A cross-sectional study of the practice types of US adult primary care physician specialists.

BACKGROUND: Many physicians listed as primary care in databases such as the American Medical Association (AMA) Masterfile do not provide traditional ambulatory primary care. OBJECTIVE: To compare physicians listed in the AMA Masterfile as primary care physician (PCPs) specialists for adult patients with their actual practice type. METHODS: We conducted a cross-sectional study of the AMA Masterfile report for PCPs who care for adults (listed as family medicine, internal medicine, medicine-paediatrics, and geriatrics) in the summer and fall of 2018 (spring of 2019 for Hartford, CT) in the primary counties of 8 metropolitan areas across the United States. We searched multiple websites to determine the actual practice type of each physician in the study counties. We correlated the 2 datasets: the AMA Masterfile list vs the results of our searches. RESULTS: Family physicians were more likely to function as traditional ambulatory PCPs than internists [1,738/2,101 (82.7%) vs 1,241/2,025 (60.9%), P < 0.001], and less likely to be hospitalists [83/2,101 (4.0%) vs 631/2,025 (31.0%), P < 0.001]. Other practice types included urgent care [105 (5.0%) family physicians, 16 (0.8%) internists] and emergency medicine [49 (2.3%) family physicians, 20 (1.0%) internists]. The AMA Masterfile identified 4,892 practicing PCPs for adult patients in the study counties, of which 3,084 (63.0%) matched by location and ambulatory PCP practice type [3,695 (75.5%) for ambulatory PCP practice type only]. CONCLUSIONS: We provide an updated estimate using a unique methodology to estimate how to correct the AMA Masterfile for PCPs who actually provide traditional ambulatory primary care to adult patients.

Autotaxin, an ectoenzyme that produces lysophosphatidic acid, promotes the entry of lymphocytes into secondary lymphoid organs.

The extracellular lysophospholipase D autotaxin (ATX) and its product, lysophosphatidic acid, have diverse functions in development and cancer, but little is known about their functions in the immune system. Here we found that ATX had high expression in the high endothelial venules of lymphoid organs and was secreted. Chemokine-activated lymphocytes expressed receptors with enhanced affinity for ATX, which provides a mechanism for targeting the secreted ATX to lymphocytes undergoing recruitment. Lysophosphatidic acid induced chemokinesis in T cells. Intravenous injection of enzymatically inactive ATX attenuated the homing of T cells to lymphoid tissues, probably through competition with endogenous ATX and exertion of a dominant negative effect. Our results support the idea of a new and general step in the homing cascade in which the ectoenzyme ATX facilitates the entry of lymphocytes into lymphoid organs.

Evaluation of vSim for Nursing in an Adult Health Nursing Course: A Multisite Pilot Study.

Virtual simulation technology is the next step in using simulation as an accepted teaching-learning pedagogy in nursing. The purpose of this multisite, quasi-experimental, three-group, posttest-only design was to evaluate the effectiveness and participant satisfaction of vSim for Nursing in an Adult Health Nursing course. Although the quantitative findings (examination scores and postsimulation scores) were not statistically significant, participants overwhelmingly found vSim for Nursing to be a positive experiential learning endeavor. Ninety-one percent of the participants (n = 61) indicated that vSim for Nursing helped them understand adult health concepts and that vSim for Nursing was beneficial to learning. vSim for Nursing warrants further investigation, using other methods to measure effectiveness to ascertain whether knowledge acquisition is indeed improved as indicated by participant data in this study.

Simulation in an Undergraduate Nursing Pharmacology Course: A Pilot Study.

This study examined the effectiveness of simulation as a method of teaching pharmacological concepts to nursing students; perceptions of satisfaction with simulation as a teaching strategy were also evaluated. Second-semester juniors participated in three simulations and completed the National League for Nursing Student Satisfaction and Self-Confidence in Learning Questionnaire and the Student Evaluation of Educational Quality Survey; a control group received traditional lectures. A unit exam on anticoagulant therapy content was administered to measure effectiveness. Findings support that simulation is as effective as traditional lecture for an undergraduate pharmacology course.

Anilinoquinazoline inhibitors of the RET kinase domain-Elaboration of the 7-position.

We have previously reported a series of anilinoquinazoline derivatives as potent and selective biochemical inhibitors of the RET kinase domain. However, these derivatives displayed diminished cellular potency. Herein we describe further optimisation of the series through modification of their physicochemical properties, delivering improvements in cell potency. However, whilst cellular selectivity against key targets could be maintained, combining cell potency and acceptable pharmacokinetics proved challenging.

Intraperitoneal transplant of Hepatocytes co-Encapsulated with mesenchymal stromal cells in modified alginate microbeads for the treatment of acute Liver failure in Pediatric patients (HELP)-An open-label, single-arm Simon's two stage phase 1 study protocol.

BACKGROUND: Pediatric acute liver failure (PALF) carries a high mortality without liver transplantation (LT) in children. Liver transplantation, though lifesaving, is limited by timely donor organ availability, the risks of major surgery and complications of life-long immunosuppression. Hepatocyte transplantation (HT) improves synthetic and detoxification functions in small animal models. The encapsulation of hepatocytes in alginate protects it from the recipient immune system while the intraperitoneal route of administration allows large volumes to be infused. The safety and possibly short-term efficacy of encapsulated hepatocytes has been observed in a named patient use. A novel type of microbeads (HMB002) has been developed, using a modified alginate and mesenchymal stromal cells (MSCs). Its safety and medium-term efficacy need to be studied in the context of clinical study while optimizing the hepatocyte function and viability using modifications of the alginate and MSCs co-encapsulation. METHODS: A single centre, non-randomised, open-label, single-arm Simon's two stage study will be conducted to evaluate the safety, biological activity and tolerability of transplantation of a single intraperitoneal dose of microbeads made from an optimum combination of a modified alginate, MSCs and hepatocytes in 17 patients less than 16 years of age with acute liver failure (Stage 1: 9 patients and Stage 2: 8 patient). Safety will be assessed by documenting moderate to severe (including life threatening and death) adverse events due to HMB002 in the first 52 weeks post-procedure. Tolerability will be assessed by observing the proportion of initiated infusions where >80% of infusion is received by the patient. Biological activity will be reflected in patient survival with native liver at 24 weeks post treatment. DISCUSSION: HMB002, if safe and efficacious in acute liver failure, could be a bridge until the liver regenerates or a suitable organ becomes available. There are multiple advantages to using HT. HT, when delivered by the intraperitoneal route, is less invasive than LT. Hepatocytes from a single donor liver can be used to treat multiple patients. Cryopreserved cells provide an off-the-shelf emergency treatment in PALF. When encapsulated, alginate encapsulation of hepatocytes precludes the need for immunosuppression unlike in LT.

"I Can't Blame Mum": A Qualitative Exploration of Relational Dynamics in Women With Female Genital Mutilation (FGM) in the United Kingdom.

Female genital mutilation (FGM) is conceptualized as an interpersonal act, commonly initiated by mothers. This study investigates relational dynamics among adult women who experienced FGM in childhood and have since migrated to the United Kingdom. A qualitative research design was employed, using semi-structured interviews and interpretative phenomenological analysis (IPA) with nine women. Three superordinate themes emerged: (a) "The 'who to blame?' conflict: Preserving goodness in parents"; (b) "Better or worse? Positioning the self in relation to others"; and (c) "Regaining power: Righting the wrongs." Implications for understanding the relational consequences of FGM and the discontinuation of its intergenerational transmission are considered.

A fundamental bimodal role for neuropeptide Y1 receptor in the immune system.

Psychological conditions, including stress, compromise immune defenses. Although this concept is not novel, the molecular mechanism behind it remains unclear. Neuropeptide Y (NPY) in the central nervous system is a major regulator of numerous physiological functions, including stress. Postganglionic sympathetic nerves innervating lymphoid organs release NPY, which together with other peptides activate five Y receptors (Y1, Y2, Y4, Y5, and y(6)). Using Y1-deficient (Y1(-/-)) mice, we showed that Y1(-/-) T cells are hyperresponsive to activation and trigger severe colitis after transfer into lymphopenic mice. Thus, signaling through Y1 receptor on T cells inhibits T cell activation and controls the magnitude of T cell responses. Paradoxically, Y1(-/-) mice were resistant to T helper type 1 (Th1) cell-mediated inflammatory responses and showed reduced levels of the Th1 cell-promoting cytokine interleukin 12 and reduced interferon gamma production. This defect was due to functionally impaired antigen-presenting cells (APCs), and consequently, Y1(-/-) mice had reduced numbers of effector T cells. These results demonstrate a fundamental bimodal role for the Y1 receptor in the immune system, serving as a strong negative regulator on T cells as well as a key activator of APC function. Our findings uncover a sophisticated molecular mechanism regulating immune cell functions that can lead to stress-induced immunosuppression.

Digital Innovation: Transition to Practice Using Apple Clips to Teach Nursing Leadership.

BACKGROUND: Nurse educators are challenged to offer high-impact learning opportunities integrating technology to engage the current generation of students. An innovative learning assignment was created using app technology to replace a traditional assignment in a nursing leadership course. METHOD: Students were assigned to create a digital video depicting a difficult situation in practice using the Clips app by Apple. The assignment used situation, background, assessment, and recommendation (SBAR) for structure and incorporated evidence-based practices. Students were surveyed to gain insight into the effectiveness and student satisfaction of the assignment. RESULTS: Students overwhelmingly supported the assignment as an innovative way to learn leadership, identifying creativity and having fun while learning as something not experienced in their other nursing courses. CONCLUSION: A digital assignment offers an opportunity to imagine learning assignments in nursing education that capture student attention in a non-traditional method reflecting the impact of technology on nursing education. [J Nurs Educ. 2020;59(5):283-286.].

Discovery and Optimization of wt-RET/KDR-Selective Inhibitors of RETV804M Kinase.

A combination of focused library and virtual screening, hit expansion, and rational design has resulted in the development of a series of inhibitors of RETV804M kinase, the anticipated drug-resistant mutant of RET kinase. These agents do not inhibit the wild type (wt) isoforms of RET or KDR and therefore offer a potential adjunct to RET inhibitors currently undergoing clinical evaluation.

Human C5aR knock-in mice facilitate the production and assessment of anti-inflammatory monoclonal antibodies.

Complement component C5a binds C5a receptor (C5aR) and facilitates leukocyte chemotaxis and release of inflammatory mediators. We used neutrophils from human C5aR knock-in mice, in which the mouse C5aR coding region was replaced with that of human C5aR, to immunize wild-type mice and to generate high-affinity antagonist monoclonal antibodies (mAbs) to human C5aR. These mAbs blocked neutrophil migration to C5a in vitro and, at low doses, both prevented and reversed inflammatory arthritis in the murine K/BxN model. Of approximately 40 mAbs generated to C5aR, all potent inhibitors recognized a small region of the second extracellular loop that seems to be critical for regulation of receptor activity. Human C5aR knock-in mice not only facilitated production of high-affinity mAbs against an important human therapeutic target but were also useful in preclinical validation of the potency of these antagonists. This strategy should be applicable to other important mAb therapeutics.

Kangaroo mother care for the prevention of neonatal hypothermia: a randomised controlled trial in term neonates.

OBJECTIVE: To test the hypothesis that kangaroo mother care (KMC) initiated either at birth or at 1 hour after birth reduces moderate or severe hypothermia in term neonates at (A) 1 hour after birth and (B) at discharge when compared with standard thermoregulation care. METHODS: Term neonates born at a tertiary delivery centre in Zambia were randomised in two phases (phase 1: birth to 1 hour, phase 2: 1 hour to discharge) to either as much KMC as possible in combination with standard thermoregulation care (KMC group) or to standard thermoregulation care (control group). The primary outcomes were moderate or severe hypothermia (axillary temperature <36.0°C) at (A) 1 hour after birth and (B) at discharge. RESULTS: The proportion of neonates with moderate or severe hypothermia did not differ between the KMC and control groups at 1 hour after birth (25% vs 27%, relative risk (RR)=0.93, 95% CI 0.59 to 1.4, P=0.78) or at discharge (7% vs 2%, RR=2.8, 95% CI 0.6 to 13.9, P=0.16). Hypothermia was not found among the infants who had KMC for at least 9 hours or 80% of the hospital stay. CONCLUSIONS: KMC practised as much as possible in combination with standard thermoregulation care initiated either at birth or at 1 hour after birth did not reduce moderate or severe hypothermia in term infants compared with standard thermoregulation care. The current study also shows that duration of KMC either for at least 80% of the time or at least 9 hours during the day of birth was effective in preventing hypothermia in term infants. CLINICAL TRIAL REGISTRATION: NCT02189759.

Identification of selective inhibitors of RET and comparison with current clinical candidates through development and validation of a robust screening cascade.

RET (REarranged during Transfection) is a receptor tyrosine kinase, which plays pivotal roles in regulating cell survival, differentiation, proliferation, migration and chemotaxis. Activation of RET is a mechanism of oncogenesis in medullary thyroid carcinomas where both germline and sporadic activating somatic mutations are prevalent. At present, there are no known specific RET inhibitors in clinical development, although many potent inhibitors of RET have been opportunistically identified through selectivity profiling of compounds initially designed to target other tyrosine kinases. Vandetanib and cabozantinib, both multi-kinase inhibitors with RET activity, are approved for use in medullary thyroid carcinoma, but additional pharmacological activities, most notably inhibition of vascular endothelial growth factor - VEGFR2 (KDR), lead to dose-limiting toxicity. The recent identification of RET fusions present in ~1% of lung adenocarcinoma patients has renewed interest in the identification and development of more selective RET inhibitors lacking the toxicities associated with the current treatments. In an earlier publication [Newton et al, 2016; 1] we reported the discovery of a series of 2-substituted phenol quinazolines as potent and selective RET kinase inhibitors. Here we describe the development of the robust screening cascade which allowed the identification and advancement of this chemical series.  Furthermore we have profiled a panel of RET-active clinical compounds both to validate the cascade and to confirm that none display a RET-selective target profile.

The discovery of 2-substituted phenol quinazolines as potent RET kinase inhibitors with improved KDR selectivity.

Deregulation of the receptor tyrosine kinase RET has been implicated in medullary thyroid cancer, a small percentage of lung adenocarcinomas, endocrine-resistant breast cancer and pancreatic cancer. There are several clinically approved multi-kinase inhibitors that target RET as a secondary pharmacology but additional activities, most notably inhibition of KDR, lead to dose-limiting toxicities. There is, therefore, a clinical need for more specific RET kinase inhibitors. Herein we report our efforts towards identifying a potent and selective RET inhibitor using vandetanib 1 as the starting point for structure-based drug design. Phenolic anilinoquinazolines exemplified by 6 showed improved affinities towards RET but, unsurprisingly, suffered from high metabolic clearance. Efforts to mitigate the metabolic liability of the phenol led to the discovery that a flanking substituent not only improved the hepatocyte stability, but could also impart a significant gain in selectivity. This culminated in the identification of 36; a potent RET inhibitor with much improved selectivity against KDR.

Immune cell transcriptome datasets reveal novel leukocyte subset-specific genes and genes associated with allergic processes.

BACKGROUND: The precise function of various resting and activated leukocyte subsets remains unclear. For instance, mast cells, basophils, and eosinophils play important roles in allergic inflammation but also participate in other immunologic responses. One strategy to understand leukocyte subset function is to define the expression and function of subset-restricted molecules. OBJECTIVE: To use a microarray dataset and bioinformatics strategies to identify novel leukocyte markers as well as genes associated with allergic or innate responses. METHODS: By using Affymetrix microarrays, we generated an immune transcriptome dataset composed of gene profiles from all of the major leukocyte subsets, including rare enigmatic subsets such as mast cells, basophils, and plasma cells. We also assessed whether analysis of genes expressed commonly by certain groups of leukocytes, such as allergic leukocytes, might identify genes associated with particular responses. RESULTS: Transcripts highly restricted to a single leukocyte subset were readily identified (>2000 subset-specific transcripts), many of which have not been associated previously with leukocyte functions. Transcripts expressed exclusively by allergy-related leukocytes revealed well known as well as novel molecules, many of which presumably contribute to allergic responses. Likewise, Nearest Neighbor Analysis of genes coexpressed with Toll-like receptors identified genes of potential relevance for innate immunity. CONCLUSION: Gene profiles from all of the major human leukocyte subsets provide a powerful means to identify genes associated with single leukocyte subsets, or different types of immune response. CLINICAL IMPLICATIONS: A comprehensive dataset of gene expression profiles of human leukocytes should provide new targets or biomarkers for human inflammatory diseases.

BAFF augments certain Th1-associated inflammatory responses.

B cell-activating factor belonging to the TNF family (BAFF; BLyS) is a critical regulator of B cell maturation and survival, and its overexpression in BAFF transgenic (Tg) mice results in the development of autoimmune disorders. BAFF also affects T cell function through binding to one of the BAFF receptors, BAFF-R. Using BAFF Tg mice, we examined a typical Th1-mediated response, the cutaneous delayed-type hypersensitivity reaction, and found a much greater degree of paw swelling and inflammation than in control mice. Importantly, delayed-type hypersensitivity scores correlated directly with BAFF levels in serum. Conversely, in a Th2-mediated model of allergic airway inflammation, BAFF Tg mice were largely protected and showed markedly reduced Ag-specific T cell proliferation and eosinophil infiltration associated with the airways. Thus, local and/or systemically distributed BAFF affects Th1 and Th2 responses and impacts on the course of some T cell-mediated inflammatory reactions. Our results are consistent with the idea that BAFF augments T cell as well as B cell responses, particularly Th1-type responses. Results in BAFF Tg mice may reflect the situation in certain autoimmune patients or virally infected individuals, because BAFF levels in blood are comparable.

Identification of T cell-restricted genes, and signatures for different T cell responses, using a comprehensive collection of microarray datasets.

We used a comprehensive collection of Affymetrix microarray datasets to ascertain which genes or molecules distinguish the known major subsets of human T cells. Our strategy allowed us to identify the genes expressed in most T cell subsets: TCR alphabeta+ and gammadelta+, three effector subsets (Th1, Th2, and T follicular helper cells), T central memory, T effector memory, activated T cells, and others. Our genechip dataset also allowed for identification of genes preferentially or exclusively expressed by T cells, compared with numerous non-T cell leukocyte subsets profiled. Cross-comparisons between microarray datasets revealed important features of certain subsets. For instance, blood gammadelta T cells expressed no unique gene transcripts, but did differ from alphabeta T cells in numerous genes that were down-regulated. Hierarchical clustering of all the genes differentially expressed between T cell subsets enabled the identification of precise signatures. Moreover, the different T cell subsets could be distinguished at the level of gene expression by a smaller subset of predictor genes, most of which have not previously been associated directly with any of the individual subsets. T cell activation had the greatest influence on gene regulation, whereas central and effector memory T cells displayed surprisingly similar gene expression profiles. Knowledge of the patterns of gene expression that underlie fundamental T cell activities, such as activation, various effector functions, and immunological memory, provide the basis for a better understanding of T cells and their role in immune defense.

Estimated folic acid intakes from simulated fortification of the New Zealand food supply.

AIM: To identify a folic acid food fortification programme that will maximise the percentage of women of child-bearing age receiving at least 400 microg folic acid/day, the amount shown to reduce the risk of neural tube defect-affected pregnancies, while not putting population groups at risk of excessive intakes. METHODS: 1997 New Zealand National Nutrition Survey data and a computer modelling programme were used to estimate folic acid intakes from simulated fortification scenarios. RESULTS: Breads fortified with folic acid at 150 microg/50 g, white flour at 100 microg/35 g and liquid milk at 200 microg/200 ml, were found to be the best fortification scenarios. Thirty one percent, 21% and 18% of women of child-bearing age received > or = 400 microg folic acid/day from the fortification of bread, white flour and milk respectively. CONCLUSIONS: The most effective scenario for folic acid fortification is bread fortified at 150 microg/50 g. However, it is impossible to fortify food at a level that ensures the majority of women of child-bearing age receive more than 400 microg folic acid/day without exposing some people to excessive amounts of folic acid. The current public health message encouraging women to select folic acid fortified foods and take folic acid supplements, needs to continue.

A complement component C3a-like peptide stimulates chemotaxis by hemocytes from an invertebrate chordate-the tunicate, Pyura stolonifera.

Recent evidence suggests that the complement system evolved as a critical host defence mechanism among invertebrates, long before the origin among vertebrates of adaptive immune responses mediated by somatically re-arranging antibodies. The current study supports that contention by identifying a complement component C3a-like peptide in the tunicate, Pyura stolonifera. Activation of P. stolonifera serum with common inflammatory elicitors (lipopolysaccharide and zymosan) resulted in the proteolytic generation of an 8.5 kDa peptide, and concomitantly conferred chemoattractant activity on the serum. The 8.5 kDa peptide shares substantial amino acid sequence homology with a previously characterised tunicate complement component C3-like protein (72% amino acid identity in an 18 amino acid overlap). It is also recognised by an anti-C3 antiserum that is known to cross react with tunicate C3 homologues. Hemocyte migration assays performed with the 8.5 kDa peptide that had been partially purified by gel filtration confirmed that the molecule acts as a powerful chemotactic agent. This suggests that the proteolytic activation of tunicate C3-like molecules can initiate inflammatory responses involving cellular recruitment by liberating a pro-inflammatory peptide akin to the vertebrate anaphylatoxin, C3a.