Lessons learned through the implementation of a rural longitudinal integrated clerkship at the University of Missouri-Columbia.

INTRODUCTION: Created in 1995, The University of Missouri School of Medicine's Rural Track Pipeline Program was designed to address physician shortages in rural Missouri through medical student participation in a series of clinical and non-clinical programs over the course of their medical training to influence graduates to choose rural practice. METHODS: To increase the likelihood of students choosing rural practice, a 46-week longitudinal integrated clerkship (LIC) was implemented at one of nine existing rural training sites. Over the course of the academic year, quantitative and qualitative data was collected to evaluate effectiveness of the curriculum and for quality improvement purposes. RESULTS: Data collection is in progress and includes student evaluation of the clerkship, faculty evaluations of students, student evaluations of faculty, student aggregate clerkship performance, and qualitative data from student and faculty debrief sessions. DISCUSSION: Based on data collected, changes are being made to the curriculum for the following academic year to enhance the student experience. The LIC will also be offered at an additional rural training site beginning in June of 2022, and then expanded to a third site in June of 2023. As each LIC is unique, our hope is our experience and lessons learned will help others in developing a LIC or improving an existing LIC.

In Vitro and In Vivo Properties of CUO246, a Novel Bacterial DNA Gyrase/Topoisomerase IV Inhibitor.

CUO246, a novel DNA gyrase/topoisomerase IV inhibitor, is active in vitro against a broad range of Gram-positive, fastidious Gram-negative, and atypical bacterial pathogens and retains activity against quinolone-resistant strains in circulation. The frequency of selection for single step mutants of wild-type S. aureus with reduced susceptibility to CUO246 was <4.64 × 10-9 at 4× and 8× MIC and remained low when using an isogenic QRDR mutant (<5.24 × 10-9 at 4× and 8× MIC). Biochemical assays indicated that CUO246 had potent inhibitory activity against both DNA gyrase (GyrAB) and topoisomerase IV (ParCE). Furthermore, CUO246 showed rapid bactericidal activity in time-kill assays and potent in vivo efficacy against S. aureus in a neutropenic murine thigh infection model. These results suggest that CUO246 may be useful in treating infections by various causative agents of acute skin and skin structure infections, respiratory tract infections, and sexually transmitted infections.

Anterior cerebral blood velocity and end-tidal CO2 responses to exercise differ in children and adults.

Little is known about the response of the cerebrovasculature to acute exercise in children and how these responses might differ with adults. Therefore, we compared changes in middle cerebral artery blood velocity (MCAVmean), end-tidal Pco2 ([Formula: see text]), blood pressure, and minute ventilation (V̇e) in response to incremental exercise between children and adults. Thirteen children [age: 9 ± 1 (SD) yr] and thirteen sex-matched adults (age: 25 ± 4 yr) completed a maximal exercise test, during which MCAVmean, [Formula: see text], and V̇e were measured continuously. These variables were measured at rest, at exercise intensities specific to individual ventilatory thresholds, and at maximum. Although MCAVmean was higher at rest in children compared with adults, there were smaller increases in children (1-12%) compared with adults (12-25%) at all exercise intensities. There were alterations in [Formula: see text] with exercise intensity in an age-dependent manner [F(2.5,54.5) = 7.983, P < 0.001; η2 = 0.266], remaining stable in children with increasing exercise intensity (37-39 mmHg; P > 0.05) until hyperventilation-induced reductions following the respiratory compensation point. In adults, [Formula: see text] increased with exercise intensity (36-45 mmHg, P < 0.05) until the ventilatory threshold. From the ventilatory threshold to maximum, adults showed a greater hyperventilation-induced hypocapnia than children. These findings show that the relative increase in MCAVmean during exercise was attenuated in children compared with adults. There was also a weaker relationship between MCAVmean and [Formula: see text] during exercise in children, suggesting that cerebral perfusion may be regulated by different mechanisms during exercise in the child.NEW & NOTEWORTHY These findings provide the first direct evidence that exercise increases cerebral blood flow in children to a lesser extent than in adults. Changes in end-tidal CO2 parallel changes in cerebral perfusion in adults but not in children, suggesting age-dependent regulatory mechanisms of cerebral blood flow during exercise.

Current functional metagenomic approaches only expand the existing protease sequence space, but does not presently add any novelty to it.

Proteases are a fundamental function in many organisms and thus many ecosystems and yet they are rarely obtained in functional metagenomic screens. Here, we have isolated an active protease gene (M1-2; 613 amino acids) which resided in a 38.4 kb fosmid clone that showed a classical protease-positive phenotype. It was classified as a zinc-dependent metalloprotease, with the closest annotated sequence as a neutral protease from Collimonas fungivorans (62 % similarity and 72 % homology). Further characterisation showed that its optimum temperature and pH were 42 °C and 8.0, respectively. Activity was inhibited by EDTA, but inhibition started to be reversed by excess Zn(2+). A putative signal peptide was identified bioinformatically and this may be why this protease was successfully isolated using a functional metagenomic screen. Bioinformatic analysis shows that this does not represent a novel protease, but simply expands the current sequence space of known proteases.

Conditional cash transfer schemes in Nigeria: potential gains for maternal and child health service uptake in a national pilot programme.

BACKGROUND: This paper describes use of a Conditional Cash Transfer (CCT) programme to encourage use of critical MNCH services among rural women in Nigeria. METHODS: The CCT programme was first implemented as a pilot in 37 primary health care facilities (PHCs), in nine Nigerian states. The programme entitles women using these facilities up to N5,000 (approximately US$30) if they attend antenatal care (ANC), skilled delivery, and postnatal care. There are 88 other PHCs from these nine states included in this study, which implemented a standard package of supply upgrades without the CCT. Data on monthly service uptake throughout the continuum of care was collected at 124 facilities during quarterly monitoring visits. An interrupted time series using segmented linear regression was applied to estimate separately the effects of the CCT programme and supply package on service uptake. RESULTS: From April 2013-March 2014, 20,133 women enrolled in the CCT. Sixty-four percent of beneficiaries returned at least once after registration, and 80% of women delivering with skilled attendance returned after delivery. The CCT intervention is associated with a statistically significant increase in the monthly number of women attending four or more ANC visits (increase of 15.12 visits per 100,000 catchment population, p < 0.01; 95% confidence interval 7.38 to 22.85), despite a negative level effect immediately after the intervention began (-45.53/100,000 catchment population; p < 0.05; 95% CI -82.71 to -8.36). A statistically significant increase was also observed in the monthly number of women receiving two or more Tetanus toxoid doses during pregnancy (21.65/100,000 catchment population; p < 0.01; 95% CI 9.23 to 34.08). Changes for other outcomes with the CCT intervention (number of women attending first ANC visit; number of deliveries with skilled attendance; number of neonates receiving OPV at birth) were not found to be statistically significant. CONCLUSIONS: The results show that the CCT intervention is capable of significant effects on service uptake, although results for several outcomes of interest were inconclusive. Key lessons learnt from the pilot phase of implementation include a need to track beneficiary retention throughout the continuum of care as closely as possible, and avert loss to follow-up.

Chemical shift prediction for denatured proteins.

While chemical shift prediction has played an important role in aspects of protein NMR that include identification of secondary structure, generation of torsion angle constraints for structure determination, and assignment of resonances in spectra of intrinsically disordered proteins, interest has arisen more recently in using it in alternate assignment strategies for crosspeaks in (1)H-(15)N HSQC spectra of sparsely labeled proteins. One such approach involves correlation of crosspeaks in the spectrum of the native protein with those observed in the spectrum of the denatured protein, followed by assignment of the peaks in the latter spectrum. As in the case of disordered proteins, predicted chemical shifts can aid in these assignments. Some previously developed empirical formulas for chemical shift prediction have depended on basis data sets of 20 pentapeptides. In each case the central residue was varied among the 20 amino common acids, with the flanking residues held constant throughout the given series. However, previous choices of solvent conditions and flanking residues make the parameters in these formulas less than ideal for general application to denatured proteins. Here, we report (1)H and (15)N shifts for a set of alanine based pentapeptides under the low pH urea denaturing conditions that are more appropriate for sparse label assignments. New parameters have been derived and a Perl script was created to facilitate comparison with other parameter sets. A small, but significant, improvement in shift predictions for denatured ubiquitin is demonstrated.

What BP target is appropriate for pregnant patients with mild chronic hypertension?

Active treatment to a lower blood pressure goal (< 140/90 mm Hg) can improve pregnancy outcomes without increasing maternal or fetal risk.

Acute Achilles tendon rupture: Skip the surgery?

Nonoperative management for acute Achilles tendon rupture results in patient-reported outcomes similar to surgery at 1 year-but higher rates of rerupture.

Can extended anticoagulation prophylaxis after discharge prevent thromboembolism?

A meta-analysis confirmed the benefit of thromboprophylaxis with a direct oral anticoagulant for high-risk nonsurgical patients after hospital discharge.

Glycan Conformation in the Heavily Glycosylated Protein, CEACAM1.

Glycans attached to glycoproteins can contribute to stability, mediate interactions with other proteins, and initiate signal transduction. Glycan conformation, which is critical to these processes, is highly variable and often depicted as sampling a multitude of conformers. These conformers can be generated by molecular dynamics simulations, and more inclusively by accelerated molecular dynamics, as well as other extended sampling methods. However, experimental assessments of the contribution that various conformers make to a native ensemble are rare. Here, we use long-range pseudo-contact shifts (PCSs) of NMR resonances from an isotopically labeled glycoprotein to identify preferred conformations of its glycans. The N-terminal domain from human Carcinoembryonic Antigen Cell Adhesion Molecule 1, hCEACAM1-Ig1, was used as the model glycoprotein in this study. It has been engineered to include a lanthanide-ion-binding loop that generates PCSs, as well as a homogeneous set of three 13C-labeled N-glycans. Analysis of the PCSs indicates that preferred glycan conformers have extensive contacts with the protein surface. Factors leading to this preference appear to include interactions between N-acetyl methyls of GlcNAc residues and hydrophobic surface pockets on the protein surface.

AssignSLP_GUI, a software tool exploiting AI for NMR resonance assignment of sparsely labeled proteins.

Not all proteins are amenable to uniform isotopic labeling with 13C and 15N, something needed for the widely used, and largely deductive, triple resonance assignment process. Among them are proteins expressed in mammalian cell culture where native glycosylation can be maintained, and proper formation of disulfide bonds facilitated. Uniform labeling in mammalian cells is prohibitively expensive, but sparse labeling with one or a few isotopically enriched amino acid types is an option for these proteins. However, assignment then relies on accessing the best match between a variety of measured NMR parameters and predictions based on 3D structure, often from X-ray crystallography. Finding this match is a challenging process that has benefitted from many computational tools, including trained neural nets for chemical shift prediction, genetic algorithms for searches through a myriad of assignment possibilities, and now AI-based prediction of high-quality structures for protein targets. AssignSLP_GUI, a new version of a software package for assignment of resonances from sparsely-labeled proteins, uses many of these tools. These tools and new additions to the package are highlighted in an application to a sparsely-labeled domain from a glycoprotein, CEACAM1.

Luminescence-based spectroelectrochemical sensor for [Tc(dmpe)3]2+/+ (dmpe = 1,2-bis(dimethylphosphino)ethane) within a charge-selective polymer film.

A spectroelectrochemical sensor consisting of an indium tin oxide (ITO) optically transparent electrode (OTE) coated with a thin film of partially sulfonated polystyrene-blockpoly(ethylene-ran-butylene)-block-polystyrene (SSEBS) was developed for [Tc(dmpe)(3)](+) (dmpe = 1,2-bis(dimethylphosphino)ethane). [Tc(dmpe)(3)](+) was preconcentrated by ion-exchange into the SSEBS film after a 20 min exposure to aqueous [Tc(dmpe)(3)](+) solution, resulting in a 14-fold increase in cathodic peak current compared to a bare OTE. Colorless [Tc(dmpe)(3)](+) was reversibly oxidized to colored [Tc(dmpe)(3)](2+) by cyclic voltammetry. Detection of [Tc(dmpe)(3)](2+) was accomplished through emission spectroscopy by electrochemically oxidizing the complex from nonemissive [Tc(dmpe)(3)](+) to emissive [Tc(dmpe)(3)](2+). The working principle of the sensor consisted of electrochemically cycling between nonemissive [Tc(dmpe)(3)](+) and emissive [Tc(dmpe)(3)](2+) and monitoring the modulated emission (λ(exc) = 532 nm; λ(em) = 660 nm). The sensor gave a linear response over the concentration range of 0.16-340.0 µM of [Tc(dmpe)(3)](2+/+) in aqueous phase with a detection limit of 24 nM.

HIV surveillance in a large, community-based study: results from the pilot study of Project Accept (HIV Prevention Trials Network 043).

BACKGROUND: Project Accept is a community randomized, controlled trial to evaluate the efficacy of community mobilization, mobile testing, same-day results, and post-test support for the prevention of HIV infection in Thailand, Tanzania, Zimbabwe, and South Africa. We evaluated the accuracy of in-country HIV rapid testing and determined HIV prevalence in the Project Accept pilot study. METHODS: Two HIV rapid tests were performed in parallel in local laboratories. If the first two rapid tests were discordant (one reactive, one non-reactive), a third HIV rapid test or enzyme immunoassay was performed. Samples were designated HIV NEG if the first two tests were non-reactive, HIV DISC if the first two tests were discordant, and HIV POS if the first two tests were reactive. Samples were re-analyzed in the United States using a panel of laboratory tests. RESULTS: HIV infection status was correctly determined based on-in country testing for 2,236 (99.5%) of 2,247 participants [7 (0.37%) of 1,907 HIV NEG samples were HIV-positive; 2 (0.63%) of 317 HIV POS samples were HIV-negative; 2 (8.3%) of 24 HIV DISC samples were incorrectly identified as HIV-positive based on the in-country tie-breaker test]. HIV prevalence was: Thailand: 0.6%, Tanzania: 5.0%, Zimbabwe 14.7%, Soweto South Africa: 19.4%, Vulindlela, South Africa: 24.4%, (overall prevalence: 14.4%). CONCLUSIONS: In-country testing based on two HIV rapid tests correctly identified the HIV infection status for 99.5% of study participants; most participants with discordant HIV rapid tests were not infected. HIV prevalence varied considerably across the study sites (range: 0.6% to 24.4%). TRIAL REGISTRATION: ClinicalTrials.gov registry number NCT00203749.

This is not the time to modify a HTN regimen.

Intensifying hypertension regimens at discharge increases risk in older patients.

Skip that repeat DXA scan in these postmenopausal women.

Repeat bone density measurement offers no advantage in predicting fracture risk in postmenopausal women who do not have osteoporosis.

Validated scoring system identifies low-risk syncope patients.

This study validated the Canadian Syncope Risk Score for predicting 30-day serious outcomes in patients presenting to the ED within 24 hours of syncope.

Using molecular dynamics trajectories to predict nuclear spin relaxation behaviour in large spin systems.

Molecular dynamics (MD) trajectories provide useful insights into molecular structure and dynamics. However, questions persist about the quantitative accuracy of those insights. Experimental NMR spin relaxation rates can be used as tests, but only if relaxation superoperators can be efficiently computed from MD trajectories - no mean feat for the quantum Liouville space formalism where matrix dimensions quadruple with each added spin 1/2. Here we report a module for the Spinach software framework that computes Bloch-Redfield-Wangsness relaxation superoperators (including non-secular terms and cross-correlations) from MD trajectories. Predicted initial slopes of nuclear Overhauser effects for sucrose trajectories using advanced water models and a force field optimised for glycans are within 25% of experimental values.

Vestibular rehabilitation for dizziness and balance disorders after concussion.

BACKGROUND AND PURPOSE: Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion. METHODS: A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8-18 years]; 47 adults older than 18 years [mean, 41 years; range, 19-73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures. RESULTS: The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P < .05). Children improved by a greater amount in dizziness severity (P = .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P < .025). DISCUSSION: Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults. CONCLUSIONS: Vestibular rehabilitation should be considered in the management of individuals post concussion who have dizziness and gait and balance dysfunction that do not resolve with rest.

Vaccine Safety.

The details of vaccine development, licensing, and monitoring have never been more important and relevant to the health care conversation in the United States. The potential exists for a preventive medicine such as a vaccine to cause harm, and physicians and patients need to understand the real balance of risks and benefits of immunization. Vaccines given in the United States undergo rigorous testing before licensure as well as extensive postlicensure safety monitoring.