Autophagy is required for self-incompatible pollen rejection in two transgenic Arabidopsis thaliana accessions.

Successful reproduction in the Brassicaceae is mediated by a complex series of interactions between the pollen and the pistil, and some species have an additional layer of regulation with the self-incompatibility trait. While the initial activation of the self-incompatibility pathway by the pollen S-locus protein 11/S locus cysteine-rich protein and the stigma S Receptor Kinase is well characterized, the downstream mechanisms causing self-pollen rejection are still not fully understood. In previous studies, we detected the presence of autophagic bodies with self-incompatible (SI) pollinations in Arabidopsis lyrata and transgenic Arabidopsis thaliana lines, but whether autophagy was essential for self-pollen rejection was unknown. Here, we investigated the requirement of autophagy in this response by crossing mutations in the essential AUTOPHAGY7 (ATG7) and ATG5 genes into two different transgenic SI A. thaliana lines in the Col-0 and C24 accessions. By using these previously characterized transgenic lines that express A. lyrata and Arabidopsis halleri self-incompatibility genes, we demonstrated that disrupting autophagy weakened their SI responses in the stigma. When the atg7 or atg5 mutations were present, an increased number of SI pollen was found to hydrate and form pollen tubes that successfully fertilized the SI pistils. Additionally, we confirmed the presence of GFP-ATG8a-labeled autophagosomes in the stigmatic papillae following SI pollinations. Together, these findings support the requirement of autophagy in the self-incompatibility response and add to the growing understanding of the intracellular mechanisms employed in the transgenic A. thaliana stigmas to reject self-pollen.

Impact of Pharmacist Intervention to Increase Compliance With Guideline-Directed Statin Therapy During an Acute Coronary Syndrome Hospitalization.

BACKGROUND: Despite evidence on poor adherence to guideline-directed statin therapy (GDST) following an acute coronary syndrome (ACS), little information has been published on pharmacist-led statin pilot programs for secondary prevention. OBJECTIVE: We sought to evaluate the impact of a pharmacist intervention (PI) on GDST during an ACS hospitalization. METHODS: A historical control (HC) group consisting of 125 ACS hospitalizations was retrospectively identified, with prospective data of 113 patients captured over 6 months in the PI group. The primary outcome of GDST was defined according to 2013 clinical guidelines and evaluated in all 238 qualifying patients. Secondary outcomes included number of interventions and use of logistic regression to investigate the relationship of ACS subtype with statin dose. RESULTS: On admission, GDST was ordered in 62.5% of the HC and 75.9% of the PI group. At discharge, the PI group had a higher rate of GDST relative to HC among all patients (86.7 % vs 77.4%, P = 0.06), and after exclusion of contraindications (84.8% vs 74.5%; P = 0.1), 10 patients required PI, accounting for an increase in GDST of 5.3%. Statin dose selection did not differ by ACS subtype (odds ratio = 0.79; 95% CI = 0.0.29-2.17; P = 0.18). CONCLUSION: PI did not significantly increase GDST. Increased compliance rates measured were primarily driven by higher baseline adherence and guideline incorporation over time.

Initial events during the evolution of C4 photosynthesis in C3 species of Flaveria.

The evolution of C4 photosynthesis in many taxa involves the establishment of a two-celled photorespiratory CO2 pump, termed C2 photosynthesis. How C3 species evolved C2 metabolism is critical to understanding the initial phases of C4 plant evolution. To evaluate early events in C4 evolution, we compared leaf anatomy, ultrastructure, and gas-exchange responses of closely related C3 and C2 species of Flaveria, a model genus for C4 evolution. We hypothesized that Flaveria pringlei and Flaveria robusta, two C3 species that are most closely related to the C2 Flaveria species, would show rudimentary characteristics of C2 physiology. Compared with less-related C3 species, bundle sheath (BS) cells of F. pringlei and F. robusta had more mitochondria and chloroplasts, larger mitochondria, and proportionally more of these organelles located along the inner cell periphery. These patterns were similar, although generally less in magnitude, than those observed in the C2 species Flaveria angustifolia and Flaveria sonorensis. In F. pringlei and F. robusta, the CO2 compensation point of photosynthesis was slightly lower than in the less-related C3 species, indicating an increase in photosynthetic efficiency. This could occur because of enhanced refixation of photorespired CO2 by the centripetally positioned organelles in the BS cells. If the phylogenetic positions of F. pringlei and F. robusta reflect ancestral states, these results support a hypothesis that increased numbers of centripetally located organelles initiated a metabolic scavenging of photorespired CO2 within the BS. This could have facilitated the formation of a glycine shuttle between mesophyll and BS cells that characterizes C2 photosynthesis.

Chilling and frost tolerance in Miscanthus and Saccharum genotypes bred for cool temperate climates.

Miscanthus hybrids are leading candidates for bioenergy feedstocks in mid to high latitudes of North America and Eurasia, due to high productivity associated with the C4 photosynthetic pathway and their tolerance of cooler conditions. However, as C4 plants, they may lack tolerance of chilling conditions (0-10 °C) and frost, particularly when compared with candidate C3 crops at high latitudes. In higher latitudes, cold tolerance is particularly important if the feedstock is to utilize fully the long, early-season days of May and June. Here, leaf gas exchange and fluorescence are used to assess chilling tolerance of photosynthesis in five Miscanthus hybrids bred for cold tolerance, a complex Saccharum hybrid (energycane), and an upland sugarcane variety with some chilling tolerance. The chilling treatment consisted of transferring warm-grown plants (25/20 °C day/night growth temperatures) to chilling (12/5 °C) conditions for 1 week, followed by assessing recovery after return to warm temperatures. Chilling tolerance was also evaluated in outdoor, spring-grown Miscanthus genotypes before and after a cold front that was punctuated by a frost event. Miscanthus×giganteus was found to be the most chilling-tolerant genotype based on its ability to maintain a high net CO2 assimilation rate (A) during chilling, and recover A to a greater degree following a return to warm conditions. This was associated with increasing its capacity for short-term dark-reversible photoprotective processes (ΦREG) and the proportion of open photosystem II reaction centres (qL) while minimizing photoinactivation (ΦNF). Similarly, in the field, M.×giganteus exhibited a significantly greater A and pre-dawn F v/F m after the cold front compared with the other chilling-sensitive Miscanthus hybrids.

Dynamics of the exponential integrate-and-fire model with slow currents and adaptation.

In order to properly capture spike-frequency adaptation with a simplified point-neuron model, we study approximations of Hodgkin-Huxley (HH) models including slow currents by exponential integrate-and-fire (EIF) models that incorporate the same types of currents. We optimize the parameters of the EIF models under the external drive consisting of AMPA-type conductance pulses using the current-voltage curves and the van Rossum metric to best capture the subthreshold membrane potential, firing rate, and jump size of the slow current at the neuron's spike times. Our numerical simulations demonstrate that, in addition to these quantities, the approximate EIF-type models faithfully reproduce bifurcation properties of the HH neurons with slow currents, which include spike-frequency adaptation, phase-response curves, critical exponents at the transition between a finite and infinite number of spikes with increasing constant external drive, and bifurcation diagrams of interspike intervals in time-periodically forced models. Dynamics of networks of HH neurons with slow currents can also be approximated by corresponding EIF-type networks, with the approximation being at least statistically accurate over a broad range of Poisson rates of the external drive. For the form of external drive resembling realistic, AMPA-like synaptic conductance response to incoming action potentials, the EIF model affords great savings of computation time as compared with the corresponding HH-type model. Our work shows that the EIF model with additional slow currents is well suited for use in large-scale, point-neuron models in which spike-frequency adaptation is important.

Delirium in the cardiovascular ICU: exploring modifiable risk factors.

OBJECTIVE: Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery ICU is not well established. We sought to determine the prevalence and risk factors for delirium among cardiac surgery ICU patients. DESIGN: Prospective observational study. SETTING: Twenty-seven-bed medical-surgical cardiac surgery ICU. PATIENTS: Two hundred consecutive patients with an expected cardiac surgery ICU length of stay >24 hrs. INTERVENTIONS: None. MEASUREMENTS: Baseline demographic data and daily assessments for delirium using the validated and reliable Confusion Assessment Method for the ICU were recorded, and quantitative tracking of delirium risk factors were conducted. Separate analyses studied the role of admission risk factors for occurrence of delirium during the cardiac surgery ICU stay and identified daily occurring risk factors for the development of delirium on a subsequent cardiac surgery ICU day. MAIN RESULTS: Prevalence of delirium was 26%, similar among cardiology and cardiac surgical patients. Nearly all (92%) exhibited the hypoactive subtype of delirium. Benzodiazepine use at admission was independently predictive of a three-fold increased risk of delirium (odds ratio 3.1 [1, 9.4], p = 0.04) during the cardiac surgery ICU stay. Of the daily occurring risk factors, patients who received benzodiazepines (2.6 [1.2, 5.7], p = 0.02) or had restraints or devices that precluded mobilization (2.9 [1.3, 6.5], p < 0.01) were more likely to have delirium the following day. Hemodynamic status was not associated with delirium. CONCLUSIONS: Delirium occurred in one in four patients in the cardiac surgery ICU and was predominately hypoactive in subtype. Chemical restraints via use of benzodiazepines or the use of physical restraints/restraining devices predisposed patients to a greater risk of delirium, pointing to areas of quality improvement that would be new to the vast majority of cardiac surgery ICUs.

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

BACKGROUND: Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. OBJECTIVE: To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. DESIGN, PARTICIPANTS: We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. MAIN MEASURES: Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors. KEY RESULTS: On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11). CONCLUSIONS: Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.

The occurrence of C(2) photosynthesis in Euphorbia subgenus Chamaesyce (Euphorbiaceae).

This study investigated whether Euphorbia subgenus Chamaesyce subsection Acutae contains C(3)-C(4) intermediate species utilizing C(2) photosynthesis, the process where photorespired CO(2) is concentrated into bundle sheath cells. Euphorbia species in subgenus Chamaesyce are generally C(4), but three species in subsection Acutae (E. acuta, E. angusta, and E. johnstonii) have C(3) isotopic ratios. Phylogenetically, subsection Acutae branches between basal C(3) clades within Euphorbia and the C(4) clade in subgenus Chamaesyce. Euphorbia angusta is C(3), as indicated by a photosynthetic CO(2) compensation point (Г) of 69 µmol mol(-1) at 30 °C, a lack of Kranz anatomy, and the occurrence of glycine decarboxylase in mesophyll tissues. Euphorbia acuta utilizes C(2) photosynthesis, as indicated by a Г of 33 µmol mol(-1) at 30 °C, Kranz-like anatomy with mitochondria restricted to the centripetal (inner) wall of the bundle sheath cells, and localization of glycine decarboxlyase to bundle sheath mitochondria. Low activities of PEP carboxylase, NADP malic enzyme, and NAD malic enzyme demonstrated no C(4) cycle activity occurs in E. acuta thereby classifying it as a Type I C(3)-C(4) intermediate. Kranz-like anatomy in E. johnstonii indicates it also utilizes C(2) photosynthesis. Given the phylogenetically intermediate position of E. acuta and E. johnstonii, these results support the hypothesis that C(2) photosynthesis is an evolutionary intermediate condition between C(3) and C(4) photosynthesis.

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

BACKGROUND: High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered. METHODS: A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics. RESULTS: Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2224 exposed to warfarin, 8383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period-and the heparinlenoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent. CONCLUSIONS: Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy.

Introducing Lifestyle Medicine Within the Mayo Clinic Alix School of Medicine in Arizona.

Purpose: High-value care is becoming increasingly important as the United States shifts toward a more sustainable health care system. Lifestyle medicine (LM) may be the highest-value model of care. Surprisingly, however, it is taught in a minority of medical schools. In this article, we describe a pilot project of introducing a brief LM course taught within the Mayo Clinic Alix School of Medicine in Arizona. The main purpose of the course was to introduce the students to LM as a specialty practice and to provide students with foundational knowledge of the pillars of LM. Results: Students reported improved personal health habits and increased confidence in LM competencies.

"Real-World" Application of Thrombolysis in Cardiac Arrest.

BACKGROUND: Current guidelines recommend consideration of thrombosis as a reversible cause of cardiac arrest. The use of thrombolytic therapy during cardiac arrest, however, is controversial. OBJECTIVE: We sought to characterize the use of thrombolytic therapy during cardiac arrest and to evaluate the rate of return of spontaneous circulation (ROSC) in a "real-word" setting. METHODS: A single-center, retrospective, cohort study of adult patients who received alteplase during cardiac arrest between 2010 and 2015 were performed at a tertiary academic medical center. RESULTS: Twenty-six patients were identified. Patients were predominantly male (65%) and Caucasian (89%) and were a median age of 64 years. Five patients had a history of preexisting venous thromboembolism, and eight patients were receiving systemic anticoagulation. Pulmonary embolism was confirmed prior to the administration of alteplase in 5 patients. The median dose of alteplase administered was 100 mg. ROSC was achieved in 65% of patients, 2 of whom survived to hospital discharge. Both surviving patients experienced a bleeding event. CONCLUSION: In a single center's experience, thrombolytic therapy is used infrequently for the management of cardiac arrest. Thrombolysis during cardiac arrest should be considered on a case-by-case basis and should be utilized only when there is a high suspicion for pulmonary embolism as the cause of arrest and when thrombolytic therapy is readily available.

Children at risk for developmental coordination disorder: judgement of changes in action capabilities.

In three separate manipulations, a group of children at risk for developmental coordination disorder (DCD; five males, seven females; mean age 11y 6mo [SD 6.8mo] who were at or below the 15th centile on the Movement ABC) and a group of typically developing children (TDC; seven males, five females; mean age 11y 3mo [SD 6.8mo]) judged the limit of their standing horizontal reach (HRmax) under two conditions in which actual HRmax differed. The manipulations were: (1) one-hand versus two-hand reach; and (2) standard versus short effective foot-length; and (3) rigid versus compliant support surface. For the foot-length and support surface manipulations (but not for the hand manipulation), children correctly judged that their actual HRmax differed in the two conditions (p<.05). On all three manipulations, TDC made significantly larger adjustments in their judgements than did children at risk for DCD (p<0.05). The TDC group adjusted their judgements in the appropriate direction on all three manipulations, whereas the DCD group adjusted in the appropriate direction for the foot-length manipulation only. The results suggest that children at risk for DCD are less adept at detecting changes in the limits of their action capabilities.

Pharmacokinetics of Sildenafil in Patients with a Left Ventricular Assist Device: A Word of Caution.

We compared maximal plasma concentrations (Cmax) of sildenafil and metabolite n-desmethyl sildenafil in 12 inpatients with left ventricular assist devices (LVADs) on sildenafil (60 mg/day) to the reference range. Sildenafil Cmax (156.8 ± 124.5 ng/ml) was elevated in 66% of patients, with a two to fivefold increase over the upper limit of the reference range in 25% of patients. Metabolite Cmax (133.3 ± 102.0 ng/ml) was elevated in 75% of patients, with a three to sevenfold increase over the upper limit of the reference range in 40% of patients. Patients with heart failure and LVADs are at increased risk of concentrated-related sildenafil adverse events.

Judgment of action capabilities in children at risk for developmental coordination disorder.

PURPOSE: To evaluate the ability to accurately perceive the limits of action capabilities in children at risk for developmental coordination disorder (DCD). METHODS: In Study 1, 9 to 12-year-old children (mean = 10.6 years, SD = 1.09) were identified as at risk for DCD and the accuracy of their perceptual judgments was compared with the judgments of a group of typically developing children (TDC). Two judgment tasks were used: Maximum vertical reach and maximum sitting height. Study 2 tested the hypothesis that a significant correlation would be found between a specific movement task and a related judgment task. Participants were randomly selected (n = 24) 10 and 11-year-old children (mean = 10.5 years, SD = 0.51). RESULTS: Magnitude of judgment error (absolute error) on all tasks was significantly (p < 0.05) greater in the DCD group than in the TDC group. Study 2 revealed a significant (p < 0.05) correlation between the movement task and the related perceptual task (r = 0.70). CONCLUSION: Compared to a typically developing group, children at risk for DCD made less accurate judgments of the limits of their action capabilities. The accuracy of a perceptual judgment was found to correlate with a related movement skill.

HIV-1 vaccine induced immune responses in newborns of HIV-1 infected mothers.

OBJECTIVE: Breast milk transmission continues to account for a large proportion of cases of mother-to-child transmission of HIV-1 worldwide. An effective HIV-1 vaccine coupled with either passive immunization or short-term antiretroviral prophylaxis represents a potential strategy to prevent breast milk transmission. This study evaluated the safety and immunogenicity of ALVAC HIV-1 vaccine with and without a subunit envelope boost in infants born to HIV-1-infected women. DESIGN: : Placebo-controlled, double-blinded study. METHODS: Infants born to HIV-1-infected mothers in the US were immunized with a prime-boost regimen using a canarypox virus HIV-1 vaccine (vCP1452) and a recombinant glycoprotein subunit vaccine (rgp120). Infants (n = 30) were randomized to receive: vCP1452 alone, vCP1452 + rgp120, or corresponding placebos. RESULTS: Local reactions were mild or moderate and no significant systemic toxicities occurred. Subjects receiving both vaccines had gp120-specific binding serum antibodies that were distinguishable from maternal antibody. Repeated gp160-specific lymphoproliferative responses were observed in 75%. Neutralizing activity to HIV-1 homologous to the vaccine strain was observed in 50% of the vCP1452 + rgp120 subjects who had lost maternal antibody by week 24. In some infants HIV-1-specific proliferative and antibody responses persisted until week 104. HIV-1-specific cytotoxic T lymphocyte responses were detected in two subjects in each treatment group; the frequency of HIV-1 specific cytotoxic T lymphocyte responses did not differ between vaccine and placebo recipients. CONCLUSION: The demonstration of vaccine-induced immune responses in early infancy supports further study of HIV-1 vaccination as a strategy to reduce breast milk transmission.

Management of outbreaks of methicillin-resistant Staphylococcus aureus infection in the neonatal intensive care unit: a consensus statement.

OBJECTIVE: In 2002, the Chicago Department of Public Health (CDPH; Chicago, Illinois) convened the Chicago-Area Neonatal MRSA Working Group (CANMWG) to discuss and compare approaches aimed at control of methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs). To better understand these issues on a regional level, the CDPH and the Evanston Department of Health and Human Services (EDHHS; Evanston, Illinois) began an investigation. DESIGN: Survey to collect demographic, clinical, microbiologic, and epidemiologic data on individual cases and clusters of MRSA infection; an additional survey collected data on infection control practices. SETTING: Level III NICUs at Chicago-area hospitals. PARTICIPANTS: Neonates and healthcare workers associated with the level III NICUs. METHODS: From June 2001 through September 2002, the participating hospitals reported all clusters of MRSA infection in their respective level III NICUs to the CDPH and the EDHHS. RESULTS: Thirteen clusters of MRSA infection were detected in level III NICUs, and 149 MRSA-positive infants were reported. Infection control surveys showed that hospitals took different approaches for controlling MRSA colonization and infection in NICUs. CONCLUSION: The CANMWG developed recommendations for the prevention and control of MRSA colonization and infection in the NICU and agreed that recommendations should expand to include future data generated by further studies. Continuing partnerships between hospital infection control personnel and public health professionals will be crucial in honing appropriate guidelines for effective approaches to the management and control of MRSA colonization and infection in NICUs.

Sudden Infant Death Syndrome and prenatal maternal smoking: rising attributed risk in the Back to Sleep era.

BACKGROUND: Parental smoking and prone sleep positioning are recognized causal features of Sudden Infant Death. This study quantifies the relationship between prenatal smoking and infant death over the time period of the Back to Sleep campaign in the United States, which encouraged parents to use a supine sleeping position for infants. METHODS: This retrospective cohort study utilized the Colorado Birth Registry. All singleton, normal birth weight infants born from 1989 to 1998 were identified and linked to the Colorado Infant Death registry. Multivariable logistic regression was used to analyze the relationship between outcomes of interest and prenatal maternal cigarette use. Potential confounders analyzed included infant gender, gestational age, and birth year as well as maternal marital status, ethnicity, pregnancy interval, age, education, and alcohol use. RESULTS: We analyzed 488,918 birth records after excluding 5835 records with missing smoking status. Smokers were more likely to be single, non-Hispanic, less educated, and to report alcohol use while pregnant (p < 0.001). The study included 598 SIDS cases of which 172 occurred in smoke-exposed infants. Smoke exposed infants were 1.9 times (95% CI 1.6 to 2.3) more likely to die of SIDS. The attributed risk associating smoking and SIDS increased during the study period from approximately 50% to 80%. During the entire study period 59% (101/172) of SIDS deaths in smoke-exposed infants were attributed to maternal smoking. CONCLUSIONS: Due to a decreased overall rate of SIDS likely due to changing infant sleep position, the attributed risk associating maternal smoking and SIDS has increased following the Back to Sleep campaign. Mothers should be informed of the 2-fold increased rate of SIDS associated with maternal cigarette consumption.

Barriers to effective symptom management in hospice.

The barriers to effective symptom management in hospice are not well described. We surveyed nurses of hospices affiliated with the Population-based Palliative Care Research Network (PoPCRN) to identify barriers to the effective management of common symptoms in terminally ill patients. 867/1710 (51%) nurses from 67 hospices in 25 U.S. States returned surveys. Of 32 symptoms, nurses reported agitation (45%), pain (40%), and dyspnea (34%) as the 'most difficult to manage.' The most common perceived barriers to effective symptom management were inability of family care providers to implement or maintain recommended treatments (38%), patients or families not wanting recommended treatments (38%), and competing demands from other distressing symptoms (37%). Patterns of barriers varied by symptom. These nurses endorsed multiple barriers contributing to unrelieved symptom distress in patients receiving hospice care. Interventions to improve symptom management in hospice may need to account for these differing barrier patterns.