Coupled myovascular expansion directs cardiac growth and regeneration.

Heart regeneration requires multiple cell types to enable cardiomyocyte (CM) proliferation. How these cells interact to create growth niches is unclear. Here, we profile proliferation kinetics of cardiac endothelial cells (CECs) and CMs in the neonatal mouse heart and find that they are spatiotemporally coupled. We show that coupled myovascular expansion during cardiac growth or regeneration is dependent upon VEGF-VEGFR2 signaling, as genetic deletion of Vegfr2 from CECs or inhibition of VEGFA abrogates both CEC and CM proliferation. Repair of cryoinjury displays poor spatial coupling of CEC and CM proliferation. Boosting CEC density after cryoinjury with virus encoding Vegfa enhances regeneration. Using Mendelian randomization, we demonstrate that circulating VEGFA levels are positively linked with human myocardial mass, suggesting that Vegfa can stimulate human cardiac growth. Our work demonstrates the importance of coupled CEC and CM expansion and reveals a myovascular niche that may be therapeutically targeted for heart regeneration.

Amblyospora khaliulini (Microsporidia: Amblyosporidae): Investigations on its life cycle and ecology in Aedes communis (Diptera: Culicidae) and Acanthocyclops vernalis (Copepoda: Cyclopidae) with redescription of the species.

A multi-year study was conducted to examine the natural ecology of the microsporidium Amblyospora khaliulini and more fully characterize parasite development and histopathology in all stages of its primary mosquito host, Aedes communis and intermediate copepod host, Acanthocyclops vernalis with redescription of the species. A. khaliulini exhibits polymorphic development, produces three morphologically and functionally distinct spores, and is both horizontally and vertically transmitted. Development in A. vernalis is restricted to females, occurs within the ovaries and results in death of the host. Development is haplophasic with division by binary and multiple fission producing rosette-shaped sporogonial plasmodia and conical uninucleate spores that are orally infectious to Ae. communis larvae. Both sexes are equally susceptible and infections are confined to testes in males and ovaries in females. Initial stages of development include uninucleate schizonts that undergo karyokinesis forming diplokaryotic meronts that divide repeatedly by binary fission. Sporogony occurs in both host sexes, but sporogenesis does not progress normally in adult males and elliptical, thin walled binucleate spores that function in vertical transmission of the microsporidium via infection of the ovaries and eggs are formed in adult females only. Development of vertically acquired infections in larval Ae. communis hosts occurs within fat body tissue, leads to the production of meiospores in male hosts only and results in death during the 4th larval stadium. Initial development is characterized by merogonial multiplication of diplokarya by synchronous binary division producing additional diplokarya. The cessation of merogony and the onset of sporogony are characterized by the simultaneous secretion of a sporophorous vesicle and meiotic division of diplokarya resulting in the formation of octonucleate sporonts that undergo cytokinesis and sporogenesis to form eight uninucleate, broadly ovoid meiospores enclosed within a sporophorous vesicle. The natural prevalence of patent vertically acquired fat body infections in field populations of Ae. communis ranged from 1.6% to 3.6%. Yearly infection rates in A. vernalis copepods ranged from 57.1% to 15.0%. Prevalence rates of horizontally acquired infections in emerging adult Ae. communis ranged from 69.0% to 11.9% in males and 50.0% to 16.4% in females.

Current Practice Patterns in the Management Of Alcohol Withdrawal Syndrome.

OBJECTIVE: The aim of this study was to examine current practice patterns surrounding the management of alcohol withdrawal syndrome (AWS) in the Northeast region of the United States. METHODS: A survey questionnaire with several treatment options related to current practice in the management of AWS was developed. All hospitals with 100 beds or more located in the Northeast region were selected, and 512 surveys were mailed to pharmacy directors of those hospitals. RESULTS: Responses from 90 hospitals in nine states were included in the analyses. For the treatment of mild, moderate, and severe AWS, most institutions utilized protocols or guidelines (66%, 73%, and 67%, respectively). However, two-thirds of the hospitals indicated that guidelines or protocols were not in place to treat benzodiazepine (BZD)-refractory AWS. A BZD-only treatment strategy was selected as the first choice for mild and moderate AWS (74% and 54%, respectively), whereas a BZD regimen in combination with a variety of other agents, including haloperidol, dexmedetomidine, phenobarbital, or propofol, was frequently used in the treatment of severe and BZD-refractory AWS. CONCLUSION: The findings suggest that considerable heterogeneity exists, particularly in the treatment of severe and BZD-refractory AWS, among hospitals in the Northeast. Given that current guidelines focus mainly on BZD therapy, the results of this survey highlight the need for updated practice guidelines utilizing other treatment strategies.

Droperidol for the treatment of acute migraine headaches.

OBJECTIVE: To evaluate the safety and efficacy of droperidol for the relief of acute migraine headaches. DATA SOURCES: A MEDLINE search (1946 to August 2014) was performed using the following keywords and associated medical subject headings: droperidol, inapsine, headache, migraine, and migraine disorder. STUDY SELECTION AND DATA EXTRACTION: The search was conducted to identify randomized controlled trials comparing droperidol with placebo or an active control in adult patients with acute migraine headaches that were published in English. Primary end points included acute headache improvement after the intervention. Safety end points included the frequency of extrapyramidal symptoms, somnolence, and cardiac adverse effects. DATA SYNTHESIS: In all, 5 manuscripts are included in this review. Patients presenting to the emergency department with acute headache desire rapid pain relief, which was the primary objective in each of the evaluated studies. Droperidol was better than placebo and at least as effective as comparator drugs such as prochlorperazine, meperidine, or olanzapine using droperidol doses of 2.5 to 5 mg, given either intramuscularly (IM) or intravenously (IV). The most commonly reported adverse effects were extrapyramidal symptoms and sedation. Cardiac adverse effects were not reported in any of the studies; however, only 2 articles described using cardiac monitoring. CONCLUSIONS: Parenteral droperidol is an effective option for the treatment of acute migraine. The minimum effective dose is 2.5 mg given IM or IV. Clinicians must be aware of the risk for adverse events, select appropriate patients, perform EKG monitoring for patients at risk of QTc prolongation, and institute treatment if necessary.

Structural characterization of glycerophospholipids by combinations of ozone- and collision-induced dissociation mass spectrometry: the next step towards "top-down" lipidomics.

The complete structural elucidation of complex lipids, including glycerophospholipids, using only mass spectrometry represents a major challenge to contemporary analytical technologies. Here, we demonstrate that product ions arising from the collision-induced dissociation (CID) of the [M + Na](+) adduct ions of phospholipids can be isolated and subjected to subsequent gas-phase ozonolysis - known as ozone-induced dissociation (OzID) - in a linear ion-trap mass spectrometer. The resulting CID/OzID experiment yields abundant product ions that are characteristic of the acyl substitution on the glycerol backbone (i.e., sn-position). This approach is shown to differentiate sn-positional isomers, such as the regioisomeric phosphatidylcholine pair of PC 16:0/18:1 and PC 18:1/16:0. Importantly, CID/OzID provides a sensitive diagnostic for the existence of an isomeric mixture in a given sample. This is of very high value for the analysis of tissue extracts since CID/OzID analyses can reveal changes in the relative abundance of isomeric constituents even within different tissues from the same animal. Finally, we demonstrate the ability to assign carbon-carbon double bond positions to individual acyl chains at specific backbone positions by adding subsequent CID and/or OzID steps to the workflow and that this can be achieved in a single step using a hybrid triple quadrupole-linear ion trap mass spectrometer. This unique approach represents the most complete and specific structural analysis of lipids by mass spectrometry demonstrated to date and is a significant step towards comprehensive top-down lipidomics.

Deep Learning Resolves Myovascular Dynamics in the Failing Human Heart.

The adult mammalian heart harbors minute levels of cycling cardiomyocytes (CMs). Large numbers of images are needed to accurately quantify cycling events using microscopy-based methods. CardioCount is a new deep learning-based pipeline to rigorously score nuclei in microscopic images. When applied to a repository of 368,434 human microscopic images, we found evidence of coupled growth between CMs and cardiac endothelial cells in the adult human heart. Additionally, we found that vascular rarefaction and CM hypertrophy are interrelated in end-stage heart failure. CardioCount is available for use via GitHub and via Google Colab for users with minimal machine learning experience.

Rapid identification of long-chain polyunsaturated fatty acids in a marine extract by HPLC-MS using data-dependent acquisition.

The collision-induced dissociation (CID) of a range of deprotonated fatty acid standards was studied using linear ion trap mass spectrometry. Neutral losses of 78, 98, and 136 Da were consistently observed for fatty acids with five or more double bonds. Comparison of the MS/MS spectra of docosahexaenoic acid (DHA) and universally (13)C-labeled DHA allowed the molecular formulas for these neutral losses to be determined as C(6)H(6), C(5)H(6)O(2), and C(8)H(8)O(2). Knowledge of fatty acid fragmentation processes was then applied to identify fatty acids from a sea anemone, Aiptasia pulchella, and dinoflagellate symbiont, Symbiodinium sp. extract. Using HPLC-MS, fatty acids were separated and analyzed by tandem mass spectrometry in data-dependent acquisition mode. Neutral loss chromatograms for 78, 98, and 136 Da allowed the identification of long-chain fatty acids with five or more double bonds. On the basis of precursor ion m/z ratios, chain length and degree of unsaturation for these fatty acids were determined. The application of this technique to an Aiptasia sp.-Symbiodinium sp. lipid extract enabled the identification of the unusual, long-chain fatty acids 24:6, 26:6, 26:7, 28:7, and 28:8 during a single 40 min HPLC-MS analysis.

A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.

STUDY OBJECTIVE: The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED). METHODS: This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables. RESULTS: A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%). CONCLUSION: Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities.

Field observations on the overwintering ecology of Culiseta melanura in the northeastern USA.

The overwintering ecology of Culiseta melanura was studied in a seasonally flooded evergreen forest swamp in south central Connecticut in an effort to clarify which larval stages successfully overwinter in the northeastern USA, and to determine the degree to which larval development and/or mortality occur during the winter months. A total of 8,626 immature Cs. melanura were collected weekly for analysis from subterranean crypts and cavities located under the roots of trees from December 13, 2011 to May 31, 2012. Despite the formation of ice on the surface water at the entrance holes to the crypts, water temperatures within the cavities remained above freezing (average = 1.8 degrees C) throughout the coldest winter months of January and February. A heterogeneous population of 2nd, 3rd, and 4th instars were recovered throughout the winter and early spring in the same relative proportions (30%, 30%, 40%, respectively), with no significant change in their comparative abundance during this period, providing unequivocal evidence that all 3 instars successfully overwinter in the region. Findings further demonstrate that larvae undergo no development during the winter and do not appear to be impacted by any measurable mortality. The cessation of larval diapause and a resumption of development was observed in mid-April and was coincident with a gradual increase in water temperature within the crypts to 9 degrees C, in agreement with a previously calculated developmental thermal minimum of 8.5 degrees C for Cs. melanura. This resulted in a protracted period of pupation that encompassed a minimum of 5 wk, followed by a staggered emergence of adults and an overlap of the residual overwintering population with larvae of the 1st summer generation.

Treatment pearls: Management of physical healthcare needs in patients with mental illness.

ABSTRACT: Clinicians caring for persons with mental illness should be aware of increased mortality, physical problems, and health disparities in this population. This article provides a brief overview of physical health problems in the context of mental illness as well as those related to psychotropic medications, and discusses strategies to manage treatment effectively.

Differentiation of Human Induced Pluripotent Stem Cells into Epicardial-Like Cells.

The epicardium is a multipotent cell layer that is vital to myocardial development and regeneration. Epicardial cells contribute to cardiac fibroblast and smooth muscle populations of the heart and secrete paracrine factors that promote cardiomyocyte proliferation and angiogenesis. Despite a central role in cardiac biology, the mechanisms by which epicardial cells influence cardiac growth are largely unknown, and robust models of the epicardium are needed. Here, we review our protocol for differentiating induced pluripotent stem cells (iPSCs) into epicardial-like cells through temporal modulation of canonical Wnt signaling. iPSC-derived epicardial cells (iECs) resemble in vivo epicardial cells morphologically and display markers characteristic of the developing epicardium. We also review our protocol for differentiating iECs into fibroblasts and smooth muscle cells through treatment with bFGF and TGF-ß1, respectively. iECs provide a platform for studying fundamental epicardial biology and can inform strategies for therapeutic heart regeneration.

Examining the Relationship Between Biometric Indicators and Pharmacy Students' Academic Performance.

Objective. To use a fitness tracking device to track student wellness habits, specifically number of steps, activity, and sleep duration, in an attempt to identify relationships between these variables and academic performance outcomes such as examination scores and course grades. Methods. A fitness tracker was issued to second professional year Doctor of Pharmacy (PharmD) students to track their daily number of steps, activity levels, and minutes of sleep. Individual data from these devices were collected using a cloud-based data aggregation platform. The outcome variables of interest were student grade point average (GPA) in core courses, as well as examination grades for 17 examinations administered across eight required courses during the study period. After exploratory analyses, the primary research questions relating steps and sleep to academic performance were addressed with a series of linear regression models. Results. No significant, identifiable relationships were found between examination grades or course GPA and the variables of interest. There was a significant negative relationship between the number of steps students took 72-hours before an examination and performance on the examination where students in the low activity group significantly outperformed those in the high activity group by an average of two points. Participants took an average of 1,466 fewer steps prior to an examination. Conclusion. Sleep and physical activity were not robust predictors of examination scores and course grades in this cohort of PharmD students. While the fitness tracker served as an impetus for the students to be more cognizant of their activity, the capital expenditure for the devices did not result in improved academic performance.

Characterization of Functional Human Skeletal Myotubes and Neuromuscular Junction Derived-From the Same Induced Pluripotent Stem Cell Source.

In vitro generation of functional neuromuscular junctions (NMJs) utilizing the same induced pluripotent stem cell (iPSC) source for muscle and motoneurons would be of great value for disease modeling and tissue engineering. Although, differentiation and characterization of iPSC-derived motoneurons are well established, and iPSC-derived skeletal muscle (iPSC-SKM) has been reported, there is a general lack of systemic and functional characterization of the iPSC-SKM. This study performed a systematic characterization of iPSC-SKM differentiated using a serum-free, small molecule-directed protocol. Morphologically, the iPSC-SKM demonstrated the expression and appropriate distribution of acetylcholine, ryanodine and dihydropyridine receptors. Fiber type analysis revealed a mixture of human fast (Type IIX, IIA) and slow (Type I) muscle types and the absence of animal Type IIB fibers. Functionally, the iPSC-SKMs contracted synchronously upon electrical stimulation, with the contraction force comparable to myofibers derived from primary myoblasts. Most importantly, when co-cultured with human iPSC-derived motoneurons from the same iPSC source, the myofibers contracted in response to motoneuron stimulation indicating the formation of functional NMJs. By demonstrating comparable structural and functional capacity to primary myoblast-derived myofibers, this defined, iPSC-SKM system, as well as the personal NMJ system, has applications for patient-specific drug testing and investigation of muscle physiology and disease.

Clonal Analysis of the Neonatal Mouse Heart using Nearest Neighbor Modeling.

By replacing lost or dysfunctional myocardium, tissue regeneration is a promising approach to treat heart failure. However, the challenge of detecting bona fide heart regeneration limits the validation of potential regenerative factors. One method to detect new cardiomyocytes is multicolor lineage tracing with clonal analysis. Clonal analysis experiments can be difficult to undertake, because labeling conditions that are too sparse lack sensitivity for rare events such as cardiomyocyte proliferation, and diffuse labeling limits the ability to resolve clones. Presented here is a protocol to undertake clonal analysis of the neonatal mouse heart by using statistical modeling of nearest neighbor distributions to resolve cardiomyocyte clones. This approach enables resolution of clones over a range of labeling conditions and provides a robust analytical approach for quantifying cardiomyocyte proliferation and regeneration. This protocol can be adapted to other tissues and can be broadly used to study tissue regeneration.

Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update.

PURPOSE: To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY: Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION: There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.

Identification of abundant alkyl ether glycerophospholipids in the human lens by tandem mass spectrometry techniques.

Previous studies have shown that the human lens contains glycerophospholipids with ether linkages. These lipids differ from conventional glycerophospholipids in that the sn-1 substituent is attached to the glycerol backbone via an 1-O-alkyl or an 1-O-alk-1'-enyl ether rather than an ester bond. The present investigation employed a combination of collision-induced dissociation (CID) and ozone-induced dissociation (OzID) to unambiguously distinguish such 1-O-alkyl and 1-O-alk-1'-enyl ethers. Using these methodologies the human lens was found to contain several abundant 1-O-alkyl glycerophosphoethanolamines, including GPEtn(16:0e/9Z-18:1), GPEtn(11Z-18:1e/9Z-18:1), and GPEtn(18:0e/9Z-18:1), as well as a related series of unusual 1-O-alkyl glycerophosphoserines, including GPSer(16:0e/9Z-18:1), GPSer(11Z-18:1e/9Z-18:1), GPSer(18:0e/9Z-18:1) that to our knowledge have not previously been observed in human tissue. Isomeric 1-O-alk-1'-enyl ethers were absent or in low abundance. Examination of the double bond position within the phospholipids using OzID revealed that several positional isomers were present, including sites of unsaturation at the n-9, n-7, and even n-5 positions. Tandem CID/OzID experiments revealed a preference for double bonds in the n-7 position of 1-O-ether linked chains, while n-9 double bonds predominated in the ester-linked fatty acids [e.g., GPEtn(11Z-18:1e/9Z-18:1) and GPSer(11Z-18:1e/9Z-18:1)]. Different combinations of these double bond positional isomers within chains at the sn-1 and sn-2 positions point to a remarkable molecular diversity of ether-lipids within the human lens.

The Report of the 2018-2019 Professional Affairs Standing Committee: The Role of Educators in Pharmacy Practice Transformation.

The 2018-2019 Professional Affairs Committee examined the potential roles and needs of clinical educators (faculty and preceptors) in leading transformation in pharmacy practice. The committee was charged to (1) discuss the potential roles and responsibilities of faculty and preceptors leading transformation and enhanced patient care services in pharmacy practice; (2) describe factors, including clinician well-being and resilience, which may influence faculty and preceptor involvement in practice transformation and the enhancement of patient care services; and (3) recommend how the efforts and successes of faculty and preceptors involved in pharmacy practice transformation can be replicated and recognized as well as identify the types of continuing professional development (CPD) that should be available to enable the influence and implementation of patient care services. This report provides a framework for addressing the committee charges by examining the roles of advocacy, collaboration, continuing professional development, and clinician resilience and well-being. The committee provides a revision to a current AACP policy regarding continuing professional development as well as several recommendations to AACP and suggestions to colleges and schools of pharmacy pertaining to the committee charges.

Simulation as a Central Feature of an Elective Course: Does Simulated Bedside Care Impact Learning?

A three-credit, simulation-based, emergency medicine elective course was designed and offered to doctor of pharmacy students for two years. The primary objective was to determine if there was a difference in exam performance stratified by student simulation experience, namely either as an active observer or as part of bedside clinical care. The secondary objective was to report student satisfaction. Examination performance for simulation-based questions was compared based on the student role (evaluator versus clinical) using the Student’s t-test. Summary responses from Likert scale-based student satisfaction responses were collected. A total of 24 students took the course: 12 in each offering. Performance was similar whether the student was assigned to the evaluation team or the clinical team for all of the comparisons (mid-term and final 2015 and 2016, all p-values > 0.05). Students were very satisfied with the course. Of the 19 questions assessing the qualitative aspects of the course, all of the students agreed or strongly agreed to 17 statements, and all of the students were neutral, agreed, or strongly agreed to the remaining two statements. Direct participation and active observation in simulation-based experiences appear to be equally valuable in the learning process, as evidenced by examination performance.

Use of a Video Module to Improve Faculty Understanding of the Pharmacists' Patient Care Process.

OBJECTIVE: To evaluate change in faculty's knowledge and perceptions after an online video module on the Pharmacists' Patient Care Process (PPCP). INNOVATION: An educational video module on the PPCP was developed and disseminated to full-time faculty members at Samford University, McWhorter School of Pharmacy. Voluntary and anonymous pre- and post-test assessments were evaluated and analyzed. CRITICAL ANALYSIS: Thirty faculty completed the pre-assessment, and 31 completed the post-assessment (73% and 75% response rates, respectively). A significant improvement in faculty perceptions was indicated by an increase in agreement with the majority (80%) of questions on attitudes toward the PPCP on the post-test. Faculty's knowledge of the introduction and assessment of PPCP within the school's curriculum was significantly increased after viewing the video module. After viewing the module, more faculty were also able to correctly identify the majority of the PPCP components and their corresponding practice activities. NEXT STEPS: A short video module was effective at improving faculty knowledge and perceptions of the PPCP. Development of a similar faculty development module is feasible for implementation in other Schools of Pharmacy.

Effect of Modafinil on Cognitive Function in Intensive Care Unit Patients: A Retrospective Cohort Study.

Modafinil therapy, a nonamphetamine cognition-enhancing agent, holds the potential to improve recovery from cognitive impairment after intensive care unit (ICU) admission. To date, however, there is a paucity of data on modafinil use in the ICU setting. The purpose of this study was to explore the role of modafinil for improvement in cognition in ICU patients. This retrospective cohort study evaluated a total of 60 ICU patients with any ventilatory support who started on modafinil during their ICU stay from January 1, 2010, to March 19, 2016. The requirements of opioids and sedatives, as well as the lowest and average scores of the Glasgow Coma Scale (GCS) and Riker Sedation-Agitation Scale (SAS), were recorded during 48 hours before and after the start of modafinil therapy in 6-hour periods. The average daily modafinil dose of 170 mg was given for a median duration of 9 days. Modafinil administration was associated with a small, nonsignificant increase in GCS by 0.34 points after controlling for age, baseline severity of illness, and changes in sedation and analgesia over time (95%CI, -0.34 to 0.73 points; P = .0743). No major modafinil-associated adverse effects were observed. Modafinil administration did not significantly improve cognitive function in ICU patients within 48 hours of initiation. However, because of lack of robust evidence, the impact of modafinil on overall patient outcomes in the ICU remains unclear and needs further investigation.