Autophagy is required for self-incompatible pollen rejection in two transgenic Arabidopsis thaliana accessions.

Successful reproduction in the Brassicaceae is mediated by a complex series of interactions between the pollen and the pistil, and some species have an additional layer of regulation with the self-incompatibility trait. While the initial activation of the self-incompatibility pathway by the pollen S-locus protein 11/S locus cysteine-rich protein and the stigma S Receptor Kinase is well characterized, the downstream mechanisms causing self-pollen rejection are still not fully understood. In previous studies, we detected the presence of autophagic bodies with self-incompatible (SI) pollinations in Arabidopsis lyrata and transgenic Arabidopsis thaliana lines, but whether autophagy was essential for self-pollen rejection was unknown. Here, we investigated the requirement of autophagy in this response by crossing mutations in the essential AUTOPHAGY7 (ATG7) and ATG5 genes into two different transgenic SI A. thaliana lines in the Col-0 and C24 accessions. By using these previously characterized transgenic lines that express A. lyrata and Arabidopsis halleri self-incompatibility genes, we demonstrated that disrupting autophagy weakened their SI responses in the stigma. When the atg7 or atg5 mutations were present, an increased number of SI pollen was found to hydrate and form pollen tubes that successfully fertilized the SI pistils. Additionally, we confirmed the presence of GFP-ATG8a-labeled autophagosomes in the stigmatic papillae following SI pollinations. Together, these findings support the requirement of autophagy in the self-incompatibility response and add to the growing understanding of the intracellular mechanisms employed in the transgenic A. thaliana stigmas to reject self-pollen.

Introducing Lifestyle Medicine Within the Mayo Clinic Alix School of Medicine in Arizona.

Purpose: High-value care is becoming increasingly important as the United States shifts toward a more sustainable health care system. Lifestyle medicine (LM) may be the highest-value model of care. Surprisingly, however, it is taught in a minority of medical schools. In this article, we describe a pilot project of introducing a brief LM course taught within the Mayo Clinic Alix School of Medicine in Arizona. The main purpose of the course was to introduce the students to LM as a specialty practice and to provide students with foundational knowledge of the pillars of LM. Results: Students reported improved personal health habits and increased confidence in LM competencies.

"Real-World" Application of Thrombolysis in Cardiac Arrest.

BACKGROUND: Current guidelines recommend consideration of thrombosis as a reversible cause of cardiac arrest. The use of thrombolytic therapy during cardiac arrest, however, is controversial. OBJECTIVE: We sought to characterize the use of thrombolytic therapy during cardiac arrest and to evaluate the rate of return of spontaneous circulation (ROSC) in a "real-word" setting. METHODS: A single-center, retrospective, cohort study of adult patients who received alteplase during cardiac arrest between 2010 and 2015 were performed at a tertiary academic medical center. RESULTS: Twenty-six patients were identified. Patients were predominantly male (65%) and Caucasian (89%) and were a median age of 64 years. Five patients had a history of preexisting venous thromboembolism, and eight patients were receiving systemic anticoagulation. Pulmonary embolism was confirmed prior to the administration of alteplase in 5 patients. The median dose of alteplase administered was 100 mg. ROSC was achieved in 65% of patients, 2 of whom survived to hospital discharge. Both surviving patients experienced a bleeding event. CONCLUSION: In a single center's experience, thrombolytic therapy is used infrequently for the management of cardiac arrest. Thrombolysis during cardiac arrest should be considered on a case-by-case basis and should be utilized only when there is a high suspicion for pulmonary embolism as the cause of arrest and when thrombolytic therapy is readily available.

Pharmacokinetics of Sildenafil in Patients with a Left Ventricular Assist Device: A Word of Caution.

We compared maximal plasma concentrations (Cmax) of sildenafil and metabolite n-desmethyl sildenafil in 12 inpatients with left ventricular assist devices (LVADs) on sildenafil (60 mg/day) to the reference range. Sildenafil Cmax (156.8 ± 124.5 ng/ml) was elevated in 66% of patients, with a two to fivefold increase over the upper limit of the reference range in 25% of patients. Metabolite Cmax (133.3 ± 102.0 ng/ml) was elevated in 75% of patients, with a three to sevenfold increase over the upper limit of the reference range in 40% of patients. Patients with heart failure and LVADs are at increased risk of concentrated-related sildenafil adverse events.

Impact of Pharmacist Intervention to Increase Compliance With Guideline-Directed Statin Therapy During an Acute Coronary Syndrome Hospitalization.

BACKGROUND: Despite evidence on poor adherence to guideline-directed statin therapy (GDST) following an acute coronary syndrome (ACS), little information has been published on pharmacist-led statin pilot programs for secondary prevention. OBJECTIVE: We sought to evaluate the impact of a pharmacist intervention (PI) on GDST during an ACS hospitalization. METHODS: A historical control (HC) group consisting of 125 ACS hospitalizations was retrospectively identified, with prospective data of 113 patients captured over 6 months in the PI group. The primary outcome of GDST was defined according to 2013 clinical guidelines and evaluated in all 238 qualifying patients. Secondary outcomes included number of interventions and use of logistic regression to investigate the relationship of ACS subtype with statin dose. RESULTS: On admission, GDST was ordered in 62.5% of the HC and 75.9% of the PI group. At discharge, the PI group had a higher rate of GDST relative to HC among all patients (86.7 % vs 77.4%, P = 0.06), and after exclusion of contraindications (84.8% vs 74.5%; P = 0.1), 10 patients required PI, accounting for an increase in GDST of 5.3%. Statin dose selection did not differ by ACS subtype (odds ratio = 0.79; 95% CI = 0.0.29-2.17; P = 0.18). CONCLUSION: PI did not significantly increase GDST. Increased compliance rates measured were primarily driven by higher baseline adherence and guideline incorporation over time.

Chilling and frost tolerance in Miscanthus and Saccharum genotypes bred for cool temperate climates.

Miscanthus hybrids are leading candidates for bioenergy feedstocks in mid to high latitudes of North America and Eurasia, due to high productivity associated with the C4 photosynthetic pathway and their tolerance of cooler conditions. However, as C4 plants, they may lack tolerance of chilling conditions (0-10 °C) and frost, particularly when compared with candidate C3 crops at high latitudes. In higher latitudes, cold tolerance is particularly important if the feedstock is to utilize fully the long, early-season days of May and June. Here, leaf gas exchange and fluorescence are used to assess chilling tolerance of photosynthesis in five Miscanthus hybrids bred for cold tolerance, a complex Saccharum hybrid (energycane), and an upland sugarcane variety with some chilling tolerance. The chilling treatment consisted of transferring warm-grown plants (25/20 °C day/night growth temperatures) to chilling (12/5 °C) conditions for 1 week, followed by assessing recovery after return to warm temperatures. Chilling tolerance was also evaluated in outdoor, spring-grown Miscanthus genotypes before and after a cold front that was punctuated by a frost event. Miscanthus×giganteus was found to be the most chilling-tolerant genotype based on its ability to maintain a high net CO2 assimilation rate (A) during chilling, and recover A to a greater degree following a return to warm conditions. This was associated with increasing its capacity for short-term dark-reversible photoprotective processes (ΦREG) and the proportion of open photosystem II reaction centres (qL) while minimizing photoinactivation (ΦNF). Similarly, in the field, M.×giganteus exhibited a significantly greater A and pre-dawn F v/F m after the cold front compared with the other chilling-sensitive Miscanthus hybrids.

Dynamics of the exponential integrate-and-fire model with slow currents and adaptation.

In order to properly capture spike-frequency adaptation with a simplified point-neuron model, we study approximations of Hodgkin-Huxley (HH) models including slow currents by exponential integrate-and-fire (EIF) models that incorporate the same types of currents. We optimize the parameters of the EIF models under the external drive consisting of AMPA-type conductance pulses using the current-voltage curves and the van Rossum metric to best capture the subthreshold membrane potential, firing rate, and jump size of the slow current at the neuron's spike times. Our numerical simulations demonstrate that, in addition to these quantities, the approximate EIF-type models faithfully reproduce bifurcation properties of the HH neurons with slow currents, which include spike-frequency adaptation, phase-response curves, critical exponents at the transition between a finite and infinite number of spikes with increasing constant external drive, and bifurcation diagrams of interspike intervals in time-periodically forced models. Dynamics of networks of HH neurons with slow currents can also be approximated by corresponding EIF-type networks, with the approximation being at least statistically accurate over a broad range of Poisson rates of the external drive. For the form of external drive resembling realistic, AMPA-like synaptic conductance response to incoming action potentials, the EIF model affords great savings of computation time as compared with the corresponding HH-type model. Our work shows that the EIF model with additional slow currents is well suited for use in large-scale, point-neuron models in which spike-frequency adaptation is important.

A School-Located Vaccination Adolescent Pilot Initiative in Chicago: Lessons Learned.

BACKGROUND: Many adolescents underutilize preventive services and are underimmunized. METHODS: To promote medical homes and increase immunization rates, we conceptualized and implemented a 3-year, 8-school pilot school-located vaccination collaborative program. We sought community, parent, and school nurse input the year prior to implementation. We selected schools with predominantly Medicaid-enrolled or Medicaid-eligible students to receive Vaccines For Children stock vaccines. Nurses employed by a mass immunizer delivered these vaccines at participating schools 3 times a year. RESULTS: Over 3 years, we delivered approximately 1800 vaccines at schools. School administrators, health centers, and neighboring private physicians generally welcomed the program. Parents did not express overt concerns about school-located vaccination. School nurses were not able to participate because of multiple school assignments. Obtaining parental consent via backpack mail was an inefficient process, and classroom incentives did not increase consent form return rate. The influenza vaccine had the most prolific uptake. The optimal time for administering vaccines was during regular school hours. CONCLUSIONS: Although school-located vaccination for adolescents is feasible, this is a paradigm shift for community members and thus accompanies challenges in implementation. High principal or school personnel turnover led to a consequent lack of institutional memory. It was difficult to communicate directly with parents. Because we were uncertain about the proportion of parents who received consent forms, we are exploring Internet-based and back-to-school registration options for making the consent form distribution and return process more rigorous. Securing an immunization champion at each school helped the immunization processes. Identifying a financially sustainable school-located vaccination model is critical for national expansion of school-located vaccination.

Initial events during the evolution of C4 photosynthesis in C3 species of Flaveria.

The evolution of C4 photosynthesis in many taxa involves the establishment of a two-celled photorespiratory CO2 pump, termed C2 photosynthesis. How C3 species evolved C2 metabolism is critical to understanding the initial phases of C4 plant evolution. To evaluate early events in C4 evolution, we compared leaf anatomy, ultrastructure, and gas-exchange responses of closely related C3 and C2 species of Flaveria, a model genus for C4 evolution. We hypothesized that Flaveria pringlei and Flaveria robusta, two C3 species that are most closely related to the C2 Flaveria species, would show rudimentary characteristics of C2 physiology. Compared with less-related C3 species, bundle sheath (BS) cells of F. pringlei and F. robusta had more mitochondria and chloroplasts, larger mitochondria, and proportionally more of these organelles located along the inner cell periphery. These patterns were similar, although generally less in magnitude, than those observed in the C2 species Flaveria angustifolia and Flaveria sonorensis. In F. pringlei and F. robusta, the CO2 compensation point of photosynthesis was slightly lower than in the less-related C3 species, indicating an increase in photosynthetic efficiency. This could occur because of enhanced refixation of photorespired CO2 by the centripetally positioned organelles in the BS cells. If the phylogenetic positions of F. pringlei and F. robusta reflect ancestral states, these results support a hypothesis that increased numbers of centripetally located organelles initiated a metabolic scavenging of photorespired CO2 within the BS. This could have facilitated the formation of a glycine shuttle between mesophyll and BS cells that characterizes C2 photosynthesis.

Delirium in the cardiovascular ICU: exploring modifiable risk factors.

OBJECTIVE: Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery ICU is not well established. We sought to determine the prevalence and risk factors for delirium among cardiac surgery ICU patients. DESIGN: Prospective observational study. SETTING: Twenty-seven-bed medical-surgical cardiac surgery ICU. PATIENTS: Two hundred consecutive patients with an expected cardiac surgery ICU length of stay >24 hrs. INTERVENTIONS: None. MEASUREMENTS: Baseline demographic data and daily assessments for delirium using the validated and reliable Confusion Assessment Method for the ICU were recorded, and quantitative tracking of delirium risk factors were conducted. Separate analyses studied the role of admission risk factors for occurrence of delirium during the cardiac surgery ICU stay and identified daily occurring risk factors for the development of delirium on a subsequent cardiac surgery ICU day. MAIN RESULTS: Prevalence of delirium was 26%, similar among cardiology and cardiac surgical patients. Nearly all (92%) exhibited the hypoactive subtype of delirium. Benzodiazepine use at admission was independently predictive of a three-fold increased risk of delirium (odds ratio 3.1 [1, 9.4], p = 0.04) during the cardiac surgery ICU stay. Of the daily occurring risk factors, patients who received benzodiazepines (2.6 [1.2, 5.7], p = 0.02) or had restraints or devices that precluded mobilization (2.9 [1.3, 6.5], p < 0.01) were more likely to have delirium the following day. Hemodynamic status was not associated with delirium. CONCLUSIONS: Delirium occurred in one in four patients in the cardiac surgery ICU and was predominately hypoactive in subtype. Chemical restraints via use of benzodiazepines or the use of physical restraints/restraining devices predisposed patients to a greater risk of delirium, pointing to areas of quality improvement that would be new to the vast majority of cardiac surgery ICUs.

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

BACKGROUND: Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. OBJECTIVE: To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. DESIGN, PARTICIPANTS: We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. MAIN MEASURES: Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors. KEY RESULTS: On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11). CONCLUSIONS: Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

BACKGROUND: High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered. METHODS: A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics. RESULTS: Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2224 exposed to warfarin, 8383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period-and the heparinlenoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent. CONCLUSIONS: Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy.

Acute coronary syndrome pathways: alignment with a bundled care reimbursement model.

Changes in public policy, population demographics, and market dynamics are spurring innovative approaches to value-based care. Annually, hospitalizations for Acute Coronary Syndromes (ACS) account for a substantial proportion of healthcare expenditures in the United States. Vanderbilt University Medical Center has developed a framework to deliver comprehensive care incorporating inpatient and outpatient care teams for patients with ACS under an episode-based, bundled reimbursement model for a term of 6 months. As such, a value-oriented pathway was created with the goals of (1) optimizing patient outcomes following ACS; (2) minimizing complications from the treatment of ACS; and (3) reducing costs of healthcare related to the treatment of ACS. In a tertiary care academic medical system receiving patients from multiple facilities involving multiple providers, standardization of care by using practice guidelines and evidence-based data coupled with a robust computerized provider order entry system provides a unique opportunity to produce a "best practice" algorithm for treating patients presenting with ACS. Presented in this study are in-hospital and postdischarge care pathways for treating a diverse group of patients presenting with ACS to our institution.

Design of a novel automated methanol feed system for pilot-scale fermentation of Pichia pastoris.

Large-scale fermentation of Pichia pastoris requires a large volume of methanol feed during the induction phase. However, a large volume of methanol feed is difficult to use in the processing suite because of the inconvenience of constant monitoring, manual manipulation steps, and fire and explosion hazards. To optimize and improve safety of the methanol feed process, a novel automated methanol feed system has been designed and implemented for industrial fermentation of P. pastoris. Details of the design of the methanol feed system are described. The main goals of the design were to automate the methanol feed process and to minimize the hazardous risks associated with storing and handling large quantities of methanol in the processing area. The methanol feed system is composed of two main components: a bulk feed (BF) system and up to three portable process feed (PF) systems. The BF system automatically delivers methanol from a central location to the portable PF system. The PF system provides precise flow control of linear, step, or exponential feed of methanol to the fermenter. Pilot-scale fermentations with linear and exponential methanol feeds were conducted using two Mut(+) (methanol utilization plus) strains, one expressing a recombinant therapeutic protein and the other a monoclonal antibody. Results show that the methanol feed system is accurate, safe, and efficient. The feed rates for both linear and exponential feed methods were within ± 5% of the set points, and the total amount of methanol fed was within 1% of the targeted volume.

The occurrence of C(2) photosynthesis in Euphorbia subgenus Chamaesyce (Euphorbiaceae).

This study investigated whether Euphorbia subgenus Chamaesyce subsection Acutae contains C(3)-C(4) intermediate species utilizing C(2) photosynthesis, the process where photorespired CO(2) is concentrated into bundle sheath cells. Euphorbia species in subgenus Chamaesyce are generally C(4), but three species in subsection Acutae (E. acuta, E. angusta, and E. johnstonii) have C(3) isotopic ratios. Phylogenetically, subsection Acutae branches between basal C(3) clades within Euphorbia and the C(4) clade in subgenus Chamaesyce. Euphorbia angusta is C(3), as indicated by a photosynthetic CO(2) compensation point (Г) of 69 µmol mol(-1) at 30 °C, a lack of Kranz anatomy, and the occurrence of glycine decarboxylase in mesophyll tissues. Euphorbia acuta utilizes C(2) photosynthesis, as indicated by a Г of 33 µmol mol(-1) at 30 °C, Kranz-like anatomy with mitochondria restricted to the centripetal (inner) wall of the bundle sheath cells, and localization of glycine decarboxlyase to bundle sheath mitochondria. Low activities of PEP carboxylase, NADP malic enzyme, and NAD malic enzyme demonstrated no C(4) cycle activity occurs in E. acuta thereby classifying it as a Type I C(3)-C(4) intermediate. Kranz-like anatomy in E. johnstonii indicates it also utilizes C(2) photosynthesis. Given the phylogenetically intermediate position of E. acuta and E. johnstonii, these results support the hypothesis that C(2) photosynthesis is an evolutionary intermediate condition between C(3) and C(4) photosynthesis.

Pediatric antiretroviral therapy.

The rate of perinatal HIV transmission has decreased significantly in developed countries. However, worldwide, it remains the main source of HIV infection within the pediatric population. Recent advances as a result of findings from clinical trials, viral resistance testing and the advent of new drugs have increased the options for initial treatment regimens. This article provides an overview of antiretroviral therapy in treatment-naive children, including recent pediatric data and updated guidelines from the NIH. It also provides information on new drugs approved for the pediatric age group, dosage information, drug resistance testing and monitoring suggestions for children and adolescents receiving antiretroviral therapy. Special issues pertaining to adherence, disclosure and contraception are also highlighted.

Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study.

BACKGROUND: Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens, suboptimal discharge instructions, and prolonged time to follow-up. Pharmacist-based interventions may be effective in promoting the safe and effective use of medications, especially among high-risk patients such as those with low health literacy. METHODS AND RESULTS: The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study is a randomized controlled trial conducted at 2 academic centers-Vanderbilt University Hospital and Brigham and Women's Hospital. Patients admitted with acute coronary syndrome or acute decompensated heart failure were randomly assigned to usual care or intervention. The intervention consisted of pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and tailored telephone follow-up after discharge. The primary outcome is the occurrence of serious medication errors in the first 30 days after hospital discharge. Secondary outcomes are health care utilization, disease-specific quality of life, and cost-effectiveness. Enrollment was completed September 2009. A total of 862 patients were enrolled, and 430 patients were randomly assigned to receive the intervention. Analyses will determine whether the intervention was effective in reducing serious medication errors, particularly in patients with low health literacy. CONCLUSIONS: The PILL-CVD study was designed to reduce serious medication errors after hospitalization through a pharmacist-based intervention. The intervention, if effective, will inform health care facilities on the use of pharmacist-assisted medication reconciliation, inpatient counseling, low-literacy adherence aids, and patient follow-up after discharge. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00632021.

Children at risk for developmental coordination disorder: judgement of changes in action capabilities.

In three separate manipulations, a group of children at risk for developmental coordination disorder (DCD; five males, seven females; mean age 11y 6mo [SD 6.8mo] who were at or below the 15th centile on the Movement ABC) and a group of typically developing children (TDC; seven males, five females; mean age 11y 3mo [SD 6.8mo]) judged the limit of their standing horizontal reach (HRmax) under two conditions in which actual HRmax differed. The manipulations were: (1) one-hand versus two-hand reach; and (2) standard versus short effective foot-length; and (3) rigid versus compliant support surface. For the foot-length and support surface manipulations (but not for the hand manipulation), children correctly judged that their actual HRmax differed in the two conditions (p<.05). On all three manipulations, TDC made significantly larger adjustments in their judgements than did children at risk for DCD (p<0.05). The TDC group adjusted their judgements in the appropriate direction on all three manipulations, whereas the DCD group adjusted in the appropriate direction for the foot-length manipulation only. The results suggest that children at risk for DCD are less adept at detecting changes in the limits of their action capabilities.