A Learning Health System Approach to Increasing Human Papillomavirus Immunizations Among Young Adults.

INTRODUCTION Immunization rates against the human papillomavirus (HPV) remain suboptimal in the young adult population. Little is known about the most effective means for encouraging vaccination in this population. METHODS The authors conducted a clinical trial of 3 methods to encourage HPV vaccination in a large Northern California integrated Health Plan. Young adults aged 18-26 with evidence of insufficient HPV vaccination were sent a bulk secure message from the Health Plan (standard outreach); those who did not respond were randomized to no further outreach, a second, personalized secure message from a specific practitioner, or a letter mailed to their home. The primary outcome was receipt of at least 1 HPV vaccine within 3 months following the initial bulk secure message. RESULTS In total, 7718 young adults were randomized. After 3 months, 86 patients (3.5%) who received no additional outreach obtained an immunization, compared with 114 (4.6%) who received the second secure message (p = 0.05) and 126 (5.1%) who received the mailed letter (p = 0.006). DISCUSSION Supplemental mailed or personalized electronic messages increased vaccination beyond no additional intervention, although gains were not clinically meaningful. These findings highlight the need for more successful alternatives to encourage uptake of such preventive health interventions among young adults. The successful conduct of this rapid-cycle, randomized trial showed that such evaluations are feasible, providing actionable data to inform implementation strategies. CONCLUSIONS Further study is needed to identify effective strategies for improving preventive health uptake in this important and underserved population. Rapid-cycle randomized evaluation strategies can provide critical information to focus efforts for achieving this goal.

Sinus arrest in familial hypokalemic periodic paralysis caused by SCN4A mutation: a case report.

BACKGROUND: Primary hypokalemic periodic paralysis (HypoPP), a rare skeletal muscle channelopathy resulting in episodic muscle weakness or paralysis under hypokalemic conditions, is caused by autosomal-dominant genetic mutations. HypoPP limits physical activity, and cardiac arrhythmias during paralytic attacks have been reported. We describe a rare familial HypoPP case complicated by sinus arrest and syncope requiring urgent temporary pacemaker implantation. CASE REPORT: A 27-year-old Vietnamese man with a family history of periodic paralysis presented with his third attack of muscle weakness triggered by intense football training the previous day. Clinical and laboratory features justified a HypoPP diagnosis. During intravenous potassium replacement, the patient experienced syncopal sinus arrest requiring urgent temporary pacemaker implantation. The patient gradually improved, responding favorably to oral potassium supplements. Genetic testing revealed an Arg1132Gln mutation in the sodium ion channel (SCN4A, chromosome 17: 63947091). At discharge, the patient received expert consultation regarding nonpharmacological preventive strategies, including avoidance of vigorous exercise and carbohydrate-rich diet. CONCLUSIONS: No evidence has established a relationship between hypokalemia and sinus arrest, and no specific treatment exists for familial HypoPP due to SCN4A mutation. Clinician awareness of this rare condition will promote appropriate diagnostic approaches and management strategies for acute paralytic attacks. Treatment should be tailored according to HypoPP phenotypes and genotypes.

Using a report card to increase HIV screening in a large primary care group practice.

BACKGROUND: Despite increased efforts to promote HIV screening, a large proportion of the US population have never been tested for HIV. OBJECTIVE: To determine whether provider education and personalised HIV screening report cards can increase HIV screening rates within a large integrated healthcare system. DESIGN: This quality improvement study provided a cohort of primary care physicians (PCPs) a brief educational intervention and personalised HIV screening report cards with quarterly performance data. PARTICIPANTS: Participants included a volunteer cohort of 20 PCPs in the department of adult and family medicine. MAIN MEASURES: Per cent of empaneled patients screened for HIV by cohort PCPs compared with PCPs at the Kaiser Permanente Oakland Medical Center (KPOAK) and the non-Oakland Medical Centers in Northern California region (Kaiser Permanente Northern California (KPNC)). KEY RESULTS: Of the 20 participating PCPs, 13 were female and 7 were male. Thirteen were internal medicine and seven family medicine physicians. The average age was 40 years and average practice experience was 9 years after residency. During the 12-month intervention, the estimated increase in HIV screening in the cohort PCP group was 2.6% as compared with 1.9% for KPOAK and 1.8% for KPNC. CONCLUSIONS: These findings suggest that performance-related report cards are associated with modestly increased rates of HIV screening by PCPs.

RADIATION DOSE MEASUREMENTS FOR HIGH-INTENSITY LASER INTERACTIONS WITH SOLID TARGETS AT SLAC.

A systematic study of photon and neutron radiation doses generated in high-intensity laser-solid interactions is underway at SLAC National Accelerator Laboratory. These laser-solid experiments are being performed using a 25 TW (up to 1 J in 40 fs) femtosecond pulsed Ti:sapphire laser at the Linac Coherent Light Source's (LCLS) Matter in Extreme Conditions (MEC) facility. Radiation measurements were performed with passive and active detectors deployed at various locations inside and outside the target chamber. Results from radiation dose measurements for laser-solid experiments at SLAC MEC in 2014 with peak intensity between 1018 and 7.1 × 1019 W cm-2 are presented.

Essential oil constituents of Etlingera yunnanensis and Hornstedtia sanhan grown in Vietnam.

The chemical composition of the essential oils obtained from the hydrodistillation of different parts of Etlingera yunnanensis (T.L. Wu & S.J. Chen) R.M. Sm. and Hornstedtia sanhan M.F. Newman (Zingiberaceae) grown in Vietnam are reported. The analysis was performed by means of a gas chromatography-flame ionization detector (GC-FID) and gas chromatography coupled with mass spectrometry (GC-MS). The essential oil of the leaves of E. yunnanensis comprised mainly germacrene D (19.2%), ß-pinene (11.6%), and α-amorphene (11.2%), while that of the stems was rich in ß-pinene (23.7%), 1,8-cineole (11.0%) and α-pinene (9.6%). The major components of the root oil of E. yunnanensis were ß-pinene (31.9%), α-pinene (13.7%) and 1,8-cineole (9.4%). However, α-pinene (25.9%, 36.3% and 14.1% for leaves, stems and roots, respectively), ß-pinene (9.7%, 11.8% and 7.2% for leaves, stems and roots, respectively) and limonene (22.1%, 24.6% and 16.2% for leaves, stems and roots, respectively) were the major compounds of H. sanhan. In addition, α-humulene (15.9%) was present in larger amounts in the leaf oil while the root oil contained the largest proportion of methyl chavicol (43.7%).

Overview of current and alternative therapies for idiopathic membranous nephropathy.

Membranous nephropathy is one of the leading causes of nephrotic syndrome in adults, which is characterized by edema, hypoalbuminemia, hyperlipidemia, lipiduria, and proteinuria. Determination of idiopathic membranous nephropathy (IMN) disease progression risk is important for guiding initial therapy, with immunosuppressive therapy being reserved for high-risk patients. Because IMN may spontaneously remit in approximately 30% of patients, it is important to carefully select which patients should begin immunosuppressive therapy so as to maximize clinical benefit while limiting toxicity. An observation period of at least 6 months with conservative management that includes the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers is recommended. Initial treatment in high-risk IMN is a 6-month course of alternating steroids and alkylating agents. Calcineurin inhibitors (CNIs) represent an alternative first-line therapeutic option for high-risk patients who refuse treatment with steroid or alkylating agent therapy or for whom these treatments are contraindicated. Additional options are essential for patients with IMN who fail to adequately respond to initial therapies or who cannot use recommended therapies due to contraindications or intolerance, risks associated with repetitive dosing with alkylating agents, or potential exacerbation of impaired renal function with CNIs. While evidence for the use of alternative therapies in IMN is modest at best, our review summarizes the available literature for rituximab, mycophenolate mofetil, adrenocorticotropic hormone, intravenous immunoglobulin, and azathioprine. Rituximab has generally demonstrated beneficial outcomes with limited toxicity. Evidence supports a role for mycophenolate mofetil, although the evidence is of low quality and limited duration. Results from ongoing studies are required before adrenocorticotropic hormone can be recommended as therapy for treatment-resistant patients. Intravenous immunoglobulin and azathioprine are unlikely to have a role in IMN. With the advent of new tools and biomarkers measuring disease activity combined with new data regarding possible treatment options, the management and prognosis of IMN are likely to improve.

Effects of spray-dried porcine plasma on growth performance, immune response, total antioxidant capacity, and gut morphology of nursery pigs.

Two experiments were conducted to evaluate the effects of spray-dried porcine plasma (SDPP) on growth performance, immunity, antioxidant capacity, and gut morphology of nursery pigs. In Exp. 1, 96 weaned pigs (Nebraska female × Danbred sire; 20 ± 1 d of age; initial BW = 6.06 ± 0.02 kg) were assigned to 16 pens and randomly allotted to the control (CTL; no SDPP) or the CTL + SDPP treatment in 2 phases (phase 1: d 0 to 14, 5% SDPP; phase 2: d 14 to 28, 2.5% SDPP). Blood samples were collected on d 0 and weekly thereafter to quantify IgG, IgA, and total antioxidant capacity. On d 14, pigs (n = 16; 8 pigs/treatment) were selected and euthanized for small intestine tissue and alveolar macrophage collection. On d 7, pigs fed SDPP had greater ADG, ADFI (P = 0.001), and G:F (P = 0.019) compared with CTL pigs. On d 28, pigs fed SDPP had greater BW (P = 0.024) and tended to have greater ADG (P = 0.074) and ADFI (P = 0.062) compared with CTL pigs. There were no differences between treatments for serum IgG, IgA, and total antioxidant capacity. On d 14, greater villus height (P = 0.011) and villus:crypt (P = 0.008) were observed in duodenal tissue sections obtained from SDPP-fed pigs compared with CTL pigs. To evaluate effects of SDPP on immune biomarkers, alveolar macrophages collected from 3 pigs/treatment on d 14 were cultured in vitro and challenged with lipopolysaccharide (LPS; 10 ng/mL). Therefore, 4 treatments included 1) CTL diet with no LPS, 2) CTL diet with LPS (CTL+), 3) SDPP diet with no LPS, and 4) SDPP diet with LPS. There were no diet effects on tumor necrosis factor-α gene expression or secretion by alveolar macrophages. For IL-10 gene expression, a diet × LPS interaction (P = 0.009) was observed where CTL+ had greater (P < 0.05) IL-10 mRNA abundance compared with other treatments. A second experiment was conducted to evaluate the in vitro effects of porcine plasma using model porcine jejunal epithelial cells (IPEC-J2). The treatments applied to the IPEC-J2 cells were 1) CTL, 2) CTL + 10% porcine plasma, 3) CTL + 5% porcine plasma, 4) CTL + 2.5% porcine plasma, or 5) CTL + 5% fetal bovine serum. The addition of porcine plasma increased (P < 0.001) proliferation of IPEC-J2 cells at 24 and 48 h following exposure to the respective treatments. In conclusion, dietary SDPP increased growth performance of nursery pigs during the first week postweaning and provide benefits to gut morphology possibly via increased proliferation of enterocytes.

New oral anticoagulants: a practical guide on prescription, laboratory testing and peri-procedural/bleeding management. Australasian Society of Thrombosis and Haemostasis.

New oral anticoagulants (NOAC) are becoming available as alternatives to warfarin to prevent systemic embolism in patients with non-valvular atrial fibrillation and for the treatment and prevention of venous thromboembolism. An in-depth understanding of their pharmacology is invaluable for appropriate prescription and optimal management of patients receiving these drugs should unexpected complications (such as bleeding) occur, or the patient requires urgent surgery. The Australasian Society of Thrombosis and Haemostasis has set out to inform physicians on the use of the different NOAC based on current available evidence focusing on: (i) selection of the most suitable patient groups to receive NOAC, (ii) laboratory measurements of NOAC in appropriate circumstances and (iii) management of patients taking NOAC in the perioperative period, and strategies to manage bleeding complications or 'reverse' the anticoagulant effects for urgent invasive procedures.

Effect of dam parity on litter performance, transfer of passive immunity, and progeny microbial ecology.

Litter performance and progeny health status may be decreased in progeny derived from primiparous sows but improve with increasing parity. The objective was to evaluate litter performance, the production and passive transfer of Ig, and fecal microbial populations in progeny derived from first parity (P1) compared with fourth parity (P4) dams. Litter performance was recorded for P1 (n = 19) and P4 (n = 24) dams including number of pigs/litter (total born, born live, stillbirths, mummified fetuses, prewean mortality, and pigs weaned) and average litter and piglet BW at birth (d 0), d 7, d 14, and at weaning (average d 19). Blood samples were collected from all dams on d 90 and 114 of gestation and d 0 of lactation. Colostrum and milk samples were collected from each dam on d 0, 7, and 14 of lactation for quantification of IgG and IgA. Blood and fecal samples were collected from each litter (n = 6 pigs/litter) on d 1, 7, and 14 after parturition. Circulating IgG and IgA concentrations were quantified in all blood samples. Denaturing gradient gel electrophoresis (DGGE) was used to characterize similarity and diversity of fecal microbes among progeny. Progeny of P1 dams had decreased average litter BW at d 7 (25.7 vs. 30.0 kg; P < 0.03) and decreased average piglet BW throughout the experiment (d 0, 7, 14, and 19; P < 0.001) compared with P4 progeny. No parity × day interactions were observed with respect to immunoglobulin or microbial analyses. Concentrations of IgA tended to be greater (P = 0.09) in samples of colostrum and milk obtained from P4 compared with P1 dams. Serum IgG concentrations were greater (P < 0.02) in P4 progeny compared with P1 progeny. Results of DGGE revealed that P1 progeny had increased (P < 0.001) microbial similarity on d 7 and decreased (P < 0.03) microbial similarity on d 14 compared with P4 progeny. Progeny of P1 dams tended (P = 0.07) to have a greater Shannon's diversity index compared with P4 progeny on d 1, and P1 progeny had a greater (P < 0.03) Shannon's diversity index compared with P4 progeny on d 7. Litter performance, passive transfer of immunity, and progeny microbial ecology were affected by dam parity.

A cytokine and angiogenic factor (CAF) analysis in plasma for selection of sorafenib therapy in patients with metastatic renal cell carcinoma.

BACKGROUND: We investigated cytokines and angiogenic factors (CAFs) in patients with metastatic renal cell carcinoma (mRCC) treated in a randomized phase II clinical trial of sorafenib versus sorafenib+ interferon-α (IFN-α) that yielded no differences in progression-free survival (PFS). We aimed to link the CAF profile to PFS and select candidate predictive and prognostic markers for further study. METHODS: The concentrations of 52 plasma CAFs were measured pretreatment (n = 69), day 28, and day 56 using multiplex bead arrays and enzyme-linked immunosorbent assay. We investigated the association between baseline levels of CAFs with PFS and posttreatment changes. RESULTS: Unsupervised CAF clustering analysis revealed two distinct mRCC patient groups with elevated proangiogenic or proinflammatory mediators. A six-marker baseline CAF signature [osteopontin, vascular endothelial growth factor (VEGF), carbonic anhydrase 9, collagen IV, VEGF receptor-2, and tumor necrosis factor-related apoptosis-inducing ligand] correlated with PFS benefit (hazard ratio 0.20 versus 2.25, signature negative versus positive, respectively; P = 0.0002). While changes in angiogenic factors were frequently attenuated by the sorafenib+ IFN combination, most key immunomodulatory mediators increased. CONCLUSIONS: Using CAF profiling, we identified two mRCC patient groups, a candidate plasma signature for predicting PFS benefit, and distinct marker changes occurring with each treatment. This platform may provide valuable insights into renal cell carcinoma biology and the molecular consequences of targeted therapies.

Prothrombin complex concentrates used alone in urgent reversal of warfarin anticoagulation.

BACKGROUND: Prothrombinex-VF (a three-factor prothrombin complex concentrate) contains little factor VII. Therefore, the Warfarin Reversal Consensus Guidelines from 2004 published by The Australasian Society of Haemostasis and Thrombosis recommend that it be administered with fresh frozen plasma to reverse warfarin anticoagulation. AIM: To evaluate the efficacy and safety of Prothrombinex-VF used alone in warfarin reversal. METHODS: Adult patients requiring urgent reversal of warfarin anticoagulation were defined as having achieved complete (target international normalized ratio (INR) <1.4) or partial reversal (target INR 1.4-2.0) of their anticoagulation. Prothrombinex-VF was given at doses of between 25 and 50 IU/kg based on the intent of reversal and an INR was obtained 30min post infusion. RESULTS: A total of 50 patients (mean age 72years, range 32-85years) was included. The median initial INR in the complete reversal arm (n= 35) was 3.5 (range 1.7-20) with 91% achieving the target INR (mean 1.1, range 0.9-1.4). In the partial reversal arm (n= 15) the mean initial INR was 5.6 (range 2.5-12) with 93% achieving the target INR (mean 1.6, range 1.4-2.2). There were no adverse effects attributed to Prothrombinex-VF. CONCLUSIONS: Prothrombinex-VF is very effective and safe when used alone to reverse warfarin anticoagulation. The supplementary use of fresh frozen plasma in these patients is not required. A review of the current Warfarin Reversal Consensus Guidelines is needed.

Purification and properties of Arabidopsis thaliana type 1 protein phosphatase (PP1).

The Arabidopsis thaliana type 1 protein phosphatase (PP1) catalytic subunit was released from its endogenous regulatory subunits by ethanol precipitation and purified by anion exchange and microcystin affinity chromatography. The enzyme was identified by MALDI-TOF mass spectrometry from a tryptic digest of the purified protein as a mixture of PP1 isoforms (TOPP 1-6) indicating that at least 4-6 of the eight known PP1 proteins are expressed in sufficient quantities for purification from A. thaliana suspension cells. The enzyme had a final specific activity of 8950 mU/mg using glycogen phosphorylase a as substrate, had a subunit molecular mass of 35 kDa as determined by SDS-PAGE and behaved as a monomeric protein of approx. 39 kDa on Superose 12 gel filtration chromatography. Similar to the mammalian type 1 protein phosphatases, the A. thaliana enzyme was potently inhibited by Inhibitor-2 (IC(50)=0.65 nM), tautomycin (IC(50)=0.06 nM), microcystin-LR (IC(50)=0.01 nM), nodularin (IC(50)=0.035 nM), calyculin A (IC(50)=0.09 nM), okadaic acid (IC(50)=20 nM) and cantharidin (IC(50)=60 nM). The enzyme was also inhibited by fostriecin (IC(50)=22 microM), NaF (IC(50)=2.1 mM), Pi (IC(50)=9.5 mM), and PPi (IC(50)=0.07 mM). Purification of the free catalytic subunit allowed it to be used to probe protein phosphatase holoenzyme complexes that were enriched on Q-Sepharose and a microcystin-Sepharose affinity matrix and confirmed several proteins to be PP1 targeting subunits.

Requirement of co-factors for the ligand-mediated activity of the insect ecdysteroid receptor in yeast.

In insects, a steroid hormone 20-hydroxyecdysone has an important role in regulating critical events such as development and reproduction. The action of 20-hydroxyecdysone is mediated by its binding to the ecdysteroid receptor (EcR), which requires a heterodimeric partner, ultraspiracle protein (USP), a homologue of the retinoid X receptor (RXR). The EcR-USP heterodimer represents a functional receptor complex capable of initiating transcription of early genes. Our goal was to establish a ligand-dependent transactivation system in yeast utilizing an insect EcR-USP heterodimer. This has been achieved using mosquito Aedes aegypti AaEcR-USP. Expression of AaEcR alone, but not USP, resulted in constitutive transcription of the ecdysone reporter gene coupled with the Drosophila heat shock protein-27 ecdysone response elements. Removal of the N-terminal A/B domain of AaEcR abolished its constitutive transcription. Constitutive transcription was also eliminated in the presence of its heterodimeric partner, AaUSPa, AaUSPb or mammalian RXR. This suggests that the A/B domain is essential for the EcR ligand-independent transactivation and its interaction with the yeast transcription complex. A ligand-mediated transactivation of Aa(Delta A/B)EcR-USP or Aa(Delta A/B)EcR-RXR heterodimers in response to an ecdysteroid agonist RH-5992 was observed only in the presence of GRIP1, a mouse co-activator. In the presence of a co-repressor, SMRT, Aa(Delta A/B)EcR-USP heterodimer exhibited a ligand-dependent repression activity. In addition, ligand-dependent transactivation systems for spruce budworm and fruit fly ecdysone receptors were also reported. This is the first report establishing the requirements of co-factors for a highly efficient ligand-dependent function of the insect EcR-USP in yeast. These findings open a way to study insect EcR-USP structure and function and to identify ligands that are specific for a certain group of insects, such as mosquitoes.

Trabeculectomy with intraoperative sponge 5-fluorouracil.

PURPOSE: To retrospectively assess the outcome of trabeculectomy surgery performed using intraoperative sponge 5-fluorouracil (5-FU) (50 mg/ml). METHODS: Trabeculectomy with intraoperative sponge 5-FU was performed on 140 eyes of 119 patients. The reduction in intraocular pressure (IOP), the number of supplementary postoperative injections, and any treatment complications were noted. RESULTS: The mean preoperative IOP was 25.7 +/- 8.6 mmHg. The mean postoperative IOP was 12.5 +/- 5.7 mmHg with a mean IOP reduction of 52 percent (P < 0.0001). One hundred twenty-one (86.4 percent) eyes required no postoperative glaucoma medications, with the mean number of glaucoma medications dropping from 2.5 +/- 1.1 before operation to 0.3 +/- 0.8 after operation (P < 0.001). One hundred five eyes received a mean of 5.3 +/- 2.7 postoperative 5-FU injections. There was no significant difference in final IOP or success rate between low- and high-risk eyes, but high-risk eyes seemed to require supplementary postoperative 5-FU. Corneal epithelial damage arose in 52 (37 percent) eyes and correlated strongly with postoperative 5-FU supplementation. CONCLUSION: Intraoperative sponge 5-FU is a reasonably safe and effective adjunct to trabeculectomy surgery.

Scintigraphic manifestations of "sternal cupping".

Sternal abnormalities in sickle-cell disease have been documented by bone scintigraphy and radiography in patients with homozygous sickle-cell anemia, but not in patients with sickle-thalassemia. We present here two unusual cases of sternal abnormalities in complicated sickle-cell disease. One is an infant with radiographic findings of "sternal cupping" and transient hypo-ossification of the sternum and sickle-thalassemia. The other patient is also a male infant with unusual, persistent under-ossification of bone, in association with radiographic findings of "sternal cupping." The second patient also had a 4P-chromosomal defect (Wolf-Hirschhorn syndrome) in which sternal hypo-ossification was described.

[Intestinal occlusion and enterocolitis caused by Gelopectose]. / Occlusion intestinale et entérocolite par Gélopectose.

A case of intestinal obstruction and enterocolitis, probably as a consequence of inappropriate use of thickened feedings, is reported. Products which thicken feedings take an important part in the treatment of gastro-oesophageal reflux in infants. In order to thicken feedings, pectin and silicium have been added to milk. However, they may lead to an obstructive medication bezoar. Thus, it is necessary to limit their use to 3-5% of feeding and to clearly explain their potential hazards to the family.