Emergency Physicians' Ethical Issues with Hospital Business Models.

BACKGROUND: The changing hospital business model has raised ethical issues for emergency physicians (EPs) in a healthcare system that often prioritizes profits over patient welfare. For-profit hospitals, driven by profit motives, may prioritize treating patients with lucrative insurance plans and those who can afford expensive treatments. Private equity investors, who now own many for-profit hospitals, focus on short-term financial gains, leading to cost-cutting measures and pressure on EPs to prioritize financial goals over patient welfare. Nonprofit hospitals, mandated to provide charity care to the underserved, may fail to meet their community service obligations, resulting in disparities in healthcare access. OBJECTIVE: This review examines the ethical challenges faced by emergency physicians (EPs) in response to the evolving hospital business model, which increasingly prioritizes profits over patient welfare. DISCUSSION: Emergency physicians face ethical dilemmas in this changing environment, including conflicts between patient care and financial interests. Upholding professional ethics and the principle of beneficence is essential. Another challenge is equitable access to healthcare, with some nonprofit hospitals reducing charity care, thus exacerbating disparities. EPs must uphold the ethical principle of justice, ensuring quality care for all patients, regardless of financial means. Conflicts of interest may arise when EPs work in hospitals owned by private equity firms or with affiliations with pharmaceutical companies or medical device manufacturers, potentially compromising patient care. CONCLUSION: Emergency physicians must navigate these ethical issues while upholding professional ethics and advocating for patients' best interests. Collaboration with hospital administrators, policymakers, and stakeholders is vital to address these concerns and prioritize patient welfare in healthcare delivery.

Proteolysis: a key post-translational modification regulating proteoglycans.

Proteoglycans are composite molecules comprising a protein backbone, i.e., the core protein, with covalently attached glycosaminoglycan chains of distinct chemical types. Most proteoglycans are secreted or attached to the cell membrane. Their specialized structures, binding properties, and biophysical attributes underlie diverse biological roles, which include modulation of tissue mechanics, cell adhesion, and the sequestration and regulated release of morphogens, growth factors, and cytokines. As an irreversible post-translational modification, proteolysis has a profound impact on proteoglycan function, abundance, and localization. Proteolysis is required for molecular maturation of some proteoglycans, clearance of extracellular matrix proteoglycans during tissue remodeling, generation of bioactive fragments from proteoglycans, and ectodomain shedding of cell-surface proteoglycans. Genetic evidence shows that proteoglycan core protein proteolysis is essential for diverse morphogenetic events during embryonic development. In contrast, dysregulated proteoglycan proteolysis contributes to osteoarthritis, cardiovascular disorders, cancer, and inflammation. Proteolytic fragments of perlecan, versican, aggrecan, brevican, collagen XVIII, and other proteoglycans are associated with independent biological activities as so-called matrikines. Yet, proteoglycan proteolysis has been investigated to only a limited extent to date. Here, we review the actions of proteases on proteoglycans and illustrate their functional impact with several examples. We discuss the applications and limitations of strategies used to define cleavage sites in proteoglycans and explain how proteoglycanome-wide proteolytic mapping, which is desirable to fully understand the impact of proteolysis on proteoglycans, can be facilitated by integrating classical proteoglycan isolation methods with mass spectrometry-based proteomics.

Post-translational regulation and proteolytic activity of the metalloproteinase ADAMTS8.

A disintegrin-like and metalloprotease domain with thrombospondin type 1 motifs (ADAMTS)8 is a secreted protease, which was recently implicated in pathogenesis of pulmonary arterial hypertension (PAH). However, the substrate repertoire of ADAMTS8 and regulation of its activity are incompletely understood. Although considered a proteoglycanase because of high sequence similarity and close phylogenetic relationship to the proteoglycan-degrading proteases ADAMTS1, 4, 5, and 15, as well as tight genetic linkage with ADAMTS15 on human chromosome 11, its aggrecanase activity was reportedly weak. Several post-translational factors are known to regulate ADAMTS proteases such as autolysis, inhibition by endogenous inhibitors, and receptor-mediated endocytosis, but their impacts on ADAMTS8 are unknown. Here, we show that ADAMTS8 undergoes autolysis at six different sites within its spacer domain. We also found that in contrast to ADAMTS4 and 5, ADAMTS8 levels were not regulated through low-density lipoprotein receptor-related protein 1 (LRP1)-mediated endocytosis. Additionally, ADAMTS8 lacked significant activity against the proteoglycans aggrecan, versican, and biglycan. Instead, we found that ADAMTS8 cleaved osteopontin, a phosphoprotein whose expression is upregulated in PAH. Multiple ADAMTS8 cleavage sites were identified using liquid chromatography-tandem mass spectrometry. Osteopontin cleavage by ADAMTS8 was efficiently inhibited by TIMP-3, an endogenous inhibitor of ADAMTS1, 4, and 5, as well as by TIMP-2, which has no previously reported inhibitory activity against other ADAMTS proteases. These differences in post-translational regulation and substrate repertoire differentiate ADAMTS8 from other family members and may help to elucidate its role in PAH.

Compensation models in emergency medicine: An ethical perspective.

There is considerable diversity in compensation models in the specialty of Emergency Medicine (EM). We review different compensation models and examine moral consequences possibly associated with the use of various models. The article will consider how different models may promote or undermine health care's quadruple aim of providing quality care, improving population health, reducing health care costs, and improving the work-life balance of health care professionals. It will also assess how different models may promote or undermine the basic bioethical principles of beneficence, non-maleficence, respect for autonomy, and justice.

Applicants with Prior Training.

Emergency medicine (EM) has its challenges, downsides, advantages, and accompanying lifestyle. Additionally, graduates of EM residency programs have abundant job opportunities. Accordingly, there is an increased interest in residency training in EM, even among residents with prior training. Transitioning from another specialty to EM can be complicated yet achievable, especially if EM is the transitioning physician's passion and career goal. Therefore, in this article, we elaborate on the transition process from another discipline to EM in light of changes in residency funding. We also explore the advantages and disadvantages of transitioning to EM with previous training in another specialty. Moreover, we expand on credit equivalencies for months already completed in another training programs, as well as the difficulties to be anticipated by transitioning physicians.

Terahertz absorption of lysozyme in solution.

Absorption of radiation by solution is described by its frequency-dependent dielectric function and can be viewed as a specific application of the dielectric theory of solutions. For ideal solutions, the dielectric boundary-value problem separates the polar response into the polarization of the void in the liquid, created by the solute, and the response of the solute dipole. In the case of a protein as a solute, protein nuclear dynamics do not project on significant fluctuations of the dipole moment in the terahertz domain of frequencies and the protein dipole can be viewed as dynamically frozen. Absorption of radiation then reflects the interfacial polarization. Here we apply an analytical theory and computer simulations to absorption of radiation by an ideal solution of lysozyme. Comparison with the experiment shows that Maxwell electrostatics fails to describe the polarization of the protein-water interface and the "Lorentz void," which does not anticipate polarization of the interface by the external field (no surface charges), better represents the data. An analytical theory for the slope of the solution absorption against the volume fraction of the solute is formulated in terms of the cavity field response function. It is calculated from molecular dynamics simulations in good agreement with the experiment. The protein hydration shell emerges as a separate sub-ensemble, which, collectively, is not described by the standard electrostatics of dielectrics.

Photosynthetic diode: electron transport rectification by wetting the quinone cofactor.

We report 11 µs of molecular dynamics simulations of the electron-transfer reaction between primary and secondary quinone cofactors in the bacterial reaction center. The main question addressed here is the mechanistic reason for unidirectional electron transfer between chemically identical cofactors. We find that electron is trapped at the secondary quinone by wetting of the protein pocket following electron transfer on the time-scale shorter than the backward transition. This mechanism provides effective rectification of the electron transport, making the reaction center a molecular diode operating by cyclic charge-induced electrowetting.

Communication: Microsecond dynamics of the protein and water affect electron transfer in a bacterial bc(1) complex.

Cross-membrane electron transport between cofactors localized in proteins of mitochondrial respiration and bacterial photosynthesis is the source of all biological energy. The statistics and dynamics of nuclear fluctuations in these protein/membrane/water heterogeneous systems are critical for their energetic efficiency. The results of 13 µs of atomistic molecular dynamics simulations of the membrane-bound bc1 bacterial complex are analyzed here. The reaction is affected by a broad spectrum of nuclear modes, with the slowest dynamics in the range of time-scales ∼0.1-1.6 µs contributing half of the reaction reorganization energy. Two reorganization energies are required to describe protein electron transfer due to dynamical arrest of protein conformations on the observation window. This mechanistic distinction allows significant lowering of activation barriers for reactions in proteins.

Hydration shells of proteins probed by depolarized light scattering and dielectric spectroscopy: orientational structure is significant, positional structure is not.

Water interfacing hydrated proteins carry properties distinct from those of the bulk and is often described as a separate entity, a "biological water." We address here the question of which dynamical and structural properties of hydration water deserve this distinction. The study focuses on different aspects of the density and orientational fluctuations of hydration water and the ability to separate them experimentally by combining depolarized light scattering with dielectric spectroscopy. We show that the dynamics of the density fluctuations of the hydration shells reflect the coupled dynamics of the solute and solvent and do not require a special distinction as "biological water." The orientations of shell water molecules carry dramatically different physics and do require a separation into a sub-ensemble. Depending on the property considered, the perturbation of water's orientational structure induced by the protein propagates 3-5 hydration shells into the bulk at normal temperature.

Depolarized light scattering and dielectric response of a peptide dissolved in water.

The density and orientational relaxation of bulk water can be separately studied by depolarized light scattering (DLS) and dielectric spectroscopy (DS), respectively. Here, we ask the question of what are the leading collective modes responsible for polarization anisotropy relaxation (DLS) and dipole moment relaxation (DS) of solutions involving mostly hydrophobic solute-water interfaces. We study, by atomistic molecular dynamics simulations, the dynamics and structure of hydration water interfacing N-Acetyl-leucine-methylamide dipeptide. The DLS response of the solution is consistent with three relaxation processes: bulk water, rotations of single solutes, and collective dipole-induced-dipole polarizability of the solutes, with the time-scale of 130-200 ps. No separate DLS response of the hydration shell has been identified by our simulations. Density fluctuations of the hydration layer, which largely contribute to the response, do not produce a dynamical process distinct from bulk water. We find that the structural perturbation of the orientational distribution of hydration waters by the dipeptide solute is quite significant and propagates ∼3-5 hydration layers into the bulk. This perturbation is still below that produced by hydrated globular proteins. Despite this structural perturbation, there is little change in the orientational dynamics of the hydration layers, compared to the bulk, as probed by both single-particle orientational dynamics and collective dynamics of the dipole moment of the shells. There is a clear distinction between the perturbation of the interfacial structure by the solute-solvent interaction potential and the perturbation of the interfacial dynamics by the corresponding forces.

A tiered mentorship program improves number of students with an identified mentor.

BACKGROUND: Mentorship is critical to professional development and academic success. Unfortunately, only about 40% of medical students can identify a mentor. While group mentorship has been evaluated - the concept of a specialty specific, tiered group mentorship program (TGMP) has not. In the latter, each member of the group represents a unique education or professional level. PURPOSE: The purpose of this study was to investigate the ability of a specialty-specific, tiered group mentorship program to improve mentorship for students interested in emergency medicine. METHODS: Groups consisted of faculty members, residents, 4th-year students pursuing a career in Emergency Medicine, and junior (MS1, MS2, and MS3) medical students (13 total groups). Students completed confidential electronic surveys before and after completion of the program. RESULTS: Of 126 students, 85 completed the Course Evaluation Survey. At program onset, 11.4% of 1st-year students, 41.7% of 2nd-year students, 50% of 3rd-year students, and 28% of the total students could identify a mentor. After completion, 68.6% of 1st years, 83.3% of 2nd years, 90% of 3rd years, and 77.6% of the total reported they could identify a mentor. Faculty were rated most important members followed by the 4th-year student. CONCLUSION: A tiered group mentorship program improved the ability of students to identify a mentor. Students identified mentoring relationships from individuals at various professional levels.

Traditional and targeted exome sequencing reveals common, rare and novel functional deleterious variants in RET-signaling complex in a cohort of living US patients with urinary tract malformations.

Signaling by the glial cell line-derived neurotrophic factor (GDNF)-RET receptor tyrosine kinase and SPRY1, a RET repressor, is essential for early urinary tract development. Individual or a combination of GDNF, RET and SPRY1 mutant alleles in mice cause renal malformations reminiscent of congenital anomalies of the kidney or urinary tract (CAKUT) in humans and distinct from renal agenesis phenotype in complete GDNF or RET-null mice. We sequenced GDNF, SPRY1 and RET in 122 unrelated living CAKUT patients to discover deleterious mutations that cause CAKUT. Novel or rare deleterious mutations in GDNF or RET were found in six unrelated patients. A family with duplicated collecting system had a novel mutation, RET-R831Q, which showed markedly decreased GDNF-dependent MAPK activity. Two patients with RET-G691S polymorphism harbored additional rare non-synonymous variants GDNF-R93W and RET-R982C. The patient with double RET-G691S/R982C genotype had multiple defects including renal dysplasia, megaureters and cryptorchidism. Presence of both mutations was necessary to affect RET activity. Targeted whole-exome and next-generation sequencing revealed a novel deleterious mutation G443D in GFRα1, the co-receptor for RET, in this patient. Pedigree analysis indicated that the GFRα1 mutation was inherited from the unaffected mother and the RET mutations from the unaffected father. Our studies indicate that 5% of living CAKUT patients harbor deleterious rare variants or novel mutations in GDNF-GFRα1-RET pathway. We provide evidence for the coexistence of deleterious rare and common variants in genes in the same pathway as a cause of CAKUT and discovered novel phenotypes associated with the RET pathway.

Dissipative electro-elastic network model of protein electrostatics.

We propose a dissipative electro-elastic network model to describe the dynamics and statistics of electrostatic fluctuations at active sites of proteins. The model combines the harmonic network of residue beads with overdamped dynamics of the normal modes of the network characterized by two friction coefficients. The electrostatic component is introduced to the model through atomic charges of the protein force field. The overall effect of the electrostatic fluctuations of the network is recorded through the frequency-dependent response functions of the electrostatic potential and electric field at the protein active site. We also consider the dynamics of displacements of individual residues in the network and the dynamics of distances between pairs of residues. The model is tested against loss spectra of residue displacements and the electrostatic potential and electric field at the heme's iron from all-atom molecular dynamics simulations of three hydrated globular proteins.

Solvated dissipative electro-elastic network model of hydrated proteins.

Elastic network models coarse grain proteins into a network of residue beads connected by springs. We add dissipative dynamics to this mechanical system by applying overdamped Langevin equations of motion to normal-mode vibrations of the network. In addition, the network is made heterogeneous and softened at the protein surface by accounting for hydration of the ionized residues. Solvation changes the network Hessian in two ways. Diagonal solvation terms soften the spring constants and off-diagonal dipole-dipole terms correlate displacements of the ionized residues. The model is used to formulate the response functions of the electrostatic potential and electric field appearing in theories of redox reactions and spectroscopy. We also formulate the dielectric response of the protein and find that solvation of the surface ionized residues leads to a slow relaxation peak in the dielectric loss spectrum, about two orders of magnitude slower than the main peak of protein relaxation. Finally, the solvated network is used to formulate the allosteric response of the protein to ion binding. The global thermodynamics of ion binding is not strongly affected by the network solvation, but it dramatically enhances conformational changes in response to placing a charge at the active site of the protein.

The effects of a 6-month mandatory military police academy training on recruits' physical fitness.

BACKGROUND: Physical fitness for health and professional performance play important roles in police workforce considering that policing is a dangerous job, associated with high physical demands. OBJECTIVES: (1) To evaluate the effects of a 6-month course of police academy training on health-related physical fitness (HRPF) of military police recruits. (2) To investigate whether recruits' HRPF still met the academy entry standards after an unsupervised 7-month period prior to academy. METHODS: We conducted an observational and longitudinal study with 219 male police recruits (aged 25.5±3.6 years; BMI of 24.4±2.5 kg/m2). HRPF parameters included the Cooper 12-min running test for cardiorespiratory fitness (CRF), curl-ups, pull-ups and push-ups for muscle strength/endurance which were evaluated 3 times: 7 months prior to academy course and pre- and post-academy training period. RESULTS: Participants maintained optimal age-related HRPF during the unsupervised period prior to academy. After academy training upon graduation, all HRPF parameters further increased an average of 7.7 to 69.0% (p < 0.001; calculated Cohen's d effect size ≥0.95). CRF was the only HRPF that improved less than 10% after the academy course. CONCLUSIONS: Police recruits that had passed the application fitness standards maintained their HRPF prior to academy, and all their HRPF parameters increased after a 6-month academy training period which was not primarily focused on exercise training. Among all components of HRPF, CRF appears to be the most challenging one to improve among police recruits. Our findings suggest that regular training with minimum physical standards could be potentially beneficial to police officers' health and career longevity.

Visualizing Staphylococcus aureus pathogenic membrane modification within the host infection environment by multimodal imaging mass spectrometry.

Bacterial pathogens have evolved virulence factors to colonize, replicate, and disseminate within the vertebrate host. Although there is an expanding body of literature describing how bacterial pathogens regulate their virulence repertoire in response to environmental signals, it is challenging to directly visualize virulence response within the host tissue microenvironment. Multimodal imaging approaches enable visualization of host-pathogen molecular interactions. Here we demonstrate multimodal integration of high spatial resolution imaging mass spectrometry and microscopy to visualize Staphylococcus aureus envelope modifications within infected murine and human tissues. Data-driven image fusion of fluorescent bacterial reporters and matrix-assisted laser desorption/ionization Fourier transform ion cyclotron resonance imaging mass spectrometry uncovered S. aureus lysyl-phosphatidylglycerol lipids, localizing to select bacterial communities within infected tissue. Absence of lysyl-phosphatidylglycerols is associated with decreased pathogenicity during vertebrate colonization as these lipids provide protection against the innate immune system. The presence of distinct staphylococcal lysyl-phosphatidylglycerol distributions within murine and human infections suggests a heterogeneous, spatially oriented microbial response to host defenses.

Proteolysis of fibrillin-2 microfibrils is essential for normal skeletal development.

The embryonic extracellular matrix (ECM) undergoes transition to mature ECM as development progresses, yet few mechanisms ensuring ECM proteostasis during this period are known. Fibrillin microfibrils are macromolecular ECM complexes serving structural and regulatory roles. In mice, Fbn1 and Fbn2, encoding the major microfibrillar components, are strongly expressed during embryogenesis, but fibrillin-1 is the major component observed in adult tissue microfibrils. Here, analysis of Adamts6 and Adamts10 mutant mouse embryos, lacking these homologous secreted metalloproteases individually and in combination, along with in vitro analysis of microfibrils, measurement of ADAMTS6-fibrillin affinities and N-terminomics discovery of ADAMTS6-cleaved sites, identifies a proteostatic mechanism contributing to postnatal fibrillin-2 reduction and fibrillin-1 dominance. The lack of ADAMTS6, alone and in combination with ADAMTS10 led to excess fibrillin-2 in perichondrium, with impaired skeletal development defined by a drastic reduction of aggrecan and cartilage link protein, impaired BMP signaling in cartilage, and increased GDF5 sequestration in fibrillin-2-rich tissue. Although ADAMTS6 cleaves fibrillin-1 and fibrillin-2 as well as fibronectin, which provides the initial scaffold for microfibril assembly, primacy of the protease-substrate relationship between ADAMTS6 and fibrillin-2 was unequivocally established by reversal of the defects in Adamts6-/- embryos by genetic reduction of Fbn2, but not Fbn1.

Electric field inside a "Rossky cavity" in uniformly polarized water.

Electric field produced inside a solute by a uniformly polarized liquid is strongly affected by dipolar polarization of the liquid at the interface. We show, by numerical simulations, that the electric "cavity" field inside a hydrated non-polar solute does not follow the predictions of standard Maxwell's electrostatics of dielectrics. Instead, the field inside the solute tends, with increasing solute size, to the limit predicted by the Lorentz virtual cavity. The standard paradigm fails because of its reliance on the surface charge density at the dielectric interface determined by the boundary conditions of the Maxwell dielectric. The interface of a polar liquid instead carries a preferential in-plane orientation of the surface dipoles thus producing virtually no surface charge. The resulting boundary conditions for electrostatic problems differ from the traditional recipes, affecting the microscopic and macroscopic fields based on them. We show that relatively small differences in cavity fields propagate into significant differences in the dielectric constant of an ideal mixture. The slope of the dielectric increment of the mixture versus the solute concentration depends strongly on which polarization scenario at the interface is realized. A much steeper slope found in the case of Lorentz interfacial polarization also implies a higher free energy penalty for polarizing such mixtures.

Activation of NFAT signaling in podocytes causes glomerulosclerosis.

Mutant forms of TRPC6 can activate NFAT-dependent transcription in vitro via calcium influx and activation of calcineurin. The same TRPC6 mutants can cause FSGS, but whether this involves an NFAT-dependent mechanism is unknown. Here, we generated mice that allow conditional induction of NFATc1. Mice with NFAT activation in nascent podocytes in utero developed proteinuria and glomerulosclerosis postnatally, resembling FSGS. NFAT activation in adult mice also caused progressive proteinuria and FSGS. Ultrastructural studies revealed podocyte foot process effacement and deposition of extracellular matrix. NFAT activation did not initially affect expression of podocin, synaptopodin, and nephrin but reduced their expression as glomerular injury progressed. In contrast, we observed upregulation of Wnt6 and Fzd9 in the mutant glomeruli before the onset of significant proteinuria, suggesting a potential role for Wnt signaling in the pathogenesis of NFAT-induced podocyte injury and FSGS. These results provide in vivo evidence for the involvement of NFAT signaling in podocytes, proteinuria, and glomerulosclerosis. Furthermore, this study suggests that NFAT activation may be a key intermediate step in the pathogenesis of mutant TRPC6-mediated FSGS and that suppression of NFAT activity may contribute to the antiproteinuric effects of calcineurin inhibitors.

Identification of novel ADAMTS1, ADAMTS4 and ADAMTS5 cleavage sites in versican using a label-free quantitative proteomics approach.

The chondroitin sulfate proteoglycan versican is important for embryonic development and several human disorders. The versican V1 splice isoform is widely expressed and cleaved by ADAMTS proteases at a well-characterized site, Glu441-Ala442. Since ADAMTS proteases cleave the homologous proteoglycan aggrecan at multiple sites, we hypothesized that additional cleavage sites existed within versican. We report a quantitative label-free approach that ranks abundance of liquid chromatography-tandem mass spectrometry (LC-MS/MS)-identified semi-tryptic peptides after versican digestion by ADAMTS1, ADAMTS4 and ADAMTS5 to identify site-specific cleavages. Recombinant purified versican V1 constructs were digested with the recombinant full-length proteases, using catalytically inactive mutant proteases in control digests. Semi-tryptic peptide abundance ratios determined by LC-MS/MS in ADAMTS:control digests were compared to the mean of all identified peptides to obtain a z-score by which outlier peptides were ranked, using semi-tryptic peptides identifying Glu441 -Ala442 cleavage as the benchmark. Tryptic peptides with higher abundance in control digests supported cleavage site identification. We identified several novel cleavage sites supporting the ADAMTS1/4/5 cleavage site preference for a P1-Glu residue in proteoglycan substrates. Digestion of proteins in vitro and application of this z-score approach is potentially widely applicable for mapping protease cleavage sites using label-free proteomics. SIGNIFICANCE: Versican abundance and turnover are relevant to the pathogenesis of several human disorders. Versican is cleaved by A Disintegrin-like And Metalloprotease with Thrombospondin type 1 motifs (ADAMTS) family members at Glu441-Ala442, generating a bioactive proteoform called versikine, but additional cleavage sites and the site-specificity of individual ADAMTS proteases is unexplored. Here, we used a label-free proteomics strategy to identify versican cleavage sites for 3 ADAMTS proteases, applying a novel z-score-based statistical approach to compare the protease digests of versican to controls (digests with inactive protease) using the known protease cleavage site as a benchmark. We identified 21 novel cleavage sites that had a comparable z-score to the benchmark. Given the functional significance of versikine, they represent potentially significant cleavages and helped to refine a substrate site preference for each protease.The z-score approach is potentially widely applicable for discovery of site-specific cleavages within an purified protein or small ensemble of proteins using any protease.