Blood product wastage reduction by utilising low-cost, low-impact multimodal physician-to-physician communication initiatives.

OBJECTIVES: To assess a multimodal physician-to-physician communication initiative that is low in cost and impact to daily workflow to reduce blood product wastage. BACKGROUND: Blood product stewardship is an important issue in all hospital systems. Previous studies have proposed low-cost interventions to reduce blood product wastage, but few have evaluated improvements in communication between the blood bank and providers. We undertook a prospective quality improvement project focusing on improving communication to reduce blood product wastage. METHODS: We conducted a prospective quality improvement project over the first quarter of 2017, identifying patients with issued but unused blood products. Each service overseeing the care of patients identified on the unit status report was contacted through two possible methods: (i) phone or (ii) proprietary Health Insurance Portability and Accountability Act of 1996 compliant digital messaging application. Collected variables included reserved blood product type and participant time spent. Outcomes included the rate of blood product release and changes in wastage compared with historical data tracked by the blood bank. RESULTS: Eight hundred and forty products were reserved during the study period, of which 436 (52%) were released. Average participant times ranged from 2 ± 1 min to 15 ± 4 min with no significant differences in time spent between participants (P = 0·194). Compared with the average product wastage 10 months prior to project initiation, there were significant reductions in the average wastage for platelets (5·3 ± 2·5 units vs 2·5 ± 1·5 units, P = 0·05), RBCs (6·1 ± 3·7 units vs 0 ± 0 units, P = 0·01) and overall wastage (58·3 ± 14·9 units vs 40 ± 15·7 units, P = 0·05). CONCLUSION: Efforts focusing on improving provider-to-provider communication can reduce blood product wastage.

Differential effects of leptin on adiponectin expression with weight gain versus obesity.

BACKGROUND/OBJECTIVE: Adiponectin exerts beneficial effects by reducing inflammation and improving lipid metabolism and insulin sensitivity. Although the adiponectin level is lower in obese individuals, whether weight gain reduces adiponectin expression in humans is controversial. We sought to investigate the role of weight gain, and consequent changes in leptin, on altering adiponectin expression in humans. METHODS/RESULTS: Forty-four normal-weight healthy subjects were recruited (mean age 29 years; 14 women) and randomized to either gain 5% of body weight by 8 weeks of overfeeding (n=34) or maintain weight (n=10). Modest weight gain of 3.8±1.2 kg resulted in increased adiponectin level (P=0.03), whereas weight maintenance resulted in no changes in adiponectin. Further, changes in adiponectin correlated positively with changes in leptin (P=0.0085). In-vitro experiments using differentiated human white preadipocytes showed that leptin increased adiponectin mRNA and protein expression, whereas a leptin antagonist had opposite effects. To understand the role of leptin in established obesity, we compared adipose tissue samples obtained from normal-weight versus obese subjects. We noted, first, that leptin activated cellular signaling pathways and increased adiponectin mRNA in the adipose tissue from normal-weight participants, but did not do so in the adipose tissue from obese participants. Second, we noted that obese subjects had increased caveolin-1 expression, which attenuates leptin-dependent increases in adiponectin. CONCLUSIONS: Modest weight gain in healthy individuals is associated with increases in adiponectin levels, which correlate positively with changes in leptin. In vitro, leptin induces adiponectin expression, which is attenuated by increased caveolin-1 expression. In addition, the adipose tissue from obese subjects shows increased caveolin-1 expression and impaired leptin signaling. This leptin signal impairment may prevent concordant increases in adiponectin levels in obese subjects despite their high levels of leptin. Therefore, impaired leptin signaling may contribute to low adiponectin expression in obesity and may provide a target for increasing adiponectin expression, hence improving insulin sensitivity and cardio-metabolic profile in obesity.

Molecular Detection of the Laurel Wilt Fungus, Raffaelea lauricola.

The laurel wilt disease fungus, Raffaelea lauricola, is killing redbay trees, spreading rapidly in the U.S. southeastern coastal plain forest, and posing a serious threat to the avocado industry in Florida. A molecular tool is urgently required to facilitate detection of this pathogen. The 5' region of the large ribosomal RNA (28S) gene is highly variable among Raffaelea spp. and ideal for this purpose but amplification of this sequence from R. lauricola has been difficult. Different amplification conditions were tested and a high-fidelity polymerase chain reaction (PCR) procedure utilizing a dNTP mix containing 7-deaza-dGTP was found to reliably amplify 28S sequences from R. lauricola. Sequencing the amplified products or cloned inserts also turned out to be difficult and required using a custom-blended sequencing mix containing 1 M betaine, 5% dimethyl sulfoxide, and dGTP-BigDye v3.1. Three GC-rich stem and loop or cruciform secondary structures were discovered, which may have interfered with amplification. This improved protocol made it possible to partially characterize the internal transcribed spacers sequence from R. lauricola, which also has interfering secondary structures. A TaqMan real-time PCR assay was designed using the species-specific 28S sequences and this allowed detection of R. lauricola from wood tissues or cultures. Wood tissues from symptomatic redbay, avocado, and sassafras trees in Florida were screened using this TaqMan assay and several were found to test positive for R. lauricola. Results were further confirmed by performing Koch's postulates for avocado specimens collected from commercial grooves.

An approximate likelihood for genetic data under a model with recombination and population splitting.

We describe a new approximate likelihood for population genetic data under a model in which a single ancestral population has split into two daughter populations. The approximate likelihood is based on the 'Product of Approximate Conditionals' likelihood and 'copying model' of Li and Stephens [Li, N., Stephens, M., 2003. Modeling linkage disequilibrium and identifying recombination hotspots using single-nucleotide polymorphism data. Genetics 165 (4), 2213-2233]. The approach developed here may be used for efficient approximate likelihood-based analyses of unlinked data. However our copying model also considers the effects of recombination. Hence, a more important application is to loosely-linked haplotype data, for which efficient statistical models explicitly featuring non-equilibrium population structure have so far been unavailable. Thus, in addition to the information in allele frequency differences about the timing of the population split, the method can also extract information from the lengths of haplotypes shared between the populations. There are a number of challenges posed by extracting such information, which makes parameter estimation difficult. We discuss how the approach could be extended to identify haplotypes introduced by migrants.

Gladiolus Rust Caused by Uromyces transversalis Makes First Nearctic Appearance in Florida.

The most serious rust pathogen of gladiolus (Gladiolus × hortulanus), Uromyces transversalis, has been listed as an exotic pathogen of concern for the United States for more than 80 years (4). Native to South Africa, the pathogen was reported in the Western Hemisphere for the first time in Brazil (2) and Argentina (1). Reports of gladiolus rust in several central Mexican states from 2004 to 2005 (3; http://www.pestalert.org/espanol/oprDetail.cfm?oprID=138 ) and interceptions at Mexican border stations and in Brazilian imports in 2005 at the port of Miami, FL collectively raised the alert level in the United States to high. In April 2006, the Hawaii Department of Agriculture notified the USDA of rust-infected gladiolus in a cut-flower shipment that was traced back to a 1,400-acre (565 ha) farm in Manatee County, FL. Inspection at the farm yielded samples that were quickly confirmed as U. transversalis by FDACS-DPI and USDA plant pathologists. The disease was identified in eight residential gardens near the commercial find and in another 700-acre (285 ha) farm in remote Hendry County, 100 miles to the southeast. In May 2006, gladiolus rust was detected in residential and commercial gladiolus in San Diego County, CA (see companion publication). On the advice of a USDA-assembled panel of experts, strict rust management guidelines and fallow host-free periods were implemented with the ultimate goal of eradication. Subsequent summer, fall, and now winter surveys in the infested commercial and residential areas have uncovered diminishing amounts of rust, with last traces detected on 9 September 2006. Commercial planting resumed at both farms in late summer, and crops remained rust free under weekly inspection until 15 February 2007 in Manatee County and 29 March 2007 in Hendry County. To insure a rust-free product, cut flowers are carefully inspected and foliage stripped at the packinghouse. Eradication will be attempted once more with a fallow host-free period before the 2007 season. U. transversalis is an autoecious rust that mainly infects Gladiolus spp., but has been known to infect other members of the Iridaceae: Anomatheca, Crocosmia, Melasphaerula, Tritonia, and Watsonia. Amphigenous uredinia form in transverse lines across gladiolus foliage and also on flower spikes under heavy disease pressure. The isolate present in Florida fits the literature description of U. transversalis in every respect (uredinia 0.5 to 1.5 mm in diameter, subglobose to ellipsoid verruculose yellow-amber urediniospores, 15 to 28 × 14 to 20 µm with wall 1.5 to 2.5 µm thick; telia also amphigenous, 0.5 to 1.3 µm in diameter, dark brown-black, subglobose to pyriform smooth amber teliospores, 20 to 30 × 15 to 20 µm with wall 1.5 to 2.0 µm thick, 4 to 6 µm thick at apex, pale brown to hyaline pedicel 30 to 40 µm long, yellow-brown paraphyses in pustule) ( http://nt.ars-grin.gov/fungaldatabases/new_allView.cfm?whichone=all&thisName=Uro myces%20transversalis&organismtype=Fungus ). Urediniospores initiated typical foliar lesions on transplanted gladiolus samples kept in the FDACS-DPI quarantine greenhouse during the diagnostic process. References: (1) J. R. Hernandez and J. F. Hennen. Sida 20:313, 2002. (2) G. P. B. Pitta et al. Biologica 47:323, 1981. (3) G. Rodriguez-Alvarado et al. Plant Dis. 90:687, 2006. (4) J. A. Stevenson. Page 82 in: Foreign Plant Diseases. USDA Fed. Hortic. Board Bureau Plant Ind. Government Printing Office, Washington DC, 1926.

Impatiens necrotic spot virus and Tomato spotted wilt virus Diagnosed in Phalaenopsis Orchids from Two Florida Nurseries.

In October 2006 (Arcadia, FL) and January 2007 (Sorrento, FL), several white Phalaenopsis orchids with large chlorotic/necrotic ringspot symptoms were sent to the Division of Plant Industry, Gainesville, FL. Symptomatic leaf tissues were tested with the Agdia immunostick-comb (Agdia, Elkhart, IN) for Impatiens necrotic spot virus (INSV), Tomato spotted wilt virus (TSWV), Cucumber mosaic, and Tobacco mosaic virus. Plants from the nursery in Sorrento, FL tested positive for TSWV, while those from the nursery in Arcadia, FL tested positive for INSV. Symptomless leaves from the infected plants tested negative for the viruses with the immunostick-comb. The plants also were tested for TSWV and INSV by double-antibody (DAS)-ELISA (Agdia Inc.) with the same results. Total RNA was extracted from one symptomatic orchid leaf from each nursery. Reverse transcription (RT)-PCR was performed with the universal tospovirus primer set BR60and BR65 (1). PCR bands of the expected size were amplified from each leaf. PCR products were sequenced directly. The orchid leaf that tested positive for TSWV by ELISA produced a 495-bp sequence with 97% identity to several isolates of the TSWV nucleocapsid protein gene listed in GenBank (Accession Nos. AY744479, AY8770391, DQ376185, and AF02659). The orchid leaf that tested positive for INSV by ELISA produced a 396-bp sequence with 98 to 99% identity to several isolates of the INSV nucleocapsid protein gene (Accession Nos. D00914, DQ425096, X66972, and AD109100). Although these viruses have been reported a few times in orchids previously (2,3), to our knowledge, this is the first time they have been reported in this host in Florida. In addition, white Phalaenopsis spp. appears to be a local lesion host and not a systemic host for these viruses. References: (1) M. Eiras et al. Fitopatol. Bras. 26:170, 2001. (2) J. S. Hu et al. Plant Dis. 77:464, 1993. (3) S. T. Koike and D. E. Mayhew. Orchids 70:746, 2001.

Impact of human immunodeficiency virus type 1 gp41 amino acid substitutions selected during enfuvirtide treatment on gp41 binding and antiviral potency of enfuvirtide in vitro.

Enfuvirtide (ENF), a novel human immunodeficiency virus type 1 (HIV-1) fusion inhibitor, has potent antiviral activity against HIV-1 both in vitro and in vivo. Resistance to ENF observed after in vitro passaging was associated with changes in a three-amino-acid (aa) motif, GIV, at positions 36 to 38 of gp41. Patients with ongoing viral replication while receiving ENF during clinical trials acquired substitutions within gp41 aa 36 to 45 in the first heptad repeat (HR-1) of gp41 in both population-based plasma virus sequences and proviral DNA sequences from isolates showing reduced susceptibilities to ENF. To investigate their impact on ENF susceptibility, substitutions were introduced into a modified pNL4-3 strain by site-directed mutagenesis, and the susceptibilities of mutant viruses and patient-derived isolates to ENF were tested. In general, susceptibility decreases for single substitutions were lower than those for double substitutions, and the levels of ENF resistance seen for clinical isolates were higher than those observed for the site-directed mutant viruses. The mechanism of ENF resistance was explored for a subset of the substitutions by expressing them in the context of a maltose binding protein chimera containing a portion of the gp41 ectodomain and measuring their binding affinity to fluorescein-labeled ENF. Changes in binding affinity for the mutant gp41 fusion proteins correlated with the ENF susceptibilities of viruses containing the same substitutions. The combined results support the key role of gp41 aa 36 to 45 in the development of resistance to ENF and illustrate that additional envelope regions contribute to the ENF susceptibility of fusion inhibitor-naïve viruses and resistance to ENF.

Identifying the motivations of African American volunteers working to prevent HIV/AIDS.

Community-based organizations that are engaged in HIV/AIDS prevention and support services often rely on volunteers. This article describes the development of a 22-item inventory that measures the motivations of volunteers who deliver HIV prevention education in the African American community. In a statewide survey of volunteers (N = 102), the two strongest motivations for volunteer activity were concern for the African American community and a desire to understand the causes and consequences of the epidemic. These motives predicted the frequency that volunteers held discussions about HIV/AIDS with members of their community. Discussion focuses on the relevance of the results for the recruitment, training, and retention of volunteers.

Where do patients with cancer die in Belfast?

BACKGROUND: Most patients with cancer prefer to die at home but the majority die in institutions. AIM: To determine place of death for patients with cancer in Belfast, to examine changes over time and identify factors associated with place of death. METHODS: A survey of deaths registered in Belfast over a six-month period for 1977, 1987 and 1997 identified patients dying from cancer. Epidemiological data included age, gender, malignancy, social class, marital status, area of residence and place of death. RESULTS: Home deaths fell from 35% in 1977 to 28% in 1997. Hospital deaths fell from 50% in 1977 to 40% in 1987 rising to 42% in 1997. Hospice deaths rose from 13% in 1977 to 25% in 1987 falling to 23% in 1997. There was an association between place of death and age, marital status, type of cancer and area of residence, but not with social class or gender. CONCLUSION: The majority of people fail to achieve a home death. Resources need to be targeted to those most at risk of an institutional death; females, the elderly, the unmarried, those with haematological malignancies and residents of South Belfast.

Personality type and neural circulatory control.

Psychosocial factors, including type A personality, anger, hostility, and anxiety, have been implicated in the pathogenesis of cardiovascular disease. Abnormal sympathetic responses to stress may help explain the link between certain behavior patterns and cardiovascular disease. We tested the hypothesis that in normal humans, type A personality characteristics are associated with exaggerated heart rate, pressor, and sympathetic nerve responses to mental and physical stress. We measured heart rate, blood pressure, and muscle sympathetic nerve activity (obtained with direct intraneural recordings) at rest and during stress in 45 healthy subjects (19 men and 26 women, age 29.2+/-8.7 years) who had no chronic diseases and were taking no medications. Subjects were divided into tertiles based on type A scores. There were no significant differences in sympathetic or hemodynamic reactivity among the 3 different intensity levels of type A characteristics. Baseline measures and responses to stress tests were similar across the 3 groups. Sympathetic and hemodynamic changes during stress tests were also similar in subject groups stratified according to anger scale and cynicism scale. Sympathetic nerve and hemodynamic measurements at rest and during stress were not different in normal subjects with type A characteristics. Abnormalities in sympathetic or cardiovascular reactivity are unlikely to be implicated in any excess of cardiovascular disease in people with type A personality characteristics.

Sympathetic activation by sildenafil.

BACKGROUND: Sildenafil citrate is an effective and widely prescribed therapy for erectile dysfunction. Little is known about the effects of sildenafil on neural control of the circulation or about the effects of sildenafil on neurocirculatory stress responses. METHODS AND RESULTS: We studied 14 normal volunteers (age 32+/-7 years) who were randomized in a double-blind crossover fashion to receive a single oral dose of sildenafil 100 mg or placebo on 2 separate study days. Blood pressure, heart rate, forearm vascular resistance, muscle sympathetic nerve activity, and plasma catecholamines were measured at baseline and at 30 and 60 minutes after sildenafil and after placebo administration. The effects of sildenafil and placebo on neural and circulatory responses to stressful stimuli (sustained handgrip, maximal forearm ischemia, mental stress, and the cold pressor test) were also evaluated. Blood pressure, heart rate, and forearm vascular resistance after sildenafil and placebo were similar. However, muscle sympathetic nerve activity increased strikingly after sildenafil (by 141+/-26%, mean+/-SEM) compared with placebo (3+/-8%) (P=0.006); plasma norepinephrine levels also increased by 31+/-5% after sildenafil administration (P=0.004). Sympathetic nerve traffic during mental, physical, and cold stresses was 2- to 8-fold higher after sildenafil than with placebo (P<0.05). CONCLUSIONS: Sildenafil causes a marked increase in sympathetic activation, evident both at rest and during stressful stimuli. Sympathetic activation by sildenafil may have implications for understanding cardiovascular events associated with sildenafil use.

Nocturnal continuous positive airway pressure decreases daytime sympathetic traffic in obstructive sleep apnea.

BACKGROUND: Patients with obstructive sleep apnea (OSA) have high levels of muscle sympathetic nerve activity (MSNA). We tested the hypothesis that long-term continuous positive airway pressure (CPAP) treatment will decrease MSNA in OSA patients. METHODS AND RESULTS: We measured blood pressure, heart rate, and MSNA in 11 normotensive, otherwise healthy patients with OSA who were treated with CPAP. The measurements were obtained at baseline and after 1 month, 6 months, and 1 year of CPAP treatment. These measurements were compared with those recorded in 9 otherwise healthy OSA patients who were not treated with CPAP for 1 year. In both untreated and treated patients, blood pressure and heart rate did not change over time. MSNA was similar during repeated measurements in the untreated group. By contrast, MSNA decreased significantly over time in patients treated with CPAP. This decrease was evident after both 6 months and 1 year of CPAP treatment (P=0.02 for both). CONCLUSIONS: CPAP treatment decreases muscle sympathetic traffic in patients with OSA. This effect of CPAP is evident only after an extended duration of therapy.

African-American volunteers carrying an HIV prevention message: selective communication.

Despite increased resources and funding, the rate of new HIV infections has not been contained within the African American community. Initiatives such as the culturally specific American Red Cross African American HIV/AIDS Program have enlisted thousands of volunteers in the fight against AIDS. This article reports the findings of a survey given to program volunteers, focusing on their prevention-related activities. The results suggest that although volunteers felt good about their level of knowledge and about their prevention work, they were selective both in terms of the audiences they addressed and in terms of the topics they covered. Specifically, volunteers were more likely to discuss HIV prevention with acquaintances than with their own family members or with a sexual partner. In addition, volunteers tended not to discuss the dangers of sharing needles.

d2_cluster: a validated method for clustering EST and full-length cDNAsequences.

Several efforts are under way to condense single-read expressed sequence tags (ESTs) and full-length transcript data on a large scale by means of clustering or assembly. One goal of these projects is the construction of gene indices where transcripts are partitioned into index classes (or clusters) such that they are put into the same index class if and only if they represent the same gene. Accurate gene indexing facilitates gene expression studies and inexpensive and early partial gene sequence discovery through the assembly of ESTs that are derived from genes that have yet to be positionally cloned or obtained directly through genomic sequencing. We describe d2_cluster, an agglomerative algorithm for rapidly and accurately partitioning transcript databases into index classes by clustering sequences according to minimal linkage or "transitive closure" rules. We then evaluate the relative efficiency of d2_cluster with respect to other clustering tools. UniGene is chosen for comparison because of its high quality and wide acceptance. It is shown that although d2_cluster and UniGene produce results that are between 83% and 90% identical, the joining rate of d2_cluster is between 8% and 20% greater than UniGene. Finally, we present the first published rigorous evaluation of under and over clustering (in other words, of type I and type II errors) of a sequence clustering algorithm, although the existence of highly identical gene paralogs means that care must be taken in the interpretation of the type II error. Upper bounds for these d2_cluster error rates are estimated at 0.4% and 0.8%, respectively. In other words, the sensitivity and selectivity of d2_cluster are estimated to be >99.6% and 99.2%.

The effect of Cys LT1 receptor blockade on airway responses to allergen.

STUDY OBJECTIVE: To evaluate the effect of a potent experimental leukotriene receptor antagonist, MK-571, on airway responses to inhaled allergen. DESIGN: Randomized, double-blind, placebo-controlled, crossover trial. SETTING: Clinical research center. SUBJECTS: Eight male volunteers with allergic asthma. INTERVENTIONS: An intravenous loading dose was followed by an 8-hour infusion of MK-571 or placebo, with a 7- to 14-day washout between treatments. Allergen challenge was performed after the loading dose and a histamine challenge was performed before and 24 hours after allergen. MEASUREMENTS AND MAIN RESULTS: Forced expiratory volume in 1 second was measured serially. MK-571 provided about 50% protection during maximum early and late responses compared with placebo (p=0.005), but airway obstruction persisted 8-24 hours after allergen on both treatment days. Airway responsiveness to histamine was not significantly attenuated at 24 hours. CONCLUSION: Blocking Cys LT1 receptors for 8 hours attenuated the early and late responses but did not interrupt the cascade of events leading to subsequent allergen-induced airway obstruction and hyperreactivity.

Baroreflex control of sympathetic nerve activity and heart rate in obstructive sleep apnea.

-Patients with obstructive sleep apnea are at increased risk for hypertension. The mechanisms underlying this increased risk are not known. We tested the hypothesis that obstructive sleep apnea, independent of factors such as hypertension, obesity, and age, is characterized by impairment of baroreflex sensitivity. We measured muscle sympathetic nerve activity (MSNA) and heart rate responses to activation and deactivation of baroreceptors in newly diagnosed, never treated, normotensive patients with obstructive sleep apnea. These responses were compared with those obtained in healthy control subjects closely matched for age, body mass index, and blood pressure. Heart rate and MSNA changes during infusion of phenylephrine (baroreceptor activation) were similar in the control subjects and patients with sleep apnea. Infusion of nitroprusside (baroreceptor deactivation) elicited similar decreases in mean arterial pressure (MAP) but lesser MSNA increases in patients with sleep apnea than in control subjects. Calculation of DeltaMSNA/DeltaMAP ratio revealed that baroreflex regulation of sympathetic activity for similar blood pressure changes was diminished in patients with sleep apnea in comparison to normal control subjects (P=0.01). However, increases in heart rate during nitroprusside infusion were comparable in both groups. Sympathetic, blood pressure and heart rate responses to the cold pressor test were also similar in the 2 groups. Our results indicate that normotensive patients with sleep apnea have a selective impairment of the sympathetic response to baroreceptor deactivation but not to baroreceptor activation or to the cold pressor test. The impairment of baroreflex sympathetic modulation in patients with sleep apnea is not accompanied by any impairment of baroreflex control of heart rate.

Concordance analysis of microbial genomes.

The set of proteins which are conserved across families of microbes contain important targets of new anti-microbial agents. We have developed a simple and efficient computational tool which determines concordances of putative gene products that show sets of proteins conserved across one set of user specified genomes and not present in another set of user specified genomes. The thresholds and the homology scoring criterion are selectable to allow the user to decide the stringency of the homologies. The system uses a relational database to store protein coding regions from different genomes, and to store the results of a complete comparison of all sequences against all sequences using the FASTA program. Using Web technology, the display of all the related proteins for a given sequence and calculation of multiple sequence alignments (using CLUSTALW) can be performed with the click of a button. The current database holds 97 365 sequences from 19 complete or partial genomes and 8798905 FASTA comparison results. A example concordance is presented which demonstrates that the target of the quinolone antibiotics could have been identified using this tool.