Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study.

BACKGROUND AND PURPOSE: The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients. METHODS: We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies. RESULTS: In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%). CONCLUSIONS: This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.

Residues of glyphosate in food and dietary exposure.

Glyphosate is the active ingredient in Roundup® brand nonselective herbicides, and residue testing for food has been conducted as part of the normal regulatory processes. Additional testing has been conducted by university researchers and nongovernmental agencies. Presence of residues needs to be put into the context of safety standards. Furthermore, to appropriately interpret residue data, analytical assays must be validated for each food sample matrix. Regulatory agency surveys indicate that 99% of glyphosate residues in food are below the European maximum residue limits (MRLs) or U.S. Environmental Protection Agency tolerances. These data support the conclusion that overall residues are not elevated above MRLs/tolerances due to agricultural practices or usage on genetically modified (GM) crops. However, it is important to understand that MRLs and tolerances are limits for legal pesticide usage. MRLs only provide health information when the sum of MRLs of all foods is compared to limits established by toxicology studies, such as the acceptable daily intake (ADI). Conclusions from dietary modeling that use actual food residues, or MRLs themselves, combined with consumption data indicate that dietary exposures to glyphosate are within established safe limits. Measurements of glyphosate in urine can also be used to estimate ingested glyphosate exposure, and studies indicate that exposure is <3% of the current European ADI for glyphosate, which is 0.5 mg glyphosate/kg body weight. Conclusions of risk assessments, based on dietary modeling or urine data, are that exposures to glyphosate from food are well below the amount that can be ingested daily over a lifetime with a reasonable certainty of no harm.

Are Stroke Survivors Discharged to the Recommended Postacute Setting?

OBJECTIVE: To examine the processes and barriers involved in providing postdischarge stroke care. DESIGN: Prospective study of discharge planners' (DP) and physical therapists' (PT) interpretation of factors contributing to patients' discharge destination. SETTING: Twenty-three hospitals in the northeastern United States. PARTICIPANTS: After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs. RESULTS: In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%). CONCLUSIONS: Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.

Validation of reliable and selective methods for direct determination of glyphosate and aminomethylphosphonic acid in milk and urine using LC-MS/MS.

Simple high-throughput procedures were developed for the direct analysis of glyphosate [N-(phosphonomethyl)glycine] and aminomethylphosphonic acid (AMPA) in human and bovine milk and human urine matrices. Samples were extracted with an acidified aqueous solution on a high-speed shaker. Stable isotope labeled internal standards were added with the extraction solvent to ensure accurate tracking and quantitation. An additional cleanup procedure using partitioning with methylene chloride was required for milk matrices to minimize the presence of matrix components that can impact the longevity of the analytical column. Both analytes were analyzed directly, without derivatization, by liquid chromatography tandem mass spectrometry using two separate precursor-to-product transitions that ensure and confirm the accuracy of the measured results. Method performance was evaluated during validation through a series of assessments that included linearity, accuracy, precision, selectivity, ionization effects and carryover. Limits of quantitation (LOQ) were determined to be 0.1 and 10 µg/L (ppb) for urine and milk, respectively, for both glyphosate and AMPA. Mean recoveries for all matrices were within 89-107% at three separate fortification levels including the LOQ. Precision for replicates was ≤ 7.4% relative standard deviation (RSD) for milk and ≤ 11.4% RSD for urine across all fortification levels. All human and bovine milk samples used for selectivity and ionization effects assessments were free of any detectable levels of glyphosate and AMPA. Some of the human urine samples contained trace levels of glyphosate and AMPA, which were background subtracted for accuracy assessments. Ionization effects testing showed no significant biases from the matrix. A successful independent external validation was conducted using the more complicated milk matrices to demonstrate method transferability.

A test method for assessing chronic oral toxicity of a pesticide to solitary nesting orchard bees, Osmia spp. (Hymenoptera: Megachilidae).

Orchard bees of the genus Osmia Panzer are important pollinators of fruit trees in various regions of the world, with some species commercially available in the United States and Europe. In addition to their pollination services, Osmia lignaria, Osmia cornifrons, Osmia bicornis, and Osmia cornuta have been identified as potential model species for solitary bees in pesticide risk assessment and have been used for the development of new methods to test acute lethal effects via contact and oral routes of exposure. Our goal was to expand the available methodology to characterize the toxicity of pesticides for these solitary bees through a chronic oral test for adult bees. Chronic oral toxicity of pesticides to orchard bees has been reported, but methods differ among research groups. In our study, O. lignaria, O. cornifrons, O. bicornis, and O. cornuta female bees had access to sucrose solution ad libitum in separate, species-specific 10-day tests. Mean body mass, mean daily consumption, and survival differed among the studied bee species. The dose-response test design was validated with dimethoate, a reference toxic compound, and chronic toxicity endpoints were estimated for the 4 Osmia species. The median lethal daily doses normalized by weight for O. lignaria, O. bicornis, O. cornuta, and O. cornifrons were within the same order of magnitude at 0.23, 0.26, 0.49, and 0.61 µg dimethoate/g bee/day, respectively. The methodology described here was aligned as much as possible with the available honey bee and bumble bee standard methods to facilitate the comparison of chronic toxicity profiles among bee species.

Characterization of the Gene Repertoire and Environmentally Driven Expression Patterns in Tanner Crab (Chionoecetes bairdi).

Tanner crab (Chionoecetes bairdi) is an economically important species that is threatened by ocean warming and bitter crab disease, which is caused by an endoparasitic dinoflagellate, Hematodinium. Little is known about disease transmission or its link to host mortality, or how ocean warming will affect pathogenicity or host susceptibility. To provide a transcriptomic resource for the Tanner crab, we generated a suite of RNA-seq libraries encompassing pooled hemolymph samples from crab displaying differing infection statuses and maintained at different temperatures (ambient (7.5˚C), elevated (10˚C), or decreased (4˚C)). After assembling a transcriptome and performing a multifactor differential gene expression analysis, we found genes influenced by temperature in relation to infection and detected some of those genes over time at the individual level using RNA-seq data from one crab. Biological processes associated with those genes include lipid storage, transcription, response to oxidative stress, cell adhesion, and morphogenesis. Alteration in lipid storage and transcription provide insight into how temperature impacts energy allocation in Hematodinium infected crabs. Alteration in expression patterns in genes associated with morphogenesis could suggest that hemocytes were changing morphology and/or type in response to temperature. This project provides insight into how Hematodinium infection could influence crab physiology as oceans warm.

Frequency of metastasis to the gastrointestinal tract determined by endoscopy in a community-based gastroenterology practice.

Metastasis to the gastrointestinal tract is rare. We performed a retrospective analysis to identify patients with metastatic disease to the gastrointestinal tract using two databases containing pathology results from all endoscopic procedures conducted by nearly 200 gastroenterologists in a community setting over a 14-year period. Forty-nine patients were diagnosed with metastasis to the gastrointestinal tract by endoscopy during the study period. Most were women (71%). The most common metastases to the gastrointestinal tract identified by endoscopy were breast cancers (n = 18), followed by melanomas (n = 12), ovarian cancers (n = 7), kidney cancers (n = 5), prostate cancers (n = 2), lung cancer (n = 1), and pancreatic cancer (n = 1). Three patients had unknown primary sites. Among women, the three leading known primary tumor sites were breast, ovary, and melanoma. Among men, the three leading primary tumor sites were melanoma, kidney, and prostate. The stomach was the most common portion of the gastrointestinal tract involved by metastases. Most affected women and were most frequently encountered in the stomach.

Molecular detection of Hematodinium sp. in Northeast Pacific Chionoecetes spp. and evidence of two species in the Northern Hemisphere.

Hematodinium is a genus of parasitic dinoflagellates that infects crustaceans worldwide including Tanner crabs Chionoecetes bairdi and snow crabs C. opilio in the Northeast Pacific Ocean. The present study describes the optimization of a PCR-based assay for the detection and monitoring of Hematodinium sp. in snow and Tanner crabs. Two fragments, 1682 and 187 bp, were amplified from the 18S ribosomal DNA region of the parasite. The assay performed well in 6 additional decapod species (1 lobster and 5 crabs) infected with Hematodinium spp., suggesting that it could be used to detect Hematodinium spp. in other decapods. We also report Hematodinium spp. infections in the majid crab, Hyas coarctatus, and the lithodid crab, Lithodes couesi. Sequencing of 18S rDNA and the adjacent internal transcribed spacer 1 (ITS1) region of Hematodinium spp. isolated from 7 host species in the present study revealed the presence of 2 Hematodinium clades, one in the blue crab Callinectes sapidus and a second in all other host species. The ITS1 sequences of the 2 clades could not be aligned, but showed a conserved secondary structure that may be related to a functional diversification during a host switch. Comparison of our data with 18S and ITS1 sequence data available in GenBank placed the north Pacific Hematodinium sp. in a clade separate from the Hematodinium sp. infecting the portunoids, C. sapidus, Liocarcinus depurator and Scylla serrata, and within a second clade that infected all other decapod hosts located in the North Pacific and North Atlantic Oceans.

Consequences of depleted SERCA2-gated calcium stores in the skin.

Sarco(endo)plasmic reticulum Ca2+-ATPase isoform 2 (SERCA2) pumps belong to the family of Ca2+-ATPases responsible for the maintenance of calcium in the endoplasmic reticulum. In epidermal keratinocytes, SERCA2-controlled calcium stores are involved in cell cycle exit and onset of terminal differentiation. Hence, their dysfunction was thought to provoke impaired keratinocyte cohesion and hampered terminal differentiation. Here, we assessed cultured keratinocytes and skin biopsies from a canine family with an inherited skin blistering disorder. Cells from lesional and phenotypically normal areas of one of these dogs revealed affected calcium homeostasis due to depleted SERCA2-gated stores. In phenotypically normal patient cells, this defect compromised upregulation of p21(WAF1) and delayed the exit from the cell cycle. Despite this abnormality it failed to impede the terminal differentiation process in the long term but instead coincided with enhanced apoptosis and appearance of chronic wounds, suggestive of secondary mutations. Collectively, these findings provide the first survey on phenotypic consequences of depleted SERCA-gated stores for epidermal homeostasis that explain how depleted SERCA2 calcium stores provoke focal lesions rather than generalized dermatoses, a phenotype highly reminiscent of the human genodermatosis Darier disease.

Glyphosate and aminomethylphosphonic acid are not detectable in human milk.

BACKGROUND: Although animal studies have shown that exposure to glyphosate (a commonly used herbicide) does not result in glyphosate bioaccumulation in tissues, to our knowledge there are no published data on whether it is detectable in human milk and therefore consumed by breastfed infants. OBJECTIVE: We sought to determine whether glyphosate and its metabolite aminomethylphosphonic acid (AMPA) could be detected in milk and urine produced by lactating women and, if so, to quantify typical consumption by breastfed infants. DESIGN: We collected milk (n = 41) and urine (n = 40) samples from healthy lactating women living in and around Moscow, Idaho and Pullman, Washington. Milk and urine samples were analyzed for glyphosate and AMPA with the use of highly sensitive liquid chromatography-tandem mass spectrometry methods validated for and optimized to each sample matrix. RESULTS: Our milk assay, which was sensitive down to 1 µg/L for both analytes, detected neither glyphosate nor AMPA in any milk sample. Mean ± SD glyphosate and AMPA concentrations in urine were 0.28 ± 0.38 and 0.30 ± 0.33 µg/L, respectively. Because of the complex nature of milk matrixes, these samples required more dilution before analysis than did urine, thus decreasing the sensitivity of the assay in milk compared with urine. No difference was found in urine glyphosate and AMPA concentrations between subjects consuming organic compared with conventionally grown foods or between women living on or near a farm/ranch and those living in an urban or suburban nonfarming area. CONCLUSIONS: Our data provide evidence that glyphosate and AMPA are not detectable in milk produced by women living in this region of the US Pacific Northwest. By extension, our results therefore suggest that dietary glyphosate exposure is not a health concern for breastfed infants. This study was registered at clinicaltrials.gov as NCT02670278.

Sonographic appearance of isolated necrotizing vasculitis of the testis.

The presentation of necrotizing vasculitis of the testis is variable and may mimic a testicular tumor. Necrotizing vasculitis of the testis is characterized by fibrinoid necrosis of the walls of small and medium-sized testicular arteries. We report a patient with isolated necrotizing vasculitis of the testis who presented with clinical imaging findings suspicious for testicular neoplasm. We describe the clinical course and sonographic characteristics of evolving necrotizing vasculitis of the testis, briefly review the literature, and discuss the implications for the diagnosis and management of this condition.

The Arabidopsis vitamin E pathway gene5-1 mutant reveals a critical role for phytol kinase in seed tocopherol biosynthesis.

We report the identification and characterization of a low tocopherol Arabidopsis thaliana mutant, vitamin E pathway gene5-1 (vte5-1), with seed tocopherol levels reduced to 20% of the wild type. Map-based identification of the responsible mutation identified a G-->A transition, resulting in the introduction of a stop codon in At5g04490, a previously unannotated gene, which we named VTE5. Complementation of the mutation with the wild-type transgene largely restored the wild-type tocopherol phenotype. A knockout mutation of the Synechocystis sp PCC 6803 VTE5 homolog slr1652 reduced Synechocystis tocopherol levels by 50% or more. Bioinformatic analysis of VTE5 and slr1652 indicated modest similarity to dolichol kinase. Analysis of extracts from Arabidopsis and Synechocystis mutants revealed increased accumulation of free phytol. Heterologous expression of these genes in Escherichia coli supplemented with free phytol and in vitro assays of recombinant protein produced phytylmonophosphate, suggesting that VTE5 and slr1652 encode phytol kinases. The phenotype of the vte5-1 mutant is consistent with the hypothesis that chlorophyll degradation-derived phytol serves as an important intermediate in seed tocopherol synthesis and forces reevaluation of the role of geranylgeranyl diphosphate reductase in tocopherol biosynthesis.

Metabolically engineered oilseed crops with enhanced seed tocopherol.

Tocochromanols (tocopherols and tocotrienols) are important lipid soluble antioxidants and are an essential part of the mammalian diet. Oilseeds are particularly rich in tocochromanols with an average concentration 10-fold higher than other plant tissues. Here we describe a systematic approach to identify rate-limiting reactions in the tocochromanol biosynthetic pathway, and the application of this knowledge to engineer tocochromanol biosynthesis in oilseed crops. Seed-specific expression of genes encoding limiting tocochromanol pathway enzymes in soybean increased total tocochromanols up to 15-fold from 320 ng/mg in WT seed to 4800 ng/mg in seed from the best performing event. Although WT soybean seed contain only traces of tocotrienols, these transgenic soybean accumulated up to 94% of their tocochromanols as tocotrienols. Upon crossing transgenic high tocochromanol soybean with transgenic high alpha-tocopherol soybean, the vitamin E activity in the best performing F2-seed was calculated to be 11-fold higher than the average WT soybean seed vitamin E activity.

Isolation and inheritance of microsatellite loci in the Dungeness crab (Brachyura: Cancridae: Cancer magister).

The isolation, PCR amplification, and descriptive statistics of six microsatellite loci are described for the Dungeness crab, Cancer magister. Also reported is the inheritance of these loci in two families obtained from artificial crosses in the laboratory. All six loci conform to expectations under Mendelian inheritance and there is no evidence for linkage between any of the loci. Allelic size ranges for three of the loci are relatively large, ranging from 135-357 bp between the smallest and largest allele detected at that locus. At two of these loci upper allelic drop out (non-amplification of the larger allele in a heterozygous individual) can be problematic for scoring. Results from cross-species amplification in nine congeners are summarized. These loci will be valuable in studies requiring high-resolution genetic markers in Dungeness crabs and related species.

Initiation and characterization of keratinocyte cultures from biopsies of normal human conjunctiva.

The purpose of the present study was to establish and characterize serum-free epithelial cultures of normal human conjunctiva using fresh biopsy tissue. To this end, small pieces of normal conjunctiva were biopsied from patients undergoing routine cataract surgery. Fragments of the tissue were placed in explant culture in medium containing fetal bovine serum for approximately 1 week to promote epithelial cell outgrowth. Cultures were then passaged multiple times into serum-free medium. Cultures generated in this way were at least 95% keratinocytes and exhibited a typical epithelial morphology, which was dependent on the extracellular Ca(2+)concentration. Immunocytochemical staining revealed that E-cadherin, P-cadherin, and involucrin were present in the cultures, with distributions consistent with their in vivo localization patterns. Distribution of keratins 19, 3, and 4 in conjunctival epithelial cultures were also consistent with in vivo patterns and distinctly different from patterns observed in epithelial cultures similarly generated from cornea and foreskin. Hence, conjunctival keratinocyte cultures retain some tissue-specific markers and do not revert to a generic, culture phenotype.