Discrepancies in Electronic Medical Prescriptions Found in a Hospital Emergency Department: A Prospective Observational Study.

The medication in an electronic prescribing system (EPS) does not always match the patient's actual medication. This prospective study analyzes the discrepancies (any inconsistency) between medication prescribed using an EPS and the medication revised by the clinical pharmacist upon admission to the observation area of the emergency department (ED). Adult patients with multimorbidity and/or polypharmacy were included. The pharmacist used multiple sources to obtain the revised medication list, including patient/carer interviews. A total of 1654 discrepancies were identified among 1131 patients. Of these patients, 64.5% had ≥1 discrepancy. The most common types of discrepancy were differences in posology (43.6%), commission (34.7%), and omission (20.9%). Analgesics (11.1%), psycholeptics (10.0%), and diuretics (8.9%) were the most affected. Furthermore, 52.5% of discrepancies affected medication that was high-alert for patients with chronic illnesses and 42.0% of medication involved withdrawal syndromes. Discrepancies increased with the number of drugs (ρ = 0.44, p < 0.01) and there was a difference between non-polypharmacy patients, polypharmacy ones and those with extreme polypharmacy (p < 0.01). Those aged over 75 years had a higher number of prescribed medications and discrepancies occurred more frequently compared with younger patients. The number of discrepancies was larger in women than in men. The EPS medication record requires verification from additional sources, including patient and/or carer interviews.

Discovery of bioactive natural products of microbial origin as inhibitors of the PD-1/PD-L1 protein-protein interaction.

The PD-1/PD-L1 protein-protein interaction (PPI) controls an adaptive immune resistance mechanism exerted by tumor cells to evade immune responses. The large-molecule nature of current commercial monoclonal antibodies against this PPI hampers their effectiveness by limiting tumor penetration and inducing severe immune-related side effects. Synthetic small-molecule inhibitors may overcome such limitations and have demonstrated promising clinical translation, but their design is challenging. Microbial natural products (NPs) are a source of small molecules with vast chemical diversity that have proved anti-tumoral activities, but which immunotherapeutic properties as PD-1/PD-L1 inhibitors had remained uncharacterized so far. Here, we have developed the first cell-based PD-1/PD-L1 blockade reporter assay to screen NPs libraries. In this study, 6000 microbial extracts of maximum biosynthetic diversity were screened. A secondary metabolite called alpha-cyclopiazonic acid (α-CPA) of a bioactive fungal extract was confirmed as a new PD-1/PD-L1 inhibitor with low micromolar range in the cellular assay and in an additional cell-free competitive assay. Thermal denaturation experiments with PD-1 confirmed that the mechanism of inhibition is based on its stabilization upon binding to α-CPA. The identification of α-CPA as a novel PD-1 stabilizer proves the unprecedented resolution of this methodology at capturing specific PD-1/PD-L1 PPI inhibitors from chemically diverse NP libraries.

Activation and Identification of a Griseusin Cluster in Streptomyces sp. CA-256286 by Employing Transcriptional Regulators and Multi-Omics Methods.

Streptomyces are well-known producers of a range of different secondary metabolites, including antibiotics and other bioactive compounds. Recently, it has been demonstrated that "silent" biosynthetic gene clusters (BGCs) can be activated by heterologously expressing transcriptional regulators from other BGCs. Here, we have activated a silent BGC in Streptomyces sp. CA-256286 by overexpression of a set of SARP family transcriptional regulators. The structure of the produced compound was elucidated by NMR and found to be an N-acetyl cysteine adduct of the pyranonaphtoquinone polyketide 3'-O-α-d-forosaminyl-(+)-griseusin A. Employing a combination of multi-omics and metabolic engineering techniques, we identified the responsible BGC. These methods include genome mining, proteomics and transcriptomics analyses, in combination with CRISPR induced gene inactivations and expression of the BGC in a heterologous host strain. This work demonstrates an easy-to-implement workflow of how silent BGCs can be activated, followed by the identification and characterization of the produced compound, the responsible BGC, and hints of its biosynthetic pathway.

Hemobilia due to a cystic artery pseudoaneurysm on ultrasound.

The present paper describes a case of hemobilia in a woman with a cystic artery pseudoaneurysm. The pseudoaneurysm could be seen with ultrasound, Doppler sonography and CT angiography. In our case, Doppler sonography was the most useful technique for diagnosis, revealing the turbulent forward and backwards flow within the gallbladder, representing the focally dilated artery. This was later confirmed by CT angiography. A recent bleeding site was found on the cholecystectomy specimen.

Presentación de una paciente con síndrome de Stevens-Johnson y necrólisis epidérmica tóxica / Presentation of a patient with stevens-johnson syndrome / toxic epidermal necrolysis

Se presentó una paciente femenina escolar de seis años de edad raza mestiza, con antecedentes de salud, sin antecedentes familiares a destacar; embarazo y parto normales, a término, sin patología perinatal, correctamente alimentada, bien inmunizada; buen crecimiento y desarrollo. Controlada por el pediatra, que acudió a su médico de familia por presentar síntomas catarrales (tos pertinaz y fiebre) recibió medicación con fenitoina y al segundo día de tratamiento comienza con manifestaciones cutáneas de ampollas que se destechan y dejan observar zonas eritematosas y húmedas que se extendieron a casi la totalidad de la superficie corporal. El síndrome de Stevens-Johnson es una dermatosis potencialmente fatal caracterizada por una extensanecrosis epidérmica y de mucosas que se acompaña de ataque al estado general. Este síndrome y la necrólisis epidérmica tóxica son reacciones de hipersensibilidad que se consideran formas polares clínico-patológicas de una misma enfermedad. Ambas son reacciones adversas cutáneas severas relacionadas con varios medicamentos. Estas enfermedades tienen impacto significante en la salud pública debido a su alta morbilidad y mortalidad. El porcentaje de superficie cutánea afectada es pronóstico y clasifica a esta dermatosis en tres grupos: síndrome Stevens Johnson (cuando afecta menos de 10 % de superficie corporal) superposición síndrome Stevens Johnson - necrólisis epidérmica tóxica (del 10 al 30 %) y necrólisis epidérmica tóxica (despegamiento cutáneo mayor al 30 %).

Six years old, mixed race school girl patient, with a health record, no family history to note, was presented. Born from a normal pregnancy and a delivery at term. Properly fed, well immunized. Good growth and development. The patient had come to her family physician because of cold symptoms with persistent cough and fever; she received a medication with phenytoin among other drugs. On the second day of treatment the patient developed cutaneous manifestations of blisters that exposed, when opened, erythematous and humid areas that extended to almost the entire body surface. The Stevens - Johnson syndrome is a potentially fatal skin disease characterized by extensive epidermal and mucosal necrosis that is accompanied by malaise. Stevens Johnson Syndrome and toxic epidermal necrolysis are hypersensitivity reactions that are considered clinic and pathologic entity of the same polar forms. Both Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe cutaneous adverse reactions associated with some medications (RACS). These conditions have significant impact on public health because of its high morbidity and mortality. The percentage of affected skin surface classifies this disease into three groups and could define the prognosis: -SSJ, when it affects less than 10% body surface - Overlapping SSJ-NET of 10-30% - NET, greater than 30% skin detachment.

Variation in the composition and in vitro proinflammatory effect of urban particulate matter from different sites.

Spatial variation in particulate matter-related health and toxicological outcomes is partly due to its composition. We studied spatial variability in particle composition and induced cellular responses in Mexico City to complement an ongoing epidemiologic study. We measured elements, endotoxins, and polycyclic aromatic hydrocarbons in two particle size fractions collected in five sites. We compared the in vitro proinflammatory response of J774A.1 and THP-1 cells after exposure to particles, measuring subsequent TNFα and IL-6 secretion. Particle composition varied by site and size. Particle constituents were subjected to principal component analysis, identifying three components: C(1) (Si, Sr, Mg, Ca, Al, Fe, Mn, endotoxin), C(2) (polycyclic aromatic hydrocarbons), and C(3) (Zn, S, Sb, Ni, Cu, Pb). Induced TNFα levels were higher and more heterogeneous than IL-6 levels. Cytokines produced by both cell lines only correlated with C(1) , suggesting that constituents associated with soil induced the inflammatory response and explain observed spatial differences.

Fiber optic sensor for acoustic detection of partial discharges in oil-paper insulated electrical systems.

A fiber optic interferometric sensor with an intrinsic transducer along a length of the fiber is presented for ultrasound measurements of the acoustic emission from partial discharges inside oil-filled power apparatus. The sensor is designed for high sensitivity measurements in a harsh electromagnetic field environment, with wide temperature changes and immersion in oil. It allows enough sensitivity for the application, for which the acoustic pressure is in the range of units of Pa at a frequency of 150 kHz. In addition, the accessibility to the sensing region is guaranteed by immune fiber-optic cables and the optical phase sensor output. The sensor design is a compact and rugged coil of fiber. In addition to a complete calibration, the in-situ results show that two types of partial discharges are measured through their acoustic emissions with the sensor immersed in oil.

Relations between PM10 composition and cell toxicity: a multivariate and graphical approach.

Previous studies have used particle mass and size as metrics to link airborne particles with deleterious health effects. Recent evidence suggests that particle composition can play an important role in PM-toxicity; however, little is known about the specific participation of components (individually or acting in groups) present in such a complex mixture that accounts for toxicity. This work explores relationships among PM(10) components in order to identify their covariant structure and how they vary in three sites in Mexico City. Relationships between PM(10) with cell toxicity and geographical location were also explored. PM(10) was analyzed for elemental composition, organic and elemental carbon, endotoxins and the induction of inhibition of cell proliferation, IL-6, TNFalpha and p53. PM(10) variables were evaluated with principal component analysis and one-way ANOVA. The inhibition of cell proliferation, IL-6 and TNFalpha were evaluated with factorial ANOVA and p53 with the Welch test. The results indicate that there is heterogeneity in particle mass, composition and toxicity in samples collected at different sites. Multivariate analysis identified three major groups: (1) S/K/Ca/Ti/Mn/Fe/Zn/Pb; (2) Cl/Cr/Ni/Cu; and (3) endotoxins, organic and elemental carbon. Groups 1 and 3 showed significant differences among sites. Factorial ANOVA modeling indicated that cell proliferation was affected by PM concentration; TNFalpha and IL-6 by the interaction of concentration and site, and p53 was different by site. Radial plots suggest the existence of complex interactions between components, resulting in characteristic patterns of toxicity by site. We conclude that interactions of PM(10) components determine specific cellular outcomes.