Development of a Screening Algorithm for Lung Disease in Systemic Juvenile Idiopathic Arthritis.

OBJECTIVE: Lung disease (LD) is an increasingly recognized complication of systemic juvenile idiopathic arthritis (sJIA). As there are no currently available guidelines for pulmonary screening in sJIA, we sought to develop such an algorithm at our institution. METHODS: A multidisciplinary workgroup was convened, including members representing rheumatology, pulmonary, stem cell transplantation, and patient families. The workgroup leaders drafted an initial algorithm based on published literature and experience at our center. A modified Delphi approach was used to achieve agreement through three rounds of anonymous, asynchronous voting and a consensus meeting. Statements approved by the workgroup were rated as appropriate with moderate or high levels of consensus. These statements were organized into the final approved screening algorithm for LD in sJIA. RESULTS: The workgroup ultimately rated 20 statements as appropriate with a moderate or high level of consensus. The approved algorithm recommends pulmonary screening for newly diagnosed patients with sJIA with clinical features that the workgroup agreed may confer increased risk for LD. These "red flag features" include baseline characteristics (young age of sJIA onset, human leukocyte antigen type, trisomy 21), high disease activity (macrophage activation syndrome [MAS], sJIA-related ICU admission, elevated MAS biomarkers), respiratory symptoms or abnormal pulmonary examination findings, and features of drug hypersensitivity-like reactions (eosinophilia, atypical rash, anaphylaxis). The workgroup achieved consensus on the recommended pulmonary work-up and monitoring guidelines. CONCLUSION: We developed a pulmonary screening algorithm for sJIA-LD through a multidisciplinary consensus-building process, which will be revised as our understanding of sJIA-LD continues to evolve.

Comparisons of Clinical Competency and Job Responsibilities of Physical Therapists With and Without Postprofessional Training.

INTRODUCTION: Understanding how educational pathways may influence clinical competence and work responsibilities is important in providing guidance to academic and clinic stakeholders and physical therapists (PTs) on PT career development. The purpose of this paper was to compare perceived clinical competency and job duties between PTs with formal mentored postprofessional clinical education with PTs without formal postprofessional clinical education. REVIEW OF LITERATURE: The understanding of self-perceived clinical competence of PTs overall in the United States is limited, especially as related to the impact of postprofessional education. Furthermore, there is limited understanding of the career pathways and development of job duties of PTs in the United States. SUBJECTS: Two thousand three hundred thirty-four PTs in the United States. METHODS: An online survey was sent to licensed PTs. This survey included items measuring self-perceived clinical competency and questions related to weekly job responsibilities. Participants were categorized as residency trained, fellowship trained, or non-residency/fellowship trained. Frequency analyses and Kruskal-Wallis tests with pairwise post hoc tests were performed comparing the 3 groups. RESULTS: Residency-trained (P < .007) and fellowship-trained (P < .001) groups demonstrated elements of higher self-perceived clinical competency compared with the non-residency-/fellowship-trained group. Both the residency- and fellowship-trained groups spent less time with patient care and more time with other responsibilities (e.g., teaching, mentoring, and research) (P < .02) during an average workweek. Fellowship-trained PTs (P < .001) spent more time with administrative duties compared with the non-residency-/fellowship-trained group. DISCUSSION AND CONCLUSION: Results from this paper demonstrate that residency- and fellowship-trained PTs have elements of higher self-perceived clinical competency and spend more of their job duties outside of direct patient care compared with PTs who were not residency or fellowship trained. These results may help guide PTs, academic institutions, and employers in planning and achieving specific career paths.

Emotional intelligence, cortisol and α-amylase response to highly stressful hyper-realistic surgical simulation of a mass casualty event scenario.

Lifetime exposure to stress leads to risk of suffering from cumulative detrimental physiological and psychological ailments. Due to the nature of healthcare and exposure to trauma, medical professionals are particularly susceptible to the negative impacts of high stress environments. emotional intelligence plays a role in ameliorating the risk of being negatively impacted by these stressors. As such, there is special interest to develop and implement training interventions for medical personnel that would allow them to improve emotional intelligence potential with the goal of enabling them to handle stress better and mitigate burnout. A hyper-realistic surgical simulation training session, replicating the intensity of a Mass-Casualty Event scenario, was implemented to allow medical professionals to experience this in real time. Overall, the training led to increased emotional intelligence, correlating with decreased hypothalamus-pituitary-adrenal axis and sympathetic nervous system stress biomarkers, cortisol and α-amylase. This novel training provides, at least, short-term improvements in emotional intelligence that is reflected with a physiological response. These results guide the ongoing effort to develop therapeutic tools to improve long term stress management, mitigate burnout and reduce post-traumatic stress risk after an exposure to a Mass-Casualty event scenario.

Characterisation of polyamide 11/copper antimicrobial composites for medical device applications.

Direct incorporation of antimicrobial additive into the polymer matrix is a cost effective approach for the development of polymer/metal antimicrobial composites. Application of these antimicrobial composite systems for manufacturing medical devices addresses the issue of device related infections. In the present study, commercially available inorganic copper based additive, Plasticopper, was incorporated into a Polyamide 11(PA 11) matrix during the polymer processing stage. These polymer composites were evaluated for their morphological, mechanical, antimicrobial and ion release properties. Isothermal crystallisation studies showed that the copper additive acted as a nucleating agent and promoted faster crystallisation. Short term mechanical studies confirmed that the incorporation of copper has reinforcing effect on the composites with 5 and 10% copper loadings and did not adversely affect the short-term mechanical performance of the polymer composites. These composite systems were shown to be active against Escherichia coli ATCC 8739 with >99.99% reduction in bacterial population. Corresponding ion release profiles for these composites indicated long term antimicrobial activity.

Epigenetic changes induced by adenosine augmentation therapy prevent epileptogenesis.

Epigenetic modifications, including changes in DNA methylation, lead to altered gene expression and thus may underlie epileptogenesis via induction of permanent changes in neuronal excitability. Therapies that could inhibit or reverse these changes may be highly effective in halting disease progression. Here we identify an epigenetic function of the brain's endogenous anticonvulsant adenosine, showing that this compound induces hypomethylation of DNA via biochemical interference with the transmethylation pathway. We show that inhibition of DNA methylation inhibited epileptogenesis in multiple seizure models. Using a rat model of temporal lobe epilepsy, we identified an increase in hippocampal DNA methylation, which correlates with increased DNA methyltransferase activity, disruption of adenosine homeostasis, and spontaneous recurrent seizures. Finally, we used bioengineered silk implants to deliver a defined dose of adenosine over 10 days to the brains of epileptic rats. This transient therapeutic intervention reversed the DNA hypermethylation seen in the epileptic brain, inhibited sprouting of mossy fibers in the hippocampus, and prevented the progression of epilepsy for at least 3 months. These data demonstrate that pathological changes in DNA methylation homeostasis may underlie epileptogenesis and reversal of these epigenetic changes with adenosine augmentation therapy may halt disease progression.

Transient X-ray fragmentation: probing a prototypical photoinduced ring opening.

We report the first study of UV-induced photoisomerization probed via core ionization by an x-ray laser. We investigated x-ray ionization and fragmentation of the cyclohexadiene-hexatriene system at 850 eV during the ring opening. We find that the ion-fragmentation patterns evolve over a picosecond, reflecting a change in the state of excitation and the molecular geometry: the average kinetic energy per ion fragment and H(+)-ion count increase as the ring opens and the molecule elongates. We discuss new opportunities for molecular photophysics created by optical pump x-ray probe experiments.

Strong field ionization to multiple electronic states in water.

High harmonic spectra show that laser-induced strong field ionization of water has a significant contribution from an inner-valence orbital. Our experiment uses the ratio of H(2)O and D(2)O high harmonic yields to isolate the characteristic nuclear motion of the molecular ionic states. The nuclear motion initiated via ionization of the highest occupied molecular orbital (HOMO) is small and is expected to lead to similar harmonic yields for the two isotopes. In contrast, ionization of the second least bound orbital (HOMO-1) exhibits itself via a strong bending motion which creates a significant isotope effect. We elaborate on this interpretation by solving the time-dependent Schrödinger equation to simulate strong field ionization and high harmonic generation from the water isotopes. We expect that this isotope marking scheme for probing excited ionic states in strong field processes can be generalized to other molecules.

Repressive effects of resveratrol on androgen receptor transcriptional activity.

BACKGROUND: The chemopreventive effects of resveratrol (RSV) on prostate cancer have been well established; the androgen receptor (AR) plays pivotal roles in prostatic tumorigenesis. However, the exact underlying molecular mechanisms about the effects of RSV on AR have not been fully elucidated. A model system is needed to determine whether and how RSV represses AR transcriptional activity. METHODOLOGY: The AR cDNA was first cloned into the retroviral vector pOZ-N and then integrated into the genome of AR-negative HeLa cells to generate the AR(+) cells. The constitutively expressed AR was characterized by monitoring hormone-stimulated nuclear translocation, DNA binding, and transcriptional activation, with the AR(-) cells serving as controls. AR(+) cells were treated with RSV, and both AR protein levels and AR transcriptional activity were measured simultaneously. Chromatin immunoprecipitation (ChIP) assays were used to detect the effects of RSV on the recruitment of AR to its cognate element (ARE). RESULTS: AR in the AR (+) stable cell line functions in a manner similar to that of endogenously expressed AR. Using this model system we clearly demonstrated that RSV represses AR transcriptional activity independently of any effects on AR protein levels. However, neither the hormone-mediated nucleus translocation nor the AR/ARE interaction was affected by RSV treatment. CONCLUSION: We demonstrated unambiguously that RSV regulates AR target gene expression, at least in part, by repressing AR transcriptional activity. Repressive effects of RSV on AR activity result from mechanisms other than the affects of AR nuclear translocation or DNA binding.

High harmonic generation from multiple orbitals in N2.

Molecular electronic states energetically below the highest occupied molecular orbital (HOMO) should contribute to laser-driven high harmonic generation (HHG), but this behavior has not been observed previously. Our measurements of the HHG spectrum of N2 molecules aligned perpendicular to the laser polarization showed a maximum at the rotational half-revival. This feature indicates the influence of electrons occupying the orbital just below the N2 HOMO, referred to as the HOMO-1. Such observations of lower-lying orbitals are essential to understanding subfemtosecond/subangstrom electronic motion in laser-excited molecules.

Laboratory evaluation of thermophilic-anaerobic digestion to produce Class A biosolids. 2. Inactivation of pathogens and indicator organisms in a continuous-flow reactor followed by batch treatment.

Thermophilic-anaerobic digestion in a single-stage, mixed, continuous-flow reactor is not approved in the United States as a process capable of producing Class A biosolids for land application. This study was designed to evaluate the inactivation of pathogens and indicator organisms in such a reactor followed by batch treatment in a smaller reactor. The combined process was evaluated at 53 degrees C with sludges from three different sources and at 51 and 55 degrees C with sludge from one of the sources. Feed sludge to the continuous-flow reactor was spiked with the pathogen surrogates Ascaris suum and vaccine-strain poliovirus. Feed and effluent were analyzed for these organisms and for indigenous Salmonella spp., fecal coliforms, Clostridium perfringens spores, and somatic and male-specific coliphages. No viable Ascaris eggs were observed in the effluent from the continuous reactor at 53 or 55 degrees C, with greater than 2-log removals across the digester in all cases. Approximately 2-log removal was observed at 51 degrees C, but all samples of effluent biosolids contained at least one viable Ascaris egg at 51 degrees C. No viable poliovirus was found in the digester effluent at any of the operating conditions, and viable Salmonella spp. were measured in the digester effluent in only one sample throughout the study. The ability of the continuous reactor to remove fecal coliforms to below the Class A monitoring limit depended on the concentration in the feed sludge. There was no significant removal of Clostridium perfringens across the continuous reactor under any condition, and there also was limited removal of somatic coliphages. The removal of male-specific coliphages across the continuous reactor appeared to be related to temperature. Overall, at least one of the Class A pathogen criteria or the fecal coliform limit was exceeded in at least one sample in the continuous-reactor effluent at each temperature. Over the range of temperatures evaluated, the maximum time required to meet the Class A criteria by batch treatment of the continuous-reactor effluent was 1 hour for Ascaris suum and Salmonella spp. and 2 hours for fecal coliforms.

Laboratory evaluation of thermophilic-anaerobic digestion to produce Class A biosolids. 1. Stabilization performance of a continuous-flow reactor at low residence time.

There is increasing interest in the United States in producing biosolids from municipal wastewater treatment that meet the criteria for Class A designation established by the U.S. Environmental Protection Agency. Class A biosolids are intended to be free of pathogens and also must meet requirements for reduction of the vector-attraction potential associated with untreated sludge. High-temperature processes are considered to produce Class A biosolids if the combination of operating temperature and treatment time exceeds minimum criteria, but this option is not applicable to mixed, continuous-flow reactors. Such reactors, or any combination of reactors that does not meet the holding time requirement at a specific temperature, must be demonstrated to inactivate pathogens to levels consistent with the Class A criteria. This study was designed to evaluate pathogen inactivation by thermophilic anaerobic digestion in a mixed, continuous-flow reactor followed by batch or plug-flow treatment. In this first of a two-part series, we describe the performance of a continuous-flow laboratory reactor with respect to physical and chemical operating parameters; microbial inactivation in the combined continuous-flow and batch treatment system is described in the second part. Sludges from three different sources were treated at 53 degrees C, while sludge from one of the sources was also treated at 55 and 51 degrees C. Relatively short hydraulic retention times (four to six days) were used to represent a conservative operating condition with respect to pathogen inactivation. Treatment of a fermented primary sludge led to an average volatile-solids (VS) destruction efficiency of 45%, while VS destruction for the other two sources was near or below 38%, the Class A criterion for vector attraction reduction. Consistent with other studies on thermophilic anaerobic digestion of sludges at short residence times, effluent concentrations of volatile fatty acids (VFAs) were relatively high. Also consistent with other studies, the most abundant VFA in the effluent was propionate. Gas production ranged from 0.3 to 0.5 m3/kg VS fed and from 0.8 to 1.3 m3/kg VS destroyed.

Processes for managing pathogens.

Wastewater contains human, animal, and plant pathogens capable of causing viral, bacterial, or parasitic infections. There are several routes whereby sewage pathogens may affect human health, including direct contact, contamination of food crops, zoonoses, and vectors. The range and numbers of pathogens in municipal wastewater vary with the level of endemic disease in the community, discharges from commercial activities, and seasonal factors. Regulations to control pathogen risk in the United States and Europe arising from land application of biosolids are based on the concept of multiple barriers to the prevention of transmission. The barriers are (i) treatment to reduce pathogen content and vector attraction, (ii) restrictions on crops grown on land to which biosolids have been applied, and (iii) minimum intervals following application and grazing or harvesting. Wastewater treatment reduces number of pathogens in the wastewater by concentrating them with the solids in the sludge. Although some treatment processes are designed specifically to inactivate pathogens, many are not, and the actual mechanisms of microbial inactivation are not fully understood for all processes. Vector attraction is reduced by stabilization (reduction of readily biodegradable material) and/or incorporation immediately following application. Concerns about health risks have renewed interest in the effects of treatment (on pathogens) and advanced treatment methods, and work performed in the United States suggests that Class A pathogen reduction can be achieved less expensively than previously thought. Effective pathogen risk management requires control to the complete chain of sludge treatment, biosolids handling and application, and post-application activities. This may be achieved by adherence to quality management systems based on hazard analysis critical control point (HACCP) principles.

Relationship between the Van Kleeck and mass-balance calculation of volatile solids loss.

An equation was developed that quantifies the relationship between volatile solids reduction (VSR) calculated by the Van Kleeck and mass-balance equations. Two sets of data were used to illustrate the significance of fixed-solids loss on the agreement between the two methods. The Van Kleeck equation assumes that fixed solids are conserved during the digestion process; however, this assumption is not needed for the mass-balance equation. Therefore, if substantial changes in the fixed-solids concentration occur, the Van Kleeck equation will not be as accurate as the mass-balance equation for computing VSR and will also underestimate VSR.