Chemical screening by time-resolved X-ray scattering to discover allosteric probes.

Drug discovery relies on efficient identification of small-molecule leads and their interactions with macromolecular targets. However, understanding how chemotypes impact mechanistically important conformational states often remains secondary among high-throughput discovery methods. Here, we present a conformational discovery pipeline integrating time-resolved, high-throughput small-angle X-ray scattering (TR-HT-SAXS) and classic fragment screening applied to allosteric states of the mitochondrial import oxidoreductase apoptosis-inducing factor (AIF). By monitoring oxidized and X-ray-reduced AIF states, TR-HT-SAXS leverages structure and kinetics to generate a multidimensional screening dataset that identifies fragment chemotypes allosterically stimulating AIF dimerization. Fragment-induced dimerization rates, quantified with time-resolved SAXS similarity analysis (kVR), capture structure-activity relationships (SAR) across the top-ranked 4-aminoquinoline chemotype. Crystallized AIF-aminoquinoline complexes validate TR-SAXS-guided SAR, supporting this conformational chemotype for optimization. AIF-aminoquinoline structures and mutational analysis reveal active site F482 as an underappreciated allosteric stabilizer of AIF dimerization. This conformational discovery pipeline illustrates TR-HT-SAXS as an effective technology for targeting chemical leads to important macromolecular states.

Antimicrobial prescribing in a secondary care setting during the COVID-19 pandemic.

Background: Increased antimicrobial resistance patterns lead to limited options for antimicrobial agents, affecting patient health and increasing hospital costs. Objectives: To investigate the antimicrobial prescribing patterns at two district hospitals in Northern Ireland before and during the COVID-19 pandemic. Methods: A mixed prospective-retrospective study was designed to compare pre- and during pandemic antimicrobial prescribing data in both hospitals using a Global Point Prevalence Survey. Results: Of the 591 patients surveyed in both hospitals, 43.8% were treated with 402 antimicrobials. A total of 82.8% of antimicrobial prescriptions were for empirical treatment. No significant difference existed in numbers of patients treated or antimicrobials used before and during the pandemic. There was a slight decrease of 3.3% in the compliance rate with hospital antimicrobial guidelines during the pandemic when compared with the pre-pandemic year of 2019, when it was 69.5%. Treatment based on patients' biomarker data also slightly decreased from 83.5% pre-pandemic (2019) to 81.5% during the pandemic (2021). Conclusions: There was no overall significant impact of the pandemic on the antimicrobial prescribing patterns in either hospital when compared with the pre-pandemic findings. The antimicrobial stewardship programmes would appear to have played an important role in controlling antimicrobial consumption during the pandemic.

The impact of Longitudinal Integrated Foundation Training: preliminary experiences in the United Kingdom.

BACKGROUND: The United Kingdom health system is challenged with retaining doctors entering specialty training directly after their second foundation year. Improving doctors' training experience during the foundation programme may aid such retention. The Longitudinal Integrated Foundation Training (LIFT) pilot scheme aimed to provide a programme that improves the quality of their foundation training experience, advance patient-centred care and provide doctors with more experience in the primary care settings. METHODS: During this pilot study, three methods were employed to evaluate and compare doctors' experiences across their 2-year foundation training programme: Horus ePortfolio assessment of six domains for good medical practice analysed using a T-test, online survey assessments analysed using a 2-tailed chi-square test, and focus group feedback sessions with thematic analysis. RESULTS: Doctors completing LIFT (n = 47) scored a higher but non-significant mean score on all six domains for good medical practice versus doctors completing traditional foundation training (n = 94). By the end of foundation training, 100% of LIFT doctors rated their understanding of how primary and secondary care work together as high versus 78.7% of traditional doctors (p < 0.05). Improvements in wellbeing were observed among LIFT doctors, along with a reduction in the proportion of doctors considering leaving medical training. A significantly greater number of LIFT doctors versus traditional doctors rated their compassion for patients as high (100% versus 86.8%; p < 0.05), intended to become general practitioners (23.1% versus 13.5%; p < 0.05) and rated the extent to which they felt well informed and able to consider a general practice career rather than a hospital career as high (91.7% versus 72.3%, respectively; p < 0.05). Some LIFT doctors felt they had reduced exposure to secondary care, received less on-call experience and considered working a half-day to be problematic; challenges ameliorated by the end of the 2-year foundation programme. CONCLUSION: The LIFT programme enhanced the quality of foundation training and improved doctors' experiences and competencies, generating valuable insights for the future of education and healthcare delivery. Applying the principles of LIFT to foundation training helps doctors to be more compassionate and patient-centred, leading to enhanced individualised patient care.

Applying HT-SAXS to chemical ligand screening.

Chemical probes are invaluable tools for investigating essential biological processes. Understanding how small-molecule probes engage biomolecular conformations is critical to developing their functional selectivity. High-throughput solution X-ray scattering is well-positioned to profile target-ligand complexes during probe development, bringing conformational insight and selection to traditional ligand binding assays. Access to high-quality synchrotron SAXS datasets and high-throughput data analysis now allows routine academic users to incorporate conformational information into small-molecule development pipelines. Here we describe a general approach for benchmarking and preparing HT-SAXS chemical screens from small fragment libraries. Using the allosteric oxidoreductase Apoptosis-Inducing Factor (AIF) as an exemplary system, we illustrate how HT-SAXS efficiently identifies an allosteric candidate among hits of a microscale thermophoresis ligand screen. We discuss considerations for pursuing HT-SAXS chemical screening with other systems of interest and reflect on advances to extend screening throughput and sensitivity.

Ensuring the quality and quantity of personal protective equipment (PPE) by enhancing the procurement process in Northern Ireland during the coronavirus disease 2019 pandemic: Challenges in the procurement process for PPE in NI.

This article outlines the purchasing process for personal protective equipment that was established for Health and Social Care in Northern Ireland in response to the outbreak of coronavirus disease 2019. The Business Services Organisation Procurement and Logistics Service, who are the sole provider of goods and services for Health and Social Care organisations, was faced with an unprecedented demand for personal protective equipment in response to the coronavirus disease 2019 pandemic. The usual procurement process was further complicated by changing messages within guidelines which resulted in confusion and anxiety when determining whether or not a product would meet the required safety guidance and was therefore suitable for purchase. In order to address these issues in a rapidly changing and escalating scenario the Department of Health asked the Business Services Organisation Procurement and Logistics Service to work with the Medicines Optimisation Innovation Centre to maximise the availability of personal protective equipment whilst ensuring that it met all requisite quality and standards. A process was implemented whereby the Medicines Optimisation Innovation Centre validated all pertinent essential documentation relating to products to ensure that all applicable standards were met, with the Business Services Organisation Procurement and Logistics Service completing all procurement due diligence tasks in line with both normal and coronavirus disease 2019 emergency derogations. It is evident from the data presented that whilst there were a significant number of potential options for supply, a large proportion of these were rejected due to failure to meet the quality assurance criteria. Thus, by the process that was put in place, a large number of unsuitable products were not purchased and only those that met extant standards were approved.

Universally Accessible Structural Data on Macromolecular Conformation, Assembly, and Dynamics by Small Angle X-Ray Scattering for DNA Repair Insights.

Structures provide a critical breakthrough step for biological analyses, and small angle X-ray scattering (SAXS) is a powerful structural technique to study dynamic DNA repair proteins. As toxic and mutagenic repair intermediates need to be prevented from inadvertently harming the cell, DNA repair proteins often chaperone these intermediates through dynamic conformations, coordinated assemblies, and allosteric regulation. By measuring structural conformations in solution for both proteins, DNA, RNA, and their complexes, SAXS provides insight into initial DNA damage recognition, mechanisms for validation of their substrate, and pathway regulation. Here, we describe exemplary SAXS analyses of a DNA damage response protein spanning from what can be derived directly from the data to obtaining super resolution through the use of SAXS selection of atomic models. We outline strategies and tactics for practical SAXS data collection and analysis. Making these structural experiments in reach of any basic and clinical researchers who have protein, SAXS data can readily be collected at government-funded synchrotrons, typically at no cost for academic researchers. In addition to discussing how SAXS complements and enhances cryo-electron microscopy, X-ray crystallography, NMR, and computational modeling, we furthermore discuss taking advantage of recent advances in protein structure prediction in combination with SAXS analysis.

Analysis of activities undertaken by ward-based clinical pharmacy technicians during patient hospital journey.

INTRODUCTION: Previous studies recognise insufficient time as an obstacle to pharmacists expanding their clinical-based activities and services. For such a reason, the role of well-trained ward-based clinical pharmacy technicians (CPTs) is to work as an integral part of the pharmacy team to achieve the best patient outcomes and medicines optimisation, releasing pharmacist time to complete more complex clinical-related activities. OBJECTIVE: To demonstrate quantitatively the range and extent of daily activities undertaken by CPTs during a patient's hospital journey. METHOD: A prospective-based study has been designed. All daily working services and activities undertaken by ward-based CPTs within a 450-bed Acute District General hospital were quantitatively collected and documented. Data were collected from five medical, two surgical and one cardiology wards of 30 beds in each over a period of 2 weeks for each ward representing a total of 70 working days (14 weeks, excluding weekends). RESULTS: Results showed the breakdown of seven different ward-based activities throughout a typical working day with the main working load being reviews of the patients' medication charts in order to supply new medicines and refer medicines-related issues to the ward pharmacist, with an average number reviewed of (23.17±0.85) representing 77.23% of the total patients in a 30-bed ward. The CPTs' highest workload was on Mondays and Fridays, mainly during the morning working hours (09:00-12:00). Also, statistically significant differences (p<0.05; Kruskal-Wallis test) existed between the workload of the three different ward specialties (medical, surgical and cardiology) in five clinical activities out of seven undertaken by CPT per day. CONCLUSION: CPTs are completing more than seven different ward pharmacy-related activities which enhance medicines optimisation, medicines management and patient care. They are a valuable resource carrying out many roles which were previously completed by junior pharmacists. Their prioritising of patients for review ensures pharmacists focus their efforts on the most vulnerable patients.

An ultrasound responsive microbubble-liposome conjugate for targeted irinotecan-oxaliplatin treatment of pancreatic cancer.

Survival rates in pancreatic cancer have remained largely unchanged over the past four decades with less than 5% of patients surviving five years following initial diagnosis. FOLFIRINOX chemotherapy, a combination of folinic acid, 5-fluoruracil, irinotecan and oxaliplatin, has shown the greatest survival benefit for patients with advanced disease but is only indicated for those with good physical performance status due to its extreme off-target toxicity. Ultrasound targeted microbubble destruction (UTMD) has emerged as an effective strategy for the targeted delivery of drug payloads to solid tumours and involves using low intensity ultrasound to disrupt (burst) MBs in the tumour vasculature, releasing encapsulated or attached drugs in a targeted manner. In this manuscript, we describe the preparation of a microbubble-liposome complex (IRMB-OxLipo) carrying two of the three cytotoxic drugs present in the FOLFIRINOX combination, namely irinotecan and oxaliplatin. Efficacy of the IRMB-OxLipo complex following UTMD was determined in Panc-01 3D spheroid and BxPC-3 human xenograft murine models of pancreatic cancer. The results revealed that tumours treated with the IRMB-OxLipo complex and ultrasound were 136% smaller than tumours treated with the same concentration of irinotecan/oxaliplatin but delivered in a conventional manner, i.e. as a non-complexed mixture. This suggests that UTMD facilitates a more effective delivery of irinotecan/oxaliplatin improving the overall effectiveness of this drug combination and to the best of our knowledge, is the first reported example of a microbubble-liposome complex used to deliver these two chemotherapies.

An analysis of the clinical appropriateness of out-of-hours emergency dental prescribing of antibiotics in Northern Ireland.

Introduction The inappropriate prescribing of antibiotics in dentistry is potentially linked to the development of antimicrobial resistance, as well as being a considerable cost to healthcare. This study analysed the clinical appropriateness of antibiotics prescribed from 'walk-in' and telephone triage out-of-hours emergency dental clinics in Northern Ireland.Methods Patient and prescribing data were collected from two out-of-hour emergency dental clinics over a two-month period between September and December 2017. In total, 434 prescriptions were analysed. Clinical appropriateness was determined on a case-by-case basis for each prescription by referencing dental prescribing guidelines.Results Over half of the prescriptions analysed (52.77%) were judged as clinically inappropriate. A total of 19.12% of prescriptions were judged as inappropriate, as the antibiotic prescribed was not indicated for the diagnosis recorded by the clinician. Local measures were not attempted in 36.6% of cases. A significant difference (p = 0.002) was observed between the clinical appropriateness of prescriptions issued via walk-in and triage appointments with triage appointments issuing more clinically appropriate prescriptions.Conclusions A significant number of prescriptions provided in out-of-hours emergency dental clinics in Northern Ireland were judged to be inappropriate according to current dental prescribing guidelines.

WORKFORCE: The career aspirations and expectations of -student -physician associates in the UK.

The NHS five year forward view 1 supports the development of a flexible workforce. Expanding the traditional medical workforce using physician associates (PAs) is increasing in popularity. This study explores the career aspirations and expectations of student PAs from a large PA school in England. Thematic analysis of qualitative data from an online survey examined the personal motivations and career aspirations of student PAs. Finally, we make nine recommendations to enhancing recruitment, retention and development of PAs post qualification. Lessons learnt from this data set are generalisable.

Association between attendance and overall academic performance on a module within a professional pharmacy degree.

BACKGROUND AND PURPOSE: As the higher education (HE) classroom begins to adopt newer internet-based technologies, the relationship between attendance and performance needs to be re-evaluated, particularly for professional degree courses such as pharmacy. In the present study, we aimed to establish if an association exists between attendance at all timetabled classes and academic performance, in a Clinical Pharmacology and Therapeutics (CPT) module, as part of the Master of Pharmacy (MPharm) degree course at Ulster University. EDUCATIONAL ACTIVITY AND SETTING: Data on attendance, final examination and coursework performance were collected over two academic years (2013-14 and 2014-15) of the CPT module at Ulster. In total 67 students were analysed. The MPharm degree at Ulster University implements an attendance policy, both as a pastoral support tool and to reinforce the need for professional conduct as a pharmacist. FINDINGS: Student (2013-14 and 2014-15, n = 35 and 32, respectively) attendance on the module across both year groups was approximately 80%. We observed positive, and statistically significant relationships between attendance and performance on the examination, and especially in the coursework elements of the module. Student failure (below 40%) in the final examination was linked to attendance below an 80% threshold in nine of 12 cases. Reasons for not attending class varied, but illness was unquestionably the most commonly cited extenuation. DISCUSSION: Taken together, these data confirm a convincing association between student attendance and academic achievement. SUMMARY: Our studies promote the use of attendance monitoring policies for professional degree courses such as pharmacy.

A descriptive systematic review of salivary therapeutic drug monitoring in neonates and infants.

AIMS: Saliva, as a matrix, offers many benefits over blood in therapeutic drug monitoring (TDM), in particular for infantile TDM. However, the accuracy of salivary TDM in infants remains an area of debate. This review explored the accuracy, applicability and advantages of using saliva TDM in infants and neonates. METHODS: Databases were searched up to and including September 2016. Studies were included based on PICO as follows: P: infants and neonates being treated with any medication, I: salivary TDM vs. C: traditional methods and O: accuracy, advantages/disadvantages and applicability to practice. Compounds were assessed by their physicochemical and pharmacokinetic properties, as well as published quantitative saliva monitoring data. RESULTS: Twenty-four studies and their respective 13 compounds were investigated. Four neutral and two acidic compounds, oxcarbazepine, primidone, fluconazole, busulfan, theophylline and phenytoin displayed excellent/very good correlation between blood plasma and saliva. Lamotrigine was the only basic compound to show excellent correlation with morphine exhibiting no correlation between saliva and blood plasma. Any compound with an acid dissociation constant (pKa) within physiological range (pH 6-8) gave a more varied response. CONCLUSION: There is significant potential for infantile saliva testing and in particular for neutral and weakly acidic compounds. Of the properties investigated, pKa was the most influential with both logP and protein binding having little effect on this correlation. To conclude, any compound with a pKa within physiological range (pH 6-8) should be considered with extra care, with the extraction and analysis method examined and optimized on a case-by-case basis.

Small angle X-ray scattering and cross-linking for data assisted protein structure prediction in CASP 12 with prospects for improved accuracy.

Experimental data offers empowering constraints for structure prediction. These constraints can be used to filter equivalently scored models or more powerfully within optimization functions toward prediction. In CASP12, Small Angle X-ray Scattering (SAXS) and Cross-Linking Mass Spectrometry (CLMS) data, measured on an exemplary set of novel fold targets, were provided to the CASP community of protein structure predictors. As solution-based techniques, SAXS and CLMS can efficiently measure states of the full-length sequence in its native solution conformation and assembly. However, this experimental data did not substantially improve prediction accuracy judged by fits to crystallographic models. One issue, beyond intrinsic limitations of the algorithms, was a disconnect between crystal structures and solution-based measurements. Our analyses show that many targets had substantial percentages of disordered regions (up to 40%) or were multimeric or both. Thus, solution measurements of flexibility and assembly support variations that may confound prediction algorithms trained on crystallographic data and expecting globular fully-folded monomeric proteins. Here, we consider the CLMS and SAXS data collected, the information in these solution measurements, and the challenges in incorporating them into computational prediction. As improvement opportunities were only partly realized in CASP12, we provide guidance on how data from the full-length biological unit and the solution state can better aid prediction of the folded monomer or subunit. We furthermore describe strategic integrations of solution measurements with computational prediction programs with the aim of substantially improving foundational knowledge and the accuracy of computational algorithms for biologically-relevant structure predictions for proteins in solution.

Defining NADH-Driven Allostery Regulating Apoptosis-Inducing Factor.

Apoptosis-inducing factor (AIF) is critical for mitochondrial respiratory complex biogenesis and for mediating necroptotic parthanatos; these functions are seemingly regulated by enigmatic allosteric switching driven by NADH charge-transfer complex (CTC) formation. Here, we define molecular pathways linking AIF's active site to allosteric switching regions by characterizing dimer-permissive mutants using small-angle X-ray scattering (SAXS) and crystallography and by probing AIF-CTC communication networks using molecular dynamics simulations. Collective results identify two pathways propagating allostery from the CTC active site: (1) active-site H454 links to S480 of AIF's central ß-strand to modulate a hydrophobic border at the dimerization interface, and (2) an interaction network links AIF's FAD cofactor, central ß-strand, and Cß-clasp whereby R529 reorientation initiates C-loop release during CTC formation. This knowledge of AIF allostery and its flavoswitch mechanism provides a foundation for biologically understanding and biomedically controlling its participation in mitochondrial homeostasis and cell death.

Working smarter on cold cases: identifying factors associated with successful cold case investigations.

Cold case squads have garnered much attention; however, they have yet to undergo significant empirical scrutiny. In the present study, the authors interviewed investigators and reviewed 189 solved and unsolved cold cases in Washington, D.C., to determine whether there are factors that can predict cold case solvability. In the interviews, new information from witnesses or information from new witnesses was cited as the most prevalent reason for case clearance. The case reviews determined that there were factors in each of the following domains that predicted whether cases would be solved during cold case investigations: Crime Context, Initial Investigation Results, Basis for Opening Cold Case, and Cold Case Investigator Actions. The results suggest that it is possible to prioritize cold case work based on the likelihood of investigations leading to clearances.

Effects of an integrated medicines management program on medication appropriateness in hospitalized patients.

PURPOSE: The effects of an integrated medicines management (IMM) program on medication appropriateness are discussed. METHODS: Patients enrolled in an IMM project within a hospital were randomly allocated to either a control or an intervention group. Patients in the control group received standard pharmaceutical care, while the intervention patients received the IMM service. The appropriateness of the medications prescribed was estimated on admission and discharge using the Medicines Appropriateness Index (MAI), which ranged from 0 (no prescribing problems) to 18 (most prescribing problems). For each medication scored, the difference between admission and discharge MAI scores for individual patients was calculated. RESULTS: Scoring was completed on 1711 medications prescribed for 117 patients. There was a statistically significant difference (p = 0.03) in the mean MAI scores on discharge between the intervention and control groups (5.69 versus 9.97, respectively). There was also a statistically significant difference (p = 0.00003) in the mean MAI scores on admission and discharge (17.48 versus 5.69, respectively) for the intervention group. The intervention group had a mean +/- S.D. difference of -11.78 +/- 14.64, while the control group had a mean +/- S.D. difference of -3.19 +/- 11.80. The difference was statistically significant (p = 0.0011) between the two groups. CONCLUSION: This study demonstrated significant improvements in the appropriateness of medications on discharge for patients receiving an IMM service compared with patients who did not receive this service.

The identification of barriers preventing the successful implementation of a surgical prophylaxis protocol.

AIM: The aim of this study was to introduce a protocol for the use of antimicrobials in surgical prophylaxis for the described procedures in Antrim Area Hospital. METHOD: Historical data of antimicrobial use were obtained from retrospective analysis of patients' charts, for those patients identified as having one of the following 'clean/contaminated' surgical procedures over the previous six months; cholecystectomy or abdominal hysterectomy. These data were analysed, and a protocol was introduced providing guidelines for the choice of antimicrobial agent, its administration time, route, dose, duration and frequency of treatment. MAIN OUTCOME MEASURE: The main outcome measure was the success of the uptake of the protocol following its implementation. RESULTS: There was a total of 285 patients identified, 105 prior to and 180 post implementation. Overall, 68% of patients received some form of prophylaxis in the first cycle, and 72% in the second. CONCLUSION: Although the introduction of the protocol led to slight improvements in compliance with standard prescribing procedures, with an increase in single-dose prophylaxis, and a reduction in prolonged prophylactic treatment, the improvements did not reach expectations. This paper attempts to identify the possible barriers to protocol implementation.