Coupled myovascular expansion directs cardiac growth and regeneration.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Current Practice Patterns in the Management Of Alcohol Withdrawal Syndrome.

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

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

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

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

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

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

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

Essential Training, Resources, and Skills of First-Year and Junior Pharmacy Practice Faculty Needed in the Development of an Individual Research Program.

OBJECTIVE: To describe types of current training/support received and elicit opinions on the level of importance of specific skills and resources needed to build confidence in conducting research for early-career pharmacy practice faculty. METHODS: A survey instrument regarding available resources, levels of importance of resources, and skills needed to improve research confidence was sent to all new early-career practice faculty members with 3 or less years of experience in academia at 129 US colleges and schools of pharmacy. RESULTS: Few respondents indicated a formal research training existed at their institution. Overall, a majority of respondents identified at least 14 specific developmental areas as moderately to very important in building confidence. Over 75% of respondents rated 15 basic skills as moderately to very important in successfully starting an individual research program. CONCLUSION: Although different types of research training programs are available, confidence in conducting research in both informal and formal ones is low. Both groups of respondents identified similar important developmental research areas that would increase their confidence and skills in achieving their early research goals.

Northern range expansion of the Asian tiger mosquito (Aedes albopictus): Analysis of mosquito data from Connecticut, USA.

BACKGROUND: The Asian tiger mosquito (Aedes albopictus) is an invasive species and important arbovirus vector that was introduced into the U.S. in the 1980's where it continues to expand its range. Winter temperature is an important constraint to its northward expansion, with potential range limits located between the 0° and -5°C mean cold month isotherm. Connecticut is located within this climatic zone and therefore, Ae. albopictus was monitored statewide to assess its northern range expansion and to delineate where populations can stably persist. METHODOLOGY/PRINCIPAL FINDINGS: Ae. albopictus females were monitored at fixed trapping sites throughout Connecticut from June-October over a 20-year period, 1997-2016. In addition, Ae. albopictus larvae and pupae were collected from tire habitats and tires were retrieved from the field in the spring and flooded to evaluate overwintering success of hatching larvae. Ae. albopictus was first detected during statewide surveillance when a single adult female was collected in 2006. This species was not collected again until 2010 and was subsequently detected each successive year with increasing abundance and distribution except following the unusually cold winters of 2014 and 2015. Ae. albopictus mosquitoes were most abundant in urban and suburban locations along the southwestern shoreline of Connecticut; however, single specimens were occasionally detected in central parts of the state. Field-collected females were also screened for arbovirus infection yielding two isolations of Cache Valley virus and one isolation of West Nile virus, highlighting the threat posed by this mosquito. Ae. albopictus overwintered in Connecticut under mild winter conditions as shown by recovery of hatched larvae from field collected tires in spring and by early season detection of larvae and pupae. CONCLUSIONS/SIGNIFICANCE: This study documents the establishment and expansion of Ae. albopictus at the northern boundary of its range in the northeastern U.S. and provides a baseline for monitoring the future spread of this species anticipated under climate change.

Continuous Lidocaine Infusion as Adjunctive Analgesia in Intensive Care Unit Patients.

Despite a paucity of data, the role of intravenous lidocaine (IVLI) as adjunctive analgesia in the intensive care unit (ICU) seems promising due to a low potential to contribute to respiratory depression. A retrospective chart review was conducted to evaluate the safety and effectiveness of IVLI for the treatment of pain in ICU patients with varying degrees of organ dysfunction from March 2014 to March 2016. The primary outcomes included the time to a ≥20% reduction in pain scores after the initiation of IVLI and the difference in opioid requirements as well as pain scores prior to and during IVLI therapy. Other variables included the presence of IVLI-related adverse events and the dosage and duration of IVLI. A total of 21 ICU patients were included from 2 different hospitals. The mean time to a ≥20% reduction in pain scores from the start of IVLI was 3.3 hours (SD = 2.2). The median morphine dose equivalents required during 6, 12, and 24 hours pre-IVLI were significantly higher compared to the same time periods after IVLI (18.3 vs 10 mg, P = .002; 41.8 vs 18.3 mg, P = .002; 93.5 vs 30.5 mg, P = .037). Neurological adverse effects of lidocaine were noted in 3 patients, but the effects were reversed on IVLI discontinuation. This report suggests that IVLI as an adjunctive agent in the treatment of acute pain may be a potential option in ICU patients who are refractory to opioids or those in whom opioid-induced respiratory depression is a concern.

Practice Patterns and Opinions on Current Clinical Practice Guidelines Regarding the Management of Delirium in the Intensive Care Unit.

OBJECTIVE: The aim of this study was to determine current delirium practices in the intensive care unit (ICU) setting and evaluate awareness and adoption of the 2013 Pain, Agitation, and Delirium (PAD) guidelines with emphasis on delirium management. DESIGN, SETTING, AND PARTICIPANTS: A large-scale, multidisciplinary, online survey was administered to physician, pharmacist, nurse, and mid-level practitioner members of the Society of Critical Care Medicine (SCCM) between September 2014 and October 2014. A total of 635 respondents completed the survey. MEASUREMENTS AND MAIN RESULTS: Nonpharmacologic interventions such as early mobilization were used in most ICUs (83%) for prevention of delirium. A majority of respondents (97%) reported using pharmacologic agents to treat hyperactive delirium. Ninety percent of the respondents answered that they were aware of the 2013 PAD guidelines, and 75% of respondents felt that their delirium practices have been changed as a result of the new guidelines. In addition, logistic regression analysis of this study showed that respondents who use delirium screening tools were twice more likely to be fully aware of key components of the updated guidelines (odds ratio [OR] = 2.07, 95% confidence interval [CI] = 1.20-3.60). CONCLUSIONS: Most critical care practitioners are fully aware and knowledgeable of key recommendations in the new guidelines and have changed their delirium practices accordingly.

Host associations of mosquitoes at eastern equine encephalitis virus foci in Connecticut, USA.

BACKGROUND: Eastern equine encephalitis virus (EEEV) is a highly pathogenic mosquito-borne arbovirus, with active transmission foci in freshwater hardwood swamps in eastern North America, where enzootic transmission is maintained between the ornithophilic mosquito, Culiseta melanura, and wild passerine birds. The role of other locally abundant mosquito species in virus transmission and their associations with vertebrate hosts as sources of blood meals within these foci are largely unknown but are of importance in clarifying the dynamics of enzootic and epidemic/epizootic transmission. METHODS: Blood-engorged mosquitoes were collected from resting boxes at four established EEEV foci in Connecticut during 2010-2011. Mosquitoes were identified to species, and the identity of vertebrate hosts was determined based on mitochondrial cytochrome b and/or cytochrome c oxidase subunit I gene sequences of polymerase chain reaction products. RESULTS: The vertebrate hosts of 378 (50.3 % of engorged mosquitoes) specimens, representing 12 mosquito species, were identified. Culiseta morsitans (n = 54; 67.5 %), Culex restuans (n = 4; 66.7 %), and Cx. pipiens (n = 2; 100 %) acquired blood meals exclusively from avian hosts, whereas Aedes cinereus (n = 6; 66.7 %), Ae. canadensis (n = 2; 100 %), and Ae. stimulans (n = 1; 100 %) obtained blood meals solely from mammals. Species that fed opportunistically on both avian and mammalian hosts included: Ae. thibaulti (n = 21 avian, and n = 181 mammalian; 57.2 %), Anopheles punctipennis (n = 8 and n = 40; 44.0 %), An. quadrimaculatus (n = 1 and n = 23; 35.7 %), Coquillettidia perturbans (n = 3 and n = 3; 46.2 %) and Ae. abserratus (n = 1 and n = 2; 23.1 %). Culex territans obtained blood meals from avian and amphibian hosts (n = 18 and n = 5; 26.6 %). Mixed blood meals originating from both avian and mammalian hosts were identified in An. quadrimaculatus (n = 1), and Cx. territans (n = 2). CONCLUSIONS: Our findings indicate that wood thrush, tufted titmouse, and a few other avian species serve as hosts for mosquitoes, and likely contribute to amplification of EEEV. Our study supports the role of Cs. morsitans in enzootic transmission of EEEV among avian species. Culex territans will seek blood from multiple vertebrate classes, suggesting that this species may contribute to epizootic transmission of the virus. Our findings support roles for Cq. perturbans and An. quadrimaculatus as epidemic/epizootic vectors to humans, horses, and white-tailed deer. Despite its abundance, the potential of Ae. thibaulti to serve as a "bridge vector" for EEEV remains unclear in the absence of any definitive knowledge on its competency for the virus. The contribution of white-tailed deer to the dynamics of EEEV transmission is not fully understood, but findings indicate repeated exposure due to frequent feeding by vector competent mosquito species.

A national survey of emergency pharmacy practice in the United States.

PURPOSE: The results of a survey to characterize pharmacy practice in emergency department (ED) settings are reported. METHODS: An electronic survey was sent to all members of the American Society of Health-System Pharmacists' Emergency Medicine Connect group and the American College of Clinical Pharmacy's Emergency Medicine Practice and Research Network. Approximately 400 nontrainee pharmacy practitioners were invited to participate in the survey, which was open for 30 days. Descriptive statistics were used for all analyses. RESULTS: Two hundred thirty-three responses to the survey that were at least partially completed were received. After the removal of duplicate responses and null records, 187 survey responses were retained. The majority of respondents were from community hospitals (59.6%) or academic medical centers (36.1%). A pharmacist's presence in the ED of more than eight hours per day on weekdays and weekends was commonly reported (68.7% of respondents); 49.4% of institutions provided more than eight hours of coverage daily. Nearly one in three institutions (34.8%) provided no weekend ED staffing. The most frequently reported hours of coverage were during the 1 p.m.-midnight time frame. The distribution of ED pharmacist activities, by category, was as follows (data are median reported time commitments): clinical, 25% (interquartile range [IQR], 15-40%); emergency response, 15% (IQR, 10-20%); order processing, 15% (IQR, 5-25%); medication reconciliation/history-taking, 10% (IQR, 5-25%); teaching, 10% (IQR, 5-15%); administrative, 5% (IQR, 3-10%); and scholarly endeavors, 0% (IQR, 0-5%). CONCLUSION: Pharmacists from academic and community EDs perform a variety of clinical, educational, and administrative activities.

Dynamics of Vector-Host Interactions in Avian Communities in Four Eastern Equine Encephalitis Virus Foci in the Northeastern U.S.

BACKGROUND: Eastern equine encephalitis (EEE) virus (Togaviridae, Alphavirus) is a highly pathogenic mosquito-borne zoonosis that is responsible for occasional outbreaks of severe disease in humans and equines, resulting in high mortality and neurological impairment in most survivors. In the past, human disease outbreaks in the northeastern U.S. have occurred intermittently with no apparent pattern; however, during the last decade we have witnessed recurring annual emergence where EEE virus activity had been historically rare, and expansion into northern New England where the virus had been previously unknown. In the northeastern U.S., EEE virus is maintained in an enzootic cycle involving the ornithophagic mosquito, Culiseta melanura, and wild passerine (perching) birds in freshwater hardwood swamps. However, the identity of key avian species that serve as principal virus reservoir and amplification hosts has not been established. The efficiency with which pathogen transmission occurs within an avian community is largely determined by the relative reservoir competence of each species and by ecological factors that influence contact rates between these avian hosts and mosquito vectors. METHODOLOGY AND PRINCIPLE FINDINGS: Contacts between vector mosquitoes and potential avian hosts may be directly quantified by analyzing the blood meal contents of field-collected specimens. We used PCR-based molecular methods and direct sequencing of the mitochondrial cytochrome b gene for profiling of blood meals in Cs. melanura, in an effort to quantify its feeding behavior on specific vertebrate hosts, and to infer epidemiologic implications in four historic EEE virus foci in the northeastern U.S. Avian point count surveys were conducted to determine spatiotemporal host community composition. Of 1,127 blood meals successfully identified to species level, >99% of blood meals were from 65 avian hosts in 27 families and 11 orders, and only seven were from mammalian hosts representing three species. We developed an empirically informed mathematical model for EEE virus transmission using Cs. melanura abundance and preferred and non-preferred avian hosts. To our knowledge this is the first mathematical model for EEE virus, a pathogen with many potential hosts, in the northeastern U.S. We measured strong feeding preferences for a number of avian species based on the proportion of mosquito blood meals identified from these bird species in relation to their observed frequencies. These included: American Robin, Tufted Titmouse, Common Grackle, Wood Thrush, Chipping Sparrow, Black-capped Chickadee, Northern Cardinal, and Warbling Vireo. We found that these bird species, most notably Wood Thrush, play a dominant role in supporting EEE virus amplification. It is also noteworthy that the competence of some of the aforementioned avian species for EEE virus has not been established. Our findings indicate that heterogeneity induced by mosquito host preference, is a key mediator of the epizootic transmission of vector-borne pathogens. CONCLUSION AND SIGNIFICANCE: Detailed knowledge of the vector-host interactions of mosquito populations in nature is essential for evaluating their vectorial capacity and for assessing the role of individual vertebrates as reservoir hosts involved in the maintenance and amplification of zoonotic agents of human diseases. Our study clarifies the host associations of Cs. melanura in four EEE virus foci in the northeastern U.S., identifies vector host preferences as the most important transmission parameter, and quantifies the contribution of preference-induced contact heterogeneity to enzootic transmission. Our study identifies Wood Thrush, American Robin and a few avian species that may serve as superspreaders of EEE virus. Our study elucidates spatiotemporal host species utilization by Cs. melanura in relation to avian host community. This research provides a basis to better understand the involvement of Cs. melanura and avian hosts in the transmission and ecology of EEE virus and the risk of human infection in virus foci.