly 50% or more (48.0% CCAE; 74.4% MDCR; 68.6% Optum CDM). Cardiovascular disease was the most commonly observed CMCOI in each database, and in two databases, nearly one in four patients with OA had two or more CMCOI (23.2% MDCR; 22.6% Optum CDM). Among the OA population with CMCOI, NSAID utilization post-OA diagnosis ranged from 33.0 to 46.2%. Following diagnosis of OA, an increase in the prescribing and dispensing of NSAIDs was observed in all databases, regardless of patient CMCOI presence. CONCLUSIONS: This study provides real-world evidence of the pattern of prescribing and dispensing of NSAIDs among patients with OA with and without CMCOI, which indicates that at least half of patients with OA in the USA have a coexisting condition. These conditions may increase the risk of side effects commonly associated with NSAIDs. Yet, at least 32% of these patients were prescribed and dispensed NSAIDs. These data support the importance of shared decision making between healthcare professionals and patients when considering NSAIDs for the treatment of OA in patients with NSAID-relevant coexisting medical conditions.

Surgical Management of Polymethylmethacrylate-Collagen Gel Complications in the Lower Eyelid: A Case Series.

BACKGROUND: As nonsurgical rejuvenation with fillers continues to grow in popularity, patients are increasingly interested in more durable results. Polymethylmethacrylate (PMMA)-collagen gel is unique among fillers in that the PMMA microspheres are not completely absorbed and phagocytosed by the body. This durability coupled with the biophysical properties of PMMA makes it a poor choice for periorbital rejuvenation, an unforgiving and highly complex anatomic area. METHODS: Between 2011 and 2018, 14 patients with PMMA granulomas in various facial areas self-referred to the senior author's practice. Of these patients, 11 were managed nonsurgically; however, all 3 patients who presented with granulomas in the infraorbital area required surgery to remove the filler and restore a natural aesthetic. RESULTS: The 3 patients with significant swelling and PMMA filler nodules in the infraorbital area with unacceptable cosmetic appearance were females between the ages of 50 and 55 years. Nonsurgical protocols were unsuccessful, and surgical removal was required. All subjects have been followed for a minimum of 2 years with no immediate- or long-term postoperative complications secondary to PMMA removal. Patients remain satisfied with the outcome of the surgery. CONCLUSIONS: Despite the evidence that the periorbital area is prone to adverse events when injected with particulate fillers, misguided enthusiasm for PMMA-collagen gel as a durable treatment continues to lead to unnecessary and severe complications in patients. The case studies presented here highlight that this product should not be introduced into the periorbital area. We also describe a surgical treatment approach for its removal if complications arise.

Symptom phenotypes in pulmonary arterial hypertension: The PAH "symptome".

Women with pulmonary arterial hypertension (PAH) experience multiple symptoms, including dyspnea, fatigue, and sleep disturbance, that impair their health-related quality of life (HRQOL). However, we know little about phenotypic subgroups of patients with PAH with similar, concurrent, multiple symptoms. The objectives of this study were to define the "symptome" by symptom cluster phenotypes and compare characteristics such as biomarkers, cardiac structure and function (echocardiography), functional capacity (6-min walk distance), and HRQOL between the groups. This cross-sectional study included 60 women with PAH. Subjects completed an assessment battery: Pulmonary Arterial Hypertension Symptom Scale, Pittsburgh Sleep Quality Index, Multidimensional Dyspnea Profile, Patient-Reported Outcomes Measurement Information System (PROMIS®) Physical Function, PROMIS® Sleep-Related Impairment, and the emPHasis-10. Subjects also underwent transthoracic echocardiography, phlebotomy, 6-min walk distance, and actigraphy. The three symptoms of dyspnea, fatigue, and sleep disturbance were used to define the symptom clusters. Other PAH symptoms, plasma and serum biomarkers, cardiac structure and function (echocardiography), exercise capacity (6-min walk distance), sleep (actigraphy), and HRQOL were compared across phenotypes. The mean age was 50 ± 18 years, 51% were non-Hispanic white, 32% were non-Hispanic Black and 40% had idiopathic PAH. Cluster analysis identified Mild (n = 28, 47%), Moderate (n = 20, 33%), and Severe Symptom Cluster Phenotypes (n = 12, 20%). There were no differences for age, race, or PAH etiology between the phenotypes. WHO functional class (p < 0.001), norepinephrine levels (p = 0.029), right atrial pressure (p = 0.001), physical function (p < 0.001), sleep onset latency (p = 0.040), and HRQOL (p < 0.001) all differed significantly across phenotypes. We identified three distinctive symptom cluster phenotypes (Mild, Moderate, and Severe) for women with PAH that also differed by PAH-related symptoms, physical function, right atrial pressure, norepinephrine levels, and HRQOL. These phenotypes could suggest targeted interventions to improve symptoms and HRQOL in those most severely affected.

Synchronous effects of targeted mitochondrial complex I inhibitors on tumor and immune cells abrogate melanoma progression.

Metabolic heterogeneity within the tumor microenvironment promotes cancer cell growth and immune suppression. We determined the impact of mitochondria-targeted complex I inhibitors (Mito-CI) in melanoma. Mito-CI decreased mitochondria complex I oxygen consumption, Akt-FOXO signaling, blocked cell cycle progression, melanoma cell proliferation and tumor progression in an immune competent model system. Immune depletion revealed roles for T cells in the antitumor effects of Mito-CI. While Mito-CI preferentially accumulated within and halted tumor cell proliferation, it also elevated infiltration of activated effector T cells and decreased myeloid-derived suppressor cells (MDSC) as well as tumor-associated macrophages (TAM) in melanoma tumors in vivo. Anti-proliferative doses of Mito-CI inhibited differentiation, viability, and the suppressive function of bone marrow-derived MDSC and increased proliferation-independent activation of T cells. These data indicate that targeted inhibition of complex I has synchronous effects that cumulatively inhibits melanoma growth and promotes immune remodeling.

Mitochondria-targeted magnolol inhibits OXPHOS, proliferation, and tumor growth via modulation of energetics and autophagy in melanoma cells.

INTRODUCTION: Melanoma is an aggressive form of skin cancer for which there are no effective drugs for prolonged treatment. The existing kinase inhibitor antiglycolytic drugs (B-Raf serine/threonine kinase or BRAF inhibitors) are effective for a short time followed by a rapid onset of drug resistance. PRESENTATION OF CASE: Here, we show that a mitochondria-targeted analog of magnolol, Mito-magnolol (Mito-MGN), inhibits oxidative phosphorylation (OXPHOS) and proliferation of melanoma cells more potently than untargeted magnolol. Mito-MGN also inhibited tumor growth in murine melanoma xenografts. Mito-MGN decreased mitochondrial membrane potential and modulated energetic and mitophagy signaling proteins. DISCUSSION: Results indicate that Mito-MGN is significantly more potent than the FDA-approved OXPHOS inhibitor in inhibiting proliferation of melanoma cells. CONCLUSION: These findings have implications in the treatment of melanomas with enhanced OXPHOS status due to metabolic reprogramming or drug resistance.

Improving Outcomes for Patients With Metastatic Colorectal Cancer: Challenges and Strategies.

At JADPRO Live 2019, Leslie A. Swanson, ARNP, and Kathleen Boyle, PA-C, reviewed guideline-concordant molecular testing and therapy in patients with metastatic colorectal cancer (mCRC), the clinical significance of emerging data for existing and novel agents used to treat mCRC, and the management of adverse events associated with mCRC therapies.

Frequency of nonaspirin NSAID-relevant coexisting medical conditions in the primary-care setting: a retrospective database review.

BACKGROUND: Coexisting medical conditions and concomitant medications contribute to treatment challenges primary-care professionals (PCPs) face daily. The current study assessed the extent and distribution of nonaspirin NSAID-relevant coexisting medical conditions of interest (CMCOI) in patients visiting PCPs. METHODS: This retrospective database review analyzed data from three large health-care claim databases to identify the frequency of nonaspirin NSAID-relevant CMCOI among adults aged ≥18 years with a PCP visit in 2013. Claim databases employed were the Truven Health MarketScan® Commercial Claims and Encounters database, representative of the privately insured (PI) population; Truven Health MarketScan Multi-State Medicaid, representative of the Medicaid population (Medicaid); and Truven MarketScan Medicare Supplemental, representative of the Medicare population with employer-based supplemental Medicare insurance (Medicare-Supplement). Nonaspirin NSAID-relevant CMCOI, asthma, cardiovascular risk factors, gastrointestinal bleeding risk factors, and renal insufficiency were chosen based on US NSAID over-the-counter Drug Facts label warnings. Frequency of CMCOI was determined for those without and with a musculoskeletal diagnosis. RESULTS: In each database, ≥19% (19.0% PI, 29.9% Medicaid, 33.6% Medicare-Supplement) had a musculoskeletal diagnosis. A greater proportion of individuals with a musculoskeletal diagnosis had one or more CMCOI compared with those without a musculoskeletal diagnosis (61.3% vs 50.4% PI, 78.1% vs 66.8% Medicaid, 87.1% vs 82.3% Medicare-Supplement). The frequency of one or more CMCOI increased with age in each database. Across databases among CMCOI, cardiovascular risk factors were most common, followed by gastrointestinal bleeding risk factors, and proportions were higher among those with a musculoskeletal diagnosis. CONCLUSION: These data confirm the high frequency of nonaspirin NSAID-relevant CMCOI among patients presenting to PCPs for musculoskeletal diagnosis, as well as among older patients. These analyses reinforce the critical role health-care professionals can play in identifying patients with nonaspirin NSAID-relevant CMCOI, providing those patients with ongoing guidance on appropriate choice and use of over-the-counter analgesics, and educating patients about the impact aging, health status, concomitant conditions, and medicines have on selection of all medicines, including analgesics.

Increasing Participation in Daily Activities among US Adults with Arthritis.

Objectives: This home-use study assessed participants' perceptions regarding a variety of life-style measures after taking acetaminophen extended-relief caplets or placebo as instructed for 10 consecutive days to reduce mild-to-moderate pain of osteoarthritis. Methods: Participants maintained usual daily activities. Screening questionnaire responses assessed participants' daily pain level and pain management strategies. End-of-study questionnaire responses evaluated participants' behaviors, attitudes, and outlook related to impact of daily pain experience on lifestyle and daily activities. Results: The acetaminophen group had significantly higher rat- ings for ability to be active throughout the day, accomplishing daily activities, waking up moving like their old selves again, feeling in charge of their pain, and doing things they like to do longer. Likewise, they found it significantly easier to live with their condition and think about things other than their pain. Conclusions: Consistent with international guidelines, healthcare professionals can design an initial multimodal treatment plan to help patients achieve short- term goals (ie, reduced pain, more active lifestyle) and then modify that regimen (eg, alter dose of analgesic, duration of physical activity) in accordance with patients' responses to treatment, thus supporting long-term goals (eg, maintenance of independence and lifestyle) many patients hope to achieve.

Prospective discovery of small molecule enhancers of an E3 ligase-substrate interaction.

Protein-protein interactions (PPIs) governing the recognition of substrates by E3 ubiquitin ligases are critical to cellular function. There is significant therapeutic potential in the development of small molecules that modulate these interactions; however, rational design of small molecule enhancers of PPIs remains elusive. Herein, we report the prospective identification and rational design of potent small molecules that enhance the interaction between an oncogenic transcription factor, ß-Catenin, and its cognate E3 ligase, SCFß-TrCP. These enhancers potentiate the ubiquitylation of mutant ß-Catenin by ß-TrCP in vitro and induce the degradation of an engineered mutant ß-Catenin in a cellular system. Distinct from PROTACs, these drug-like small molecules insert into a naturally occurring PPI interface, with contacts optimized for both the substrate and ligase within the same small molecule entity. The prospective discovery of 'molecular glue' presented here provides a paradigm for the development of small molecule degraders targeting hard-to-drug proteins.

Mitochondria-targeted drugs stimulate mitophagy and abrogate colon cancer cell proliferation.

Mutations in the KRAS proto-oncogene are present in 50% of all colorectal cancers and are increasingly associated with chemotherapeutic resistance to frontline biologic drugs. Accumulating evidence indicates key roles for overactive KRAS mutations in the metabolic reprogramming from oxidative phosphorylation to aerobic glycolysis in cancer cells. Here, we sought to exploit the more negative membrane potential of cancer cell mitochondria as an untapped avenue for interfering with energy metabolism in KRAS variant-containing and KRAS WT colorectal cancer cells. Mitochondrial function, intracellular ATP levels, cellular uptake, energy sensor signaling, and functional effects on cancer cell proliferation were assayed. 3-Carboxyl proxyl nitroxide (Mito-CP) and Mito-Metformin, two mitochondria-targeted compounds, depleted intracellular ATP levels and persistently inhibited ATP-linked oxygen consumption in both KRAS WT and KRAS variant-containing colon cancer cells and had only limited effects on nontransformed intestinal epithelial cells. These anti-proliferative effects reflected the activation of AMP-activated protein kinase (AMPK) and the phosphorylation-mediated suppression of the mTOR target ribosomal protein S6 kinase B1 (RPS6KB1 or p70S6K). Moreover, Mito-CP and Mito-Metformin released Unc-51-like autophagy-activating kinase 1 (ULK1) from mTOR-mediated inhibition, affected mitochondrial morphology, and decreased mitochondrial membrane potential, all indicators of mitophagy. Pharmacological inhibition of the AMPK signaling cascade mitigated the anti-proliferative effects of Mito-CP and Mito-Metformin. This is the first demonstration that drugs selectively targeting mitochondria induce mitophagy in cancer cells. Targeting bioenergetic metabolism with mitochondria-targeted drugs to stimulate mitophagy provides an attractive approach for therapeutic intervention in KRAS WT and overactive mutant-expressing colon cancer.

Cancer cell chemokines direct chemotaxis of activated stellate cells in pancreatic ductal adenocarcinoma.

The mechanisms by which the extreme desmoplasia observed in pancreatic tumors develops remain unknown and its role in pancreatic cancer progression is unsettled. Chemokines have a key role in the recruitment of a wide variety of cell types in health and disease. Transcript and protein profile analyses of human and murine cell lines and human tissue specimens revealed a consistent elevation in the receptors CCR10 and CXCR6, as well as their respective ligands CCL28 and CXCL16. Elevated ligand expression was restricted to tumor cells, whereas receptors were in both epithelial and stromal cells. Consistent with its regulation by inflammatory cytokines, CCL28 and CCR10, but not CXCL16 or CXCR6, were upregulated in human pancreatitis tissues. Cytokine stimulation of pancreatic cancer cells increased CCL28 secretion in epithelial tumor cells but not an immortalized activated human pancreatic stellate cell line (HPSC). Stellate cells exhibited dose- and receptor-dependent chemotaxis in response to CCL28. This functional response was not linked to changes in activation status as CCL28 had little impact on alpha smooth muscle actin levels or extracellular matrix deposition or alignment. Co-culture assays revealed CCL28-dependent chemotaxis of HPSC toward cancer but not normal pancreatic epithelial cells, consistent with stromal cells being a functional target for the epithelial-derived chemokine. These data together implicate the chemokine CCL28 in the inflammation-mediated recruitment of cancer-associated stellate cells into the pancreatic cancer parenchyma.

Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review.

BACKGROUND: One approach to overcoming healthcare system barriers and facilitating timely access to quality care and patient satisfaction is with a patient navigator. A patient navigator is a trained person who individually assists patients, families and caregivers navigate the healthcare system barriers efficiently and effectively at any point along the care continuum, improving patient care at all levels of an organization. OBJECTIVES: To synthesize the best available evidence on the effectiveness of a patient navigator on patient satisfaction in adult patients 18 years and older in ambulatory care settings. INCLUSION CRITERIA TYPES OF PARTICIPANTS: This review considered studies that involved adults of any ethnicity, race or gender, aged 18 years or older, regardless of diagnoses, stage of illness, whether the illness is acute or chronic or previous treatment, who had been receiving care in an ambulatory care setting. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: This review considered studies on the use of a patient navigator as an additional intervention to usual care for promoting patient satisfaction for adult patients in an ambulatory care setting. Usual care without a patient navigator was considered as a comparator. TYPES OF STUDIES: This review considered experimental and observational studies. OUTCOMES: The outcome considered was patient satisfaction. SEARCH STRATEGY: The literature search included published and unpublished studies in the English Language from 1990 through July 2015. A search of PubMed, CINAHL, Excerpta Medica Database (EMBASE), Academic Search Premier, Cochrane Library, PsycINFO and Health Source: Nursing/Academic Edition, Social Work Abstracts and Web of Science was conducted. A search for gray literature and electronic hand searching of relevant journals was also performed. METHODOLOGICAL QUALITY: Two reviewers independently evaluated the included studies for methodological quality utilizing standardized critical appraisal instruments from the Joanna Briggs Institute. DATA EXTRACTION: Standardized data extraction tools from Joanna Briggs Institute were used by two independent reviewers for data extraction. DATA SYNTHESIS: A statistical meta-analysis was not possible due to heterogeneity between the included studies. Results are presented in a narrative form. RESULTS: Four studies were included in this review, two were randomized controlled trials (RCTs), one was a quasi-experimental pre-post-test design study and one was a cohort study. The four studies showed that a patient navigator had clinical benefit for patient satisfaction, care coordination and patient access to timely healthcare services. One RCT reported a mean satisfaction score of 4.3 for navigated patients and 2.9 for non-navigated patients; P < 0.001. A second RCT showed an odds ratio 1.29; 95% confidence interval 0.92-1.82 for navigated versus non-navigated patients. The quasi-experimental pre-test-post-test study showed navigated patient satisfaction with a mean = 11.45 (standard deviation [SD], 3.69) in comparison with the non-navigated patient (mean, 14.95; SD, 1.69) (F = 11.85; P = 0.000). The cohort study demonstrated a mean satisfaction score of 90.7 for navigated patients and 85.5 for non-navigated patients; P = 0.03. The four studies showed no clinically significant results; however, the patient navigator role may promote relationships among the healthcare team, reducing barriers for patient-centered care and enhanced patient satisfaction. CONCLUSION: There is a paucity of evidence on the effectiveness of a patient navigator on patient satisfaction. In the four studies selected for inclusion, a patient navigator had a positive effect on patient satisfaction, although none of the studies demonstrated statistical significance with a patient navigator on patient satisfaction. The effect of a patient navigator remains questionable with differences in perceptions on the best individual for the role and the expected role perception and performance. A standardized approach to the role of the patient navigator may maximize health outcomes and positively affect the quality of life for all patients.

Diabetes and Depression Care: A Randomized Controlled Pilot Trial.

OBJECTIVE: We examined the comparative effectiveness of an integrated intervention for Type 2 diabetes mellitus (T2DM) and depression by employing patient prioritized planning (PPP) to incorporate patients' financial, social, and emotional needs versus an integrated intervention alone. METHODS: A randomized controlled pilot trial randomly assigned 78 patients prescribed pharmacotherapy for T2DM in primary care to an integrated intervention for T2DM and depression employing PPP to incorporate patients' financial, social, and emotional needs (enhanced intervention) versus an integrated intervention alone (basic intervention). Hemoglobin A1C (HbA1C) assays measured glycemic control and the Center for Epidemiologic Studies Depression Scale (CES-D) assessed depression. RESULTS: Patients in the enhanced intervention had a significantly greater mean change in HbA1C from baseline in comparison with the basic intervention at 12 weeks (enhanced intervention -0.63 vs basic intervention 0.15; p = .027). Patients in the enhanced intervention also had a significantly greater mean change in CES-D from baseline in comparison with patients in the basic intervention group at 12 weeks (enhanced intervention -3.75 vs basic intervention 0.93; p = .041). CONCLUSIONS: Our pilot trial results indicate that an integrated care intervention employing PPP to incorporate financial, social and emotional needs for primary care patients with T2DM and depression may be effective.

Mitochondria-Targeted Analogues of Metformin Exhibit Enhanced Antiproliferative and Radiosensitizing Effects in Pancreatic Cancer Cells.

Metformin (Met) is an approved antidiabetic drug currently being explored for repurposing in cancer treatment based on recent evidence of its apparent chemopreventive properties. Met is weakly cationic and targets the mitochondria to induce cytotoxic effects in tumor cells, albeit not very effectively. We hypothesized that increasing its mitochondria-targeting potential by attaching a positively charged lipophilic substituent would enhance the antitumor activity of Met. In pursuit of this question, we synthesized a set of mitochondria-targeted Met analogues (Mito-Mets) with varying alkyl chain lengths containing a triphenylphosphonium cation (TPP(+)). In particular, the analogue Mito-Met10, synthesized by attaching TPP(+) to Met via a 10-carbon aliphatic side chain, was nearly 1,000 times more efficacious than Met at inhibiting cell proliferation in pancreatic ductal adenocarcinoma (PDAC). Notably, in PDAC cells, Mito-Met10 potently inhibited mitochondrial complex I, stimulating superoxide and AMPK activation, but had no effect in nontransformed control cells. Moreover, Mito-Met10 potently triggered G1 cell-cycle phase arrest in PDAC cells, enhanced their radiosensitivity, and more potently abrogated PDAC growth in preclinical mouse models, compared with Met. Collectively, our findings show how improving the mitochondrial targeting of Met enhances its anticancer activities, including aggressive cancers like PDAC in great need of more effective therapeutic options. Cancer Res; 76(13); 3904-15. ©2016 AACR.

Genetic Confirmation that the H5 Protein Is Required for Vaccinia Virus DNA Replication.

UNLABELLED: The duplication of the poxvirus double-stranded DNA genome occurs in cytoplasmic membrane-delimited factories. This physical autonomy from the host nucleus suggests that poxvirus genomes encode the full repertoire of proteins committed for genome replication. Biochemical and genetic analyses have confirmed that six viral proteins are required for efficient DNA synthesis; indirect evidence has suggested that the multifunctional H5 protein may also have a role. Here we show that H5 localizes to replication factories, as visualized by immunofluorescence and immunoelectron microscopy, and can be retrieved upon purification of the viral polymerase holoenzyme complex. The temperature-sensitive (ts) mutant Dts57, which was generated by chemical mutagenesis and has a lesion in H5, exhibits defects in DNA replication and morphogenesis under nonpermissive conditions, depending upon the experimental protocol. The H5 variant encoded by the genome of this mutant is ts for function but not stability. For a more precise investigation of how H5 contributes to DNA synthesis, we placed the ts57 H5 allele in an otherwise wild-type viral background and also performed small interfering RNA-mediated depletion of H5. Finally, we generated a complementing cell line, CV-1-H5, which allowed us to generate a viral recombinant in which the H5 open reading frame was deleted and replaced with mCherry (vΔH5). Analysis of vΔH5 allowed us to demonstrate conclusively that viral DNA replication is abrogated in the absence of H5. The loss of H5 does not compromise the accumulation of other early viral replication proteins or the uncoating of the virion core, suggesting that H5 plays a direct and essential role in facilitating DNA synthesis. IMPORTANCE: Variola virus, the causative agent of smallpox, is the most notorious member of the Poxviridae family. Poxviruses are unique among DNA viruses that infect mammalian cells, in that their replication is restricted to the cytoplasm of the cell. This physical autonomy from the nucleus has both cell biological and genetic ramifications. Poxviruses must establish cytoplasmic niches that support replication, and the genomes must encode the repertoire of proteins necessary for genome synthesis. Here we focus on H5, a multifunctional and abundant viral protein. We confirm that H5 associates with the DNA polymerase holoenzyme and localizes to the sites of DNA synthesis. By generating an H5-expressing cell line, we were able to isolate a deletion virus that lacks the H5 gene and show definitively that genome synthesis does not occur in the absence of H5. These data support the hypothesis that H5 is a crucial participant in cytoplasmic poxvirus genome replication.

New insights into root causes of pediatric accidental unsupervised ingestions of over-the-counter medications.

CONTEXT: Changes to regulations, packaging, and labeling and ongoing educational efforts are intended to support appropriate use of medicines. Yet annually poison centers receive > 500 000 reports of accidental or unsupervised exposure to medicines for children under 6 years of age. OBJECTIVE: To identify root (i.e., fundamental and preventable) causes of accidental unsupervised ingestions (AUIs), we designed a questionnaire and conducted a follow-up survey of caregivers who contacted McNeil Consumer Healthcare (McNeil) following an AUI by a child under 12 years of age. METHODS: Reports received between 1 October 2008 and 22 January 2009 were screened retrospectively for specific Medical Dictionary of Regulatory Activities (MedDRA) Preferred Terms relating to AUIs. Using the questionnaire, we collected information about the child, caregiver, medicines involved in AUI, management of AUI, and storage location of medicines. RESULTS: Two hundred twenty reports met inclusion criteria and attempts to contact these caregivers were made throughout a 2-week period in March 2009; caregivers completed the questionnaire for 45 reports. All AUIs occurred in children under 7 years and 56% were boys. In 56% of AUI cases, the child involved was the intended recipient of the medicine; in 71%, a pediatric medicine was involved. Most AUIs occurred in the child's home; most caregivers reported not observing the AUI. Sixty percent of caregivers reported that the medicine involved in AUI was not in the normal storage location when AUI occurred. Among children involved in AUIs, 84% did not experience any symptoms. Seven children experienced mild, self-limiting symptoms which resolved. AUIs often occurred < 24 h after last therapeutic use when the medicine was removed from its normal storage location. CONCLUSIONS: These new insights may help guide-targeted interventions and educational efforts to focus caregivers' attention to reengaging childproofing mechanisms and returning medicines to a secure location, high and out of sight, immediately after use.

An evaluation of the appropriateness and safety of nurse and midwife prescribing in Ireland.

AIM: To evaluate the clinical appropriateness and safety of nurse and midwife prescribing practice. BACKGROUND: The number of countries introducing nurse and midwife prescribing is increasing; however, concerns over patient safety remain. DESIGN: A multi-site documentation evaluation was conducted using purposeful and random sampling. The sample included 142 patients' records and 208 medications prescribed by 25 Registered Nurse Prescribers. METHODS: Data were extracted from patient and prescription records between March-May 2009. Two expert reviewers applied the modified Medication Appropriate Index tool (8 criteria) to each drug. The percentage of appropriate or inappropriate responses for each criterion was reported. Reviewer concordance was measured using the Cohen's kappa statistic (inter-rater reliability). RESULTS: Nurse or midwife prescribers from eight hospitals working in seventeen different areas of practice were included. The reviewers judged that 95-96% of medicines prescribed were indicated and effective for the diagnosed condition. Criteria relating to dosage, directions, drug-drugs or disease-condition interaction, and duplication of therapy were judged appropriate in 87-92% of prescriptions. Duration of therapy received the lowest value at 76%. Overall, reviewers indicated that between 69 (reviewer 2)-80% (reviewer 1) of prescribing decisions met all eight criteria. CONCLUSION: The majority of nurse and midwife prescribing decisions were deemed safe and clinically appropriate. However, risk of inappropriate prescribing with the potential for drug errors was detected. Continuing education and evaluation of prescribing practice, especially related to drug and condition interactions, is required to maximize appropriate and safe prescribing.

Sleep disordered breathing in patients receiving therapy with buprenorphine/naloxone.

Patients using chronic opioids are at risk for exceptionally complex and potentially lethal disorders of breathing during sleep, including central and obstructive apnoeas, hypopnoeas, ataxic breathing and nonapnoeic hypoxaemia. Buprenorphine, a partial µ-opioid agonist with limited respiratory toxicity, is widely used for the treatment of opioid dependency and chronic nonmalignant pain. However, its potential for causing sleep disordered breathing has not been studied. 70 consecutive patients admitted for therapy with buprenorphine/naloxone were routinely evaluated with sleep medicine consultation and attended polysomnography. The majority of patients were young (mean±sd age 31.8±12.3 years), nonobese (mean±sd body mass index 24.9±5.9 kg·m(-2)) and female (60%). Based upon the apnoea/hypopnoea index (AHI), at least mild sleep disordered breathing (AHI ≥5 events·h(-1)) was present in 63% of the group. Moderate (AHI ≥15- <30 events·h(-1)) and severe (AHI ≥30 events·h(-1)) sleep apnoea was present in 16% and 17%, respectively. Hypoxaemia, defined as an arterial oxygen saturation measured by pulse oximetry, of <90% for ≥10% of sleep time, was present in 27 (38.6%) patients. Despite the putative protective ceiling effect regarding ventilatory suppression observed during wakefulness, buprenorphine may induce significant alterations of breathing during sleep at routine therapeutic doses.