Don't sweat the small stuff: A SWOT analysis for critical care pharmacists, appreciation for the past, present and future of the profession, and a call for reflection.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Improved drug target deconvolution with PISA-DIA using an extended, overlapping temperature gradient.

Thermal proteome profiling (TPP) is a powerful tool for drug target deconvolution. Recently, data-independent acquisition mass spectrometry (DIA-MS) approaches have demonstrated significant improvements to depth and missingness in proteome data, but traditional TPP (a.k.a. CEllular Thermal Shift Assay "CETSA") workflows typically employ multiplexing reagents reliant on data-dependent acquisition (DDA). Herein, we introduce a new experimental design for the Proteome Integral Solubility Alteration via label-free DIA approach (PISA-DIA). We highlight the proteome coverage and sensitivity achieved by using multiple overlapping thermal gradients alongside DIA-MS, which maximizes efficiencies in PISA sample concatenation and safeguards against missing protein targets that exist at high melting temperatures. We demonstrate our extended PISA-DIA design has superior proteome coverage as compared to using tandem-mass tags (TMT) necessitating DDA-MS analysis. Importantly, we demonstrate our PISA-DIA approach has the quantitative and statistical rigor using A-1331852, a specific inhibitor of BCL-xL. Due to the high melt temperature of this protein target, we utilized our extended multiple gradient PISA-DIA workflow to identify BCL-xL. We assert our novel overlapping gradient PISA-DIA-MS approach is ideal for unbiased drug target deconvolution, spanning a large temperature range whilst minimizing target dropout between gradients, increasing the likelihood of resolving the protein targets of novel compounds.

Proteomic biomarkers in seminal plasma as predictors of reproductive potential in azoospermic men.

Introduction: Azoospermia, characterized by an absence of sperm in the ejaculate, represents the most severe form of male infertility. While surgical sperm retrieval in obstructive azoospermia (OA) is successful in the majority of cases, patients with non-obstructive azoospermia (NOA) show retrieval rates of only about 50% and thus frequently have unnecessary surgery. Surgical intervention could be avoided if patients without preserved spermatogenesis are identified preoperatively. This prospective study aimed to discover biomarkers in seminal plasma that could be employed for a non-invasive differential diagnosis of OA/NOA in order to rationalize surgery recommendations and improve success rates. Methods: All patients signed written informed consent, underwent comprehensive andrological evaluation, received human genetics to exclude relevant pathologies, and patients with azoospermia underwent surgical sperm retrieval. Using label-free LC-MS/MS, we compared the proteomes of seminal plasma samples from fertile men (healthy controls (HC), n=8) and infertile men diagnosed with 1) OA (n=7), 2) NOA with successful sperm retrieval (mixed testicular atrophy (MTA), n=8), and 3) NOA without sperm retrieval (Sertoli cell-only phenotype (SCO), n=7). Relative abundance changes of two candidate markers of sperm retrieval, HSPA2 and LDHC, were confirmed by Western Blot. Results: We found the protein expression levels of 42 proteins to be significantly down-regulated (p ≤ 0.05) in seminal plasma from SCO NOA patients relative to HC whereas only one protein was down-regulated in seminal plasma from MTA patients. Analysis of tissue and cell expression suggested that the testis-specific proteins LDHC, PGK2, DPEP3, and germ-cell enriched heat-shock proteins HSPA2 and HSPA4L are promising biomarkers of spermatogenic function. Western blotting revealed a significantly lower abundance of LDHC and HSPA2 in the seminal plasma of men with NOA (SCO and MTA) compared to controls. Discussion: The results indicate that certain testis-specific proteins when measured in seminal plasma, could serve as indicators of the presence of sperm in the testis and predict the success of sperm retrieval. Used in conjunction with conventional clinical assessments, these proteomic biomarkers may assist in the non-invasive diagnosis of idiopathic male infertility.

Teacher's social desirability bias and Migrant students: A study on explicit and implicit prejudices with a list experiment.

Scholarly research has consistently shown that teachers present negative assessments of and attitudes toward migrant students. However, previous studies have not clearly addressed the distinction between implicit and explicit prejudices, or identified their underlying sources. This study identifies the explicit and implicit prejudices held by elementary and middle school teachers regarding the learning abilities of an ethnic minority group: Haitian students within the Chilean educational system. We use a list experiment to assess how social desirability and intergroup attitudes toward minority students influence teachers' prejudices. The findings reveal that teachers harbor implicit prejudices towards Haitian students and are truthful in reporting their attitudes, thereby contradicting the desirability bias hypothesis. We suggest that teachers rely on stereotypes associated with the students' nationality when assessing Haitian students' learning abilities. The implications of these results are discussed in relation to theories grounded in stereotypes and intergroup attitudes.

Segmented RF shield design to minimize eddy currents for low-field Halbach MRI systems.

MRI systems have a thin conducting layer placed between the gradient and RF coils, this acts as a shield at the RF-frequency, minimizing noise coupled into the experiment, and decreasing the coupling between the RF and gradient coils. Ideally, this layer should be transparent to the gradient fields to reduce eddy currents. In this work the design of such a shield, specifically for low-field point-of-care Halbach based MRI devices, is discussed. A segmented double layer shield is designed and constructed based on eddy current simulations. Subsequently, the performance of the improved shield is compared to a reference shield by measuring the eddy current decay times as well as using noise measurements. A maximum reduction factor of 2.9 in the eddy current decay time is observed. The segmented shield couples in an equivalent amount of noise when compared to the unsegmented reference shield. Turbo spin echo images of a phantom and the brain of a healthy volunteer show improvements in terms of blurring using the segmented shield.

Flexible metasurface for improving brain imaging at 7T.

PURPOSE: Ultra-high field MRI offers unprecedented detail for noninvasive visualization of the human brain. However, brain imaging is challenging at 7T due to the B 1 + $$ {}_1^{+} $$ field inhomogeneity, which results in signal intensity drops in temporal lobes and a bright region in the brain center. This study aims to evaluate using a metasurface to improve brain imaging at 7T and simplify the investigative workflow. METHODS: Two flexible metasurfaces comprising a periodic structure of copper strips and parallel-plate capacitive elements printed on an ultra-thin substrate were optimized for brain imaging and implemented via PCB. We considered two setups: (1) two metasurfaces located near the temporal lobes and (2) one metasurface placed near the occipital lobe. The effect of metasurface placement on the transmit efficiency and specific absorption rate was evaluated via electromagnetic simulation studies with voxelized models. In addition, their impact on signal-to-noise ratio (SNR) and diagnostic image quality was assessed in vivo for two male and one female volunteers. RESULTS: Placement of metasurfaces near the regions of interest led to an increase in homogeneity of the transmit field by 5% and 10.5% in the right temporal lobe and occipital lobe for a male subject, respectively. SAR efficiency values changed insignificantly, dropping by less than 8% for all investigated setups. In vivo studies also confirmed the numerically predicted improvement in field distribution and receive sensitivity in the desired ROI. CONCLUSION: Optimized metasurfaces enable homogenizing transmit field distribution in the brain at 7T. The proposed lightweight and flexible structure can potentially provide MR examination with higher diagnostic value images.

Clinical experience with bromocriptine for central hyperthermia after brain insult.

INTRODUCTION: Bromocriptine is a dopamine receptor agonist used for central hyperthermia with limited data. We describe our single-center experience utilizing bromocriptine for central hyperthermia, including the population treated, most common dosing regimens, adverse events, and discontinuation reasons. METHODS: A retrospective study was conducted screening patients who were admitted to intensive care units for acute neurological insults and administered bromocriptine for central hyperthermia between April 2016 and September 2022. Baseline characteristics, disease severity markers, and bromocriptine doses were collected. Body temperatures prior to the first dose of bromocriptine, at the time of dose, and after each dose were recorded. Co-administration of additional hyperthermia management therapies was noted. RESULTS: Thirty patients were included. The most common diagnosis was traumatic brain injury (TBI) (N = 14). The most common reason for discontinuation was resolution of indication (N = 14). Discontinuation due to mild adverse effects occurred in four patients; hepatotoxicity was the most common. There was a paired mean difference of -0.37°C (p = 0.005) between temperatures before and after bromocriptine initiation. CONCLUSION: Bromocriptine is a potential therapy for the management of central hyperthermia in patients with severe acute neurologic insults who have failed other therapies. Bromocriptine was well tolerated and associated with a low incidence of adverse events.

Identification of Serum Biomarkers to Monitor Therapeutic Response in Intestinal-Type Gastric Cancer.

There are a limited number of clinically useful serum biomarkers to predict tumor onset or treatment response in gastric cancer (GC). For this reason, we explored the serum proteome of the gp130Y757F murine model of intestinal-type gastric cancer (IGC). We identified 30 proteins with significantly elevated expression in early gp130Y757F IGC and 12 proteins that were significantly elevated in late gp130Y757F IGC compared to age- and gender-matched wild-type mice. Within these signatures, there was an overlap of 10 proteins commonly elevated in both early- and late-stage disease. These results highlight the potential to identify serum biomarkers of disease stage. Since IGC in the gp130Y757F model can be reversed following therapeutic inhibition of Interleukin (IL)-11, we explored whether the protein signatures we identified could be used to monitor tumor regression. We compared two different therapeutic modalities and found 5 proteins to be uniquely differentially expressed between control animals and animals halfway through treatment, with 10 differentially expressed at the end of treatment. Our findings highlight the potential to identify reliable biomarkers to track IGC tumor regression in response to treatment.

The Drosophila ZNRF1/2 homologue, detour, interacts with HOPS complex and regulates autophagy.

Autophagy, the process of elimination of cellular components by lysosomal degradation, is essential for animal development and homeostasis. Using the autophagy-dependent Drosophila larval midgut degradation model we identified an autophagy regulator, the RING domain ubiquitin ligase CG14435 (detour). Depletion of detour resulted in increased early-stage autophagic vesicles, premature tissue contraction, and overexpression of detour or mammalian homologues, ZNRF1 and ZNRF2, increased autophagic vesicle size. The ablation of ZNRF1 or ZNRF2 in mammalian cells increased basal autophagy. We identified detour interacting proteins including HOPS subunits, deep orange (dor/VPS18), Vacuolar protein sorting 16A (VPS16A), and light (lt/VPS41) and found that detour promotes their ubiquitination. The detour mutant accumulated autophagy-related proteins in young adults, displayed premature ageing, impaired motor function, and activation of innate immunity. Collectively, our findings suggest a role for detour in autophagy, likely through regulation of HOPS complex, with implications for healthy aging.

Twisted pair transmission line coil - a flexible, self-decoupled and robust element for 7 T MRI.

OBJECTIVE: This study evaluates the performance of a twisted pair transmission line coil as a transceive element for 7 T MRI in terms of physical flexibility, robustness to shape deformations, and interelement decoupling. METHODS: Each coil element was created by shaping a twisted pair of wires into a circle. One wire was interrupted at the top, while the other was interrupted at the bottom, and connected to the matching circuit. Electromagnetic simulations were conducted to determine the optimal number of twists per length (in terms of B1+ field efficiency, SAR efficiency, sensitivity to elongation, and interelement decoupling properties) and for investigating the fundamental operational principle of the coil through fields streamline visualisation. A comparison between the twisted pair coil and a conventional loop coil in terms of B1+ fields, maxSAR10g, and stability of S11 when the coil was deformed was performed. Experimentally measured interelement coupling between individual elements of multichannel arrays was also investigated. RESULTS: Increasing the number of twists per length resulted in a more physically robust coil. Poynting vector streamline visualisation showed that the twisted pair coil concentrated most of the energy in the near field. The twisted pair coil exhibited comparable B1+ fields and improved maxSAR10g to the conventional coil but demonstrated exceptional stability with respect to coil deformation and a strong self-decoupling nature when placed in an array configuration. DISCUSSION: The findings highlight the robustness of the twisted pair coil, showcasing its stability under shape variations. This coil holds great potential as a flexible RF coil for various imaging applications using multiple-element arrays, benefiting from its inherent decoupling.

Rethinking False Positive Exercise Electrocardiographic Stress Tests by Assessing Coronary Microvascular Function.

BACKGROUND: Exercise electrocardiographic stress testing (EST) has historically been validated against the demonstration of obstructive coronary artery disease. However, myocardial ischemia can occur because of coronary microvascular dysfunction (CMD) in the absence of obstructive coronary artery disease. OBJECTIVES: The aim of this study was to assess the specificity of EST to detect an ischemic substrate against the reference standard of coronary endothelium-independent and endothelium-dependent microvascular function in patients with angina with nonobstructive coronary arteries (ANOCA). METHODS: Patients with ANOCA underwent invasive coronary physiological assessment using adenosine and acetylcholine. CMD was defined as impaired endothelium-independent and/or endothelium-dependent function. EST was performed using a standard Bruce treadmill protocol, with ischemia defined as the appearance of ≥0.1-mV ST-segment depression 80 ms from the J-point on electrocardiography. The study was powered to detect specificity of ≥91%. RESULTS: A total of 102 patients were enrolled (65% women, mean age 60 ± 8 years). Thirty-two patients developed ischemia (ischemic group) during EST, whereas 70 patients did not (nonischemic group); both groups were phenotypically similar. Ischemia during EST was 100% specific for CMD. Acetylcholine flow reserve was the strongest predictor of ischemia during exercise. Using endothelium-independent and endothelium-dependent microvascular dysfunction as the reference standard, the false positive rate of EST dropped to 0%. CONCLUSIONS: In patients with ANOCA, ischemia on EST was highly specific of an underlying ischemic substrate. These findings challenge the traditional belief that EST has a high false positive rate.

A Review of Parallel Transmit Arrays for Ultra-High Field MR Imaging.

Parallel transmission (pTX) techniques are required to tackle a number of challenges, e.g., the inhomogeneous distribution of the transmit field and elevated specific absorption rate (SAR), in ultra-high field (UHF) MR imaging. Additionally, they offer multiple degrees of freedom to create temporally- and spatially-tailored transverse magnetization. Given the increasing availability of MRI systems at 7 T and above, it is anticipated that interest in pTX applications will grow accordingly. One of the key components in MR systems capable of pTX is the design of the transmit array, as this has a major impact on performance in terms of power requirements, SAR and RF pulse design. While several reviews on pTX pulse design and the clinical applicability of UHF exist, there is currently no systematic review of pTX transmit/transceiver coils and their associated performance. In this article, we analyze transmit array concepts to determine the strengths and weaknesses of different types of design. We systematically review the different types of individual antennas employed for UHF, their combination into pTX arrays, and methods to decouple the individual elements. We also reiterate figures-of-merit (FoMs) frequently employed to describe the performance of pTX arrays and summarize published array designs in terms of these FoMs.

Managing Patients With Unlabeled Passive Implants on MR Systems Operating Below 1.5 T.

The standard of care for managing a patient with an implant is to identify the item and to assess the relative safety of scanning the patient. Because the 1.5 T MR system is the most prevalent scanner in the world and 3 T is the highest field strength in widespread use, implants typically have "MR Conditional" (i.e., an item with demonstrated safety in the MR environment within defined conditions) labeling at 1.5 and/or 3 T only. This presents challenges for a facility that has a scanner operating at a field strength below 1.5 T when encountering a patient with an implant, because scanning the patient is considered "off-label." In this case, the supervising physician is responsible for deciding whether to scan the patient based on the risks associated with the implant and the benefit of magnetic resonance imaging (MRI). For a passive implant, the MRI safety-related concerns are static magnetic field interactions (i.e., force and torque) and radiofrequency (RF) field-induced heating. The worldwide utilization of scanners operating below 1.5 T combined with the increasing incidence of patients with implants that need MRI creates circumstances that include patients potentially being subjected to unsafe imaging conditions or being denied access to MRI because physicians often lack the knowledge to perform an assessment of risk vs. benefit. Thus, physicians must have a complete understanding of the MRI-related safety issues that impact passive implants when managing patients with these products on scanners operating below 1.5 T. This monograph provides an overview of the various clinical MR systems operating below 1.5 T and discusses the MRI-related factors that influence safety for passive implants. Suggestions are provided for the management of patients with passive implants labeled MR Conditional at 1.5 and/or 3 T, referred to scanners operating below 1.5 T. The purpose of this information is to empower supervising physicians with the essential knowledge to perform MRI exams confidently and safely in patients with passive implants. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 3.

ChaMP-CMD: A Phenotype-Blinded, Randomized Controlled, Cross-Over Trial.

BACKGROUND: Angina with nonobstructive coronary arteries is a common condition for which no effective treatment has been established. We hypothesized that the measurement of coronary flow reserve (CFR) allows identification of patients with angina with nonobstructive coronary arteries who would benefit from anti-ischemic therapy. METHODS: Patients with angina with nonobstructive coronary arteries underwent blinded invasive CFR measurement and were randomly assigned to receive 4 weeks of amlodipine or ranolazine. After a 1-week washout, they crossed over to the other drug for 4 weeks; final assessment was after the cessation of study medication for another 4 weeks. The primary outcome was change in treadmill exercise time, and the secondary outcome was change in Seattle Angina Questionnaire summary score in response to anti-ischemic therapy. Analysis was on a per protocol basis according to the following classification: coronary microvascular disease (CMD group) if CFR<2.5 and reference group if CFR≥2.5. The study protocol was registered before the first patient was enrolled (International Standard Randomised Controlled Trial Number: ISRCTN94728379). RESULTS: Eighty-seven patients (61±8 years of age; 62% women) underwent random assignment (57 CMD group and 30 reference group). Baseline exercise time and Seattle Angina Questionnaire summary scores were similar between groups. The CMD group had a greater increment (delta) in exercise time than the reference group in response to both amlodipine (difference in delta, 82 s [95% CI, 37-126 s]; P<0.001) and ranolazine (difference in delta, 68 s [95% CI, 21-115 s]; P=0.005). The CMD group reported a greater increment (delta) in Seattle Angina Questionnaire summary score than the reference group in response to ranolazine (difference in delta, 7 points [95% CI, 0-15]; P=0.048), but not to amlodipine (difference in delta, 2 points [95% CI, -5 to 8]; P=0.549). CONCLUSIONS: Among phenotypically similar patients with angina with nonobstructive coronary arteries, only those with an impaired CFR derive benefit from anti-ischemic therapy. These findings support measurement of CFR to diagnose and guide management of this otherwise heterogeneous patient group.

Characterizing Mechanisms of Ischemia in Patients With Myocardial Bridges.

BACKGROUND: Myocardial bridges (MBs) are prevalent and can be associated with acute and chronic ischemic syndromes. We sought to determine the substrates for ischemia in patients with angina with nonobstructive coronary arteries and a MB in the left anterior descending artery. METHODS: Patients with angina with nonobstructive coronary arteries underwent the acquisition of intracoronary pressure and flow during rest, supine bicycle exercise, and adenosine infusion. Coronary wave intensity analysis was performed, with perfusion efficiency defined as accelerating wave energy/total wave energy (%). Epicardial endothelial dysfunction was defined as a reduction in epicardial vessel diameter ≥20% in response to intracoronary acetylcholine infusion. Patients with angina with nonobstructive coronary arteries and a MB were compared with 2 angina with nonobstructive coronary arteries groups with no MB: 1 with coronary microvascular disease (CMD: coronary flow reserve, <2.5) and 1 with normal coronary flow reserve (reference: coronary flow reserve, ≥2.5). RESULTS: Ninety-two patients were enrolled in the study (30 MB, 33 CMD, and 29 reference). Fractional flow reserve in these 3 groups was 0.86±0.05, 0.92±0.04, and 0.94±0.05; coronary flow reserve was 2.5±0.5, 2.0±0.3, and 3.2±0.6. Perfusion efficiency increased numerically during exercise in the reference group (65±9%-69±13%; P=0.063) but decreased in the CMD (68±10%-50±10%; P<0.001) and MB (66±9%-55±9%; P<0.001) groups. The reduction in perfusion efficiency had distinct causes: in CMD, this was driven by microcirculation-derived energy in early diastole, whereas in MB, this was driven by diminished accelerating wave energy, due to the upstream bridge, in early systole. Epicardial endothelial dysfunction was more common in the MB group (54% versus 29% reference and 38% CMD). Overall, 93% of patients with a MB had an identifiable ischemic substrate. CONCLUSIONS: MBs led to impaired coronary perfusion efficiency during exercise, which was due to diminished accelerating wave energy in early systole compared with the reference group. Additionally, there was a high prevalence of endothelial and microvascular dysfunction. These ischemic mechanisms may represent distinct treatment targets.

The use of electronic health record embedded MRC-ICU as a metric for critical care pharmacist workload.

Objectives: A lack of pharmacist-specific risk-stratification scores in the electronic health record (EHR) may limit resource optimization. The medication regimen complexity-intensive care unit (MRC-ICU) score was implemented into our center's EHR for use by clinical pharmacists. The purpose of this evaluation was to evaluate MRC-ICU as a predictor of pharmacist workload and to assess its potential as an additional dimension to traditional workload measures. Materials and methods: Data were abstracted from the EHR on adult ICU patients, including MRC-ICU scores and 2 traditional measures of pharmacist workload: numbers of medication orders verified and interventions logged. This was a single-center study of an EHR-integrated MRC-ICU tool. The primary outcome was the association of MRC-ICU with institutional metrics of pharmacist workload. Associations were assessed using the initial 24-h maximum MRC-ICU score's Pearson's correlation with overall admission workload and the day-to-day association using generalized linear mixed-effects modeling. Results: A total of 1205 patients over 5083 patient-days were evaluated. Baseline MRC-ICU was correlated with both cumulative order volume (Spearman's rho 0.41, P < .001) and cumulative interventions placed (Spearman's rho 0.27, P < .001). A 1-point increase in maximum daily MRC-ICU was associated with a 31% increase in order volume (95% CI, 24%-38%) and 4% increase in interventions (95% CI, 2%-5%). Discussion and conclusion: The MRC-ICU is a validated score that has been previously correlated with important patient-centered outcomes. Here, MRC-ICU was modestly associated with 2 traditional objective measures of pharmacist workload, including orders verified and interventions placed, which is an important step for its use as a tool for resource utilization needs.

Developmental transcriptomes predict adult social behaviours in the socially flexible sweat bee, Lasioglossum baleicum.

Natural variation can provide important insights into the genetic and environmental factors that shape social behaviour and its evolution. The sweat bee, Lasioglossum baleicum, is a socially flexible bee capable of producing both solitary and eusocial nests. We demonstrate that within a single nesting aggregation, soil temperatures are a strong predictor of the social structure of nests. Sites with warmer temperatures in the spring have a higher frequency of social nests than cooler sites, perhaps because warmer temperatures provide a longer reproductive window for those nests. To identify the molecular correlates of this behavioural variation, we generated a de novo genome assembly for L. baleicum, and we used transcriptomic profiling to compare adults and developing offspring from eusocial and solitary nests. We find that adult, reproductive females have similar expression profiles regardless of social structure in the nest, but that there are strong differences between reproductive females and workers from social nests. We also find substantial differences in the transcriptomic profiles of stage-matched pupae from warmer, social-biased sites compared to cooler, solitary-biased sites. These transcriptional differences are strongly predictive of adult reproductive state, suggesting that the developmental environment may set the stage for adult behaviours in L. baleicum. Together, our results help to characterize the molecular mechanisms shaping variation in social behaviour and highlight a potential role of environmental tuning during development as a factor shaping adult behaviour and physiology in this socially flexible bee.