Assessment of the feasibility of developing a clinical pathway using a clinical order log.

A clinical pathway (CP) is a tool for effectively managing a care process. There are several research efforts on developing clinical pathways (CPs) in the process mining domain. However, the nature of the data affects data analysis results, and patient clinical variability makes it challenging to develop CPs. Thus, it is crucial to determine candidate care processes that can be standardized as CPs before applying process mining techniques. This paper proposed a method for assessing CP feasibility regarding clinical complexity using clinical order logs from electronic health records. The proposed method consists of data preparation, activity & trace homogeneity evaluations, and process inspection using process mining. Each step consists of metrics to measure the homogeneity of processes and a visualization method to demonstrate the diversity of processes based on the log. The case study was conducted with five surgical groups of patients from a tertiary hospital in South Korea to validate the proposed method. The five groups of patients were successfully assessed. In addition, the visualization methods helped clinical experts grasp the diversity of care processes.

Differentially Expressed Gene Profile of Acanthamoeba castellanii Induced by an Endosymbiont Legionella pneumophila.

Legionella pneumophila is an opportunistic pathogen that survives and proliferates within protists such as Acanthamoeba spp. in environment. However, intracellular pathogenic endosymbiosis and its implications within Acanthamoeba spp. remain poorly understood. In this study, RNA sequencing analysis was used to investigate transcriptional changes in A. castellanii in response to L. pneumophila infection. Based on RNA sequencing data, we identified 1,211 upregulated genes and 1,131 downregulated genes in A. castellanii infected with L. pneumophila for 12 hr. After 24 hr, 1,321 upregulated genes and 1,379 downregulated genes were identified. Gene ontology (GO) analysis revealed that L. pneumophila endosymbiosis enhanced hydrolase activity, catalytic activity, and DNA binding while reducing oxidoreductase activity in the molecular function (MF) domain. In particular, multiple genes associated with the GO term 'integral component of membrane' were downregulated during endosymbiosis. The endosymbiont also induced differential expression of various methyltransferases and acetyltransferases in A. castellanii. Findings herein are may significantly contribute to understanding endosymbiosis of L. pneumophila within A. castellanii.

Application of Histone Deacetylase Inhibitors MPK472 and KSK64 as a Potential Treatment Option for Acanthamoeba Keratitis.

Treatment of Acanthamoeba keratitis (AK) is difficult because Acanthamoeba cysts are resistant to drugs, and as such, successful treatment requires an effective approach that inhibits cyst formation. Histone deacetylase inhibitors (HDACis) are involved in cell proliferation, differentiation, and apoptotic cell death. In this study, the effects of HDACis such as MPK472 and KSK64 on Acanthamoeba castellanii trophozoites and cysts were observed. MPK472 and KSK64 showed at least 60% amoebicidal activity against Acanthamoeba trophozoites at a concentration of 10 µM upon 8 h of treatment. Neither of the two HDACis affected mature cysts, but significant amoebicidal activities (36.4 and 33.9%) were observed against encysting Acanthamoeba following treatment with 5 and 10 µM HDACis for 24 h. Light microscopy and transmission electron microscopy results confirmed that the encystation of Acanthamoeba was inhibited by the two HDACis. In addition to this, low cytopathic effects on human corneal epithelial (HCE) cells were observed following treatment with MPK472 and KSK64 for 24 h. Our results indicate that the HDACis MPK472 and KSK64 could be used as new candidates for the development of an optimal therapeutic option for AK.

Early childhood educators' knowledge about language and literacy: Associations with practice and children's learning.

Educators' language and literacy knowledge is considered important for informing classroom practices and thereby supporting children's early language and literacy development. This includes both disciplinary content knowledge (knowledge concerning how oral and written language are structured and map to one another) and knowledge for practice (knowledge of effective strategies and practices for supporting early language and literacy). In this study, we examined the associations among 485 early childhood educators' content knowledge and knowledge for practice, their observed language and literacy practices, and the emergent literacy learning of 2004 children enrolled in their classrooms. We found significant, positive correlations between measures of educators' content knowledge and knowledge for practice and classroom practice, indicating that early childhood educators with greater levels of knowledge tended to exhibit more desirable classroom language and literacy practices. We also found significant, positive associations between educators' knowledge and children's print concept, letter naming, and phonological awareness learning, but not children's oral language learning. The associations between educators' knowledge and children's print concept learning were mediated by classroom practice. Together, these results reiterate the importance of educators' language and literacy knowledge and also provide some support for practice as the mechanism through which knowledge relates to children's learning.

Expedient Synthesis of Alphitolic Acid and Its Naturally Occurring 2- O-Ester Derivatives.

The expedient synthesis of alphitolic acid (1) as well as its natural C-3-epimer and 2- O-ester derivatives was accomplished in a few steps from the readily commercially available betulin (9). A Rubottom oxidation delivered an α-hydroxy group in a stereo- and chemoselective manner. The diastereoselective reduction of the α-hydroxy ketone was key to accessing the 1,2-diol moiety of this class of natural products. Our concise and stereoselective synthetic protocol allowed the gram-scale synthesis of these natural products, which will facilitate future biological evaluations.

Comparison of Proteins Secreted into Extracellular Space of Pathogenic and Non-pathogenic Acanthamoeba castellanii.

Pathogenic Acanthamoeba spp. cause granulomatous amoebic encephalitis and keratitis. Acanthamoeba keratitis (AK) is a rare but serious ocular infection that can result in permanent visual impairment or blindness. However, pathogenic factors of AK remain unclear and treatment for AK is arduous. Expression levels of proteins secreted into extracellular space were compared between A. castellanii pathogenic (ACP) and non-pathogenic strains. Two-dimensional polyacrylamide gel electrophoresis revealed 123 differentially expressed proteins, including 34 increased proteins , 7 qualitative increased proteins, 65 decreased proteins, and 17 qualitative decreased proteins in ACP strain. Twenty protein spots with greater than 5-fold increase in ACP strain were analyzed by liquid chromatography triple quadrupole mass spectrometry. These proteins showed similarity each to inosine-uridine preferring nucleoside hydrolase, carboxylesterase, oxygen-dependent choline dehydrogenase, periplasmic-binding protein proteinases and hypothetical proteins. These proteins expressed higher in ACP may provide some information to understand pathogenicity of Acanthamoeba.

Application of clinical pathway using electronic medical record system in pediatric patients with supracondylar fracture of the humerus: a before and after comparative study.

BACKGROUND: This study was performed to investigate the usefulness of clinical pathway (CP) using an electronic medical record (EMR) in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus, by analyzing the length of hospital stay, hospital cost and satisfaction of the medical teams. METHODS: This before and after comparative study included consecutive children who underwent closed pinning for supracondylar fracture of the humerus since 2009. The pre-CP group consists of 90 patients with the mean age of 5.7 years, and the post-CP group consists of 32 patients with the mean age of 6.2 years. Multidisciplinary work-team developed CP using an EMR system in March 2011. The length of hospital stay was the primary outcome variable, and hospital cost and medical team's satisfaction score were secondary outcome variables. The non-inferiority test was used to demonstrate the efficiency of the pathway. RESULTS: The length of hospital stay decreased from 2.9 ± 0.7 days to 2.4 ± 0.7 days by 15.0%, after the implementation of CP, and the lower bound of the 95% CI of the difference (0.14 day) was within the non-inferiority margin of -0.3 days. The hospital cost decreased from 1162.2 ± 236.7 US$ to 1139.8 ± 291.1 US$ by 1.9% and the lower bound of the 95% CI of the difference was -81.3 US$, which did not exceed the non-inferiority margin of -116.2 US$. Therefore, the post-CP group was not inferior compared with the pre-CP group in term of the length of hospital stay and total hospital cost. There was significant increase in the satisfaction score for doctors after implementation of CP (p < 0.001), but, no change in the satisfaction score for nursing staffs (p = 0.793). CONCLUSIONS: The development and implementation of CP, using an EMR, in pediatric patients undergoing closed pinning for supracondylar fracture of the humerus enhances the treatment efficiency by streamlining the treatment process with no increases of the length of the hospital stay and total hospital costs.

Effects of implementing a clinical pathway on antibiotic prophylaxis for patients who underwent an elective surgery.

A reduction in the unnecessary use of antibiotic prophylaxis can prevent antibiotic resistance and adverse drug events. We aimed to evaluate the effects of implementing clinical pathways (CPs) on adherence to a systematic and appropriate duration of antibiotic prophylaxis. We identified 61 eligible CPs and a total of 44,062 patients who underwent elective surgeries associated with CPs. The Poisson mixed model with an interrupted time-series analysis frame was applied to the patient-level data. This enabled a comparison of the adherence rate before and after CP implementation. Furthermore, we examined the effect of application or completion of CP on the adherence rate after implementation. Adherence to the antibiotic prophylaxis guideline substantially increased (incident rate ratio [IRR] 8.05; 95 confidence interval [CI] 2.64-24.55), compared with that before implementation. Following the implementation into the electronic entry system, we observed an improved adherence not only in CP completion but also in attempted CP execution (IRR of the executed but not completed cases 1.54; 95% CI 1.17-2.04; IRR of the executed and competed cases, 1.94; 95% CI 1.4-2.69). The implementation of CP into the electronic prescribing system was associated with a significant increase in the appropriate use of antibiotic prophylaxis among patients who underwent elective surgeries. The results suggest that a computer-assisted CP system for electronic health records could improve antibiotic adherence without significant expense.

Production of a polyclonal antibody against inosine-uridine preferring nucleoside hydrolase of Acanthamoeba castellanii and its access to diagnosis of Acanthamoeba keratitis.

Acanthamoeba keratitis (AK) is a rare disease but its prevalence throughout the globe continues to grow, primarily due to increased contact lens usage. Since early-stage symptoms associated with AK closely resemble those from other corneal infections, accurate diagnosis is difficult and this often results in delayed treatment and exacerbation of the disease, which can lead to permanent visual impairment. Accordingly, developing a rapid Acanthamoeba-specific diagnostic method is highly desired. In the present study, a rapid and differential method for AK diagnosis was developed using the secretory proteins derived from the pathogenic Acanthamoeba. Among the vast quantities of proteins secreted by the pathogenic Acanthamoeba, an open reading frame of the inosine-uridine preferring nucleoside hydrolase (IPNH) gene was obtained. After expressing and purifying the IPNH protein using the pGEX 4T-3 vector system, mice were immunized with the purified proteins for polyclonal antibody generation. Western blot was performed using protein lysates of the human corneal cell, non-pathogenic amoeba, pathogenic amoeba, and clinical amoeba isolate along with lysates from other causes of keratitis such as Staphylococcus aureus, Pseudomonas aeruginosa, and Fusarium solani to confirm Acanthamoeba-specificity. Western blot using the polyclonal IPNH antibody revealed that IPNH was Acanthamoeba-specific since these proteins were only observed in lysates of Acanthamoeba origin or its culture media. Our findings indicate that the IPNH antibody of Acanthamoeba may serve as a potential agent for rapid and differential AK diagnosis.

Bone formation of demineralized human dentin block graft with different demineralization time: In vitro and in vivo study.

OBJECTIVE: To evaluate structural and physicochemical characteristics of demineralized human dentin block with increasing demineralization time and to assess new bone formation when onlay grafted at different demineralization times in rat calvaria. STUDY DESIGN: Extracted human permanent teeth were pretreated and demineralized for 10-90 min. Scanning electron microscopy, X-ray diffraction analysis, inductively coupled plasma spectrometry, and energy dispersive X-ray analysis were performed. Demineralized dentin blocks (DDBs) with the representatives of the different demineralization times (10 and 60 min) were implanted in vivo onto rat calvaria (male Sprague-Dawley, n = 20 for each carrier). For controls, collagen sponge and human freeze-dried corticocancellous bone blocks (FDBB) were implanted onto calvaria (n = 20). The rats were sacrificed 2 or 8 weeks postoperatively and evaluated radiographically, histologically, and histomorphometrically. RESULTS: With increasing demineralization time, the surface structure of dentin blocks showed increased number and size of dentinal tubules. Moreover, the organic components increased, whereas inorganic components decreased. Crystallinity decreased sharply between 10 and 30 min demineralization time. In our in vivo study, at both time points, animals with DDBs showed significantly better bone formation than controls (p < 0.05). The DDB/60 group showed significantly increased new bone area and bone density than the DDB/10 group at 8 weeks (p < 0.05), but showed higher resorption that significantly decreased total augmented area compared with the DDB/10 group (p < 0.05). CONCLUSION: DDB increased new bone formation and bone density. Further studies are needed to determine the optimal demineralization time to maximize space maintenance and bone formation of the graft material.

The distribution and morphology of calbindin D28K- and calretinin-immunoreactive neurons in the visual cortex of mouse.

We studied the distribution and morphology of calbindin D28K- and calretinin-immunoreactive (IR) neurons in the mouse visual cortex with immunocytochemistry. Most of the calbindin D28K-IR neurons were located in layers II/III and V, while calretinin-IR neurons were predominantly located in layers II/III. The labeled neurons showed variations in morphology. The majority of the calbindin D28K-IR neurons were stellate and round or oval cells with multipolar dendrites. The majority of calretinin-IR neurons were vertical fusiform cells with long processes traveling perpendicular to the pial surface. In the mouse visual cortex, 20.2% of calbindin D28K-IR neurons contained calretinin and 27.2% of calretinin-IR neurons contained calbindin D28K. These results indicate that the calcium-binding proteins, calbindin D28K and calretinin are distributed in specific layers and in selective cell types of the mouse visual cortex.