Peripheral Nerve Stimulation in Postoperative Analgesia: A Narrative Review.

PURPOSE OF REVIEW: Recent research has shown the effectiveness of peripheral nerve stimulators (PNS) in managing chronic pain conditions. Ongoing studies aim to explore its potential application in treating acute postoperative pain states. The purpose of this systematic review is to assess the role of PNS in providing relief for postoperative pain. RECENT FINDINGS: Clinical studies investigating the use of peripheral nerve stimulators (PNS) for analgesia following various surgeries, such as total knee arthroplasty, anterior cruciate ligament repair, ankle arthroplasty, rotator cuff repair, hallux valgus correction, and extremity amputation, have shown promising results. Lead placement locations include the brachial plexus, sciatic, femoral, tibial, genicular, perineal, sural, radial, median, and ulnar nerves. These studies consistently report clinically significant reductions in pain scores, and some even indicate a decrease in opioid consumption following PNS for postoperative pain. PNS involves the subcutaneous placement of electrode leads to target peripheral nerve(s) followed by delivery of an electric current via an external pulse generator. While the precise mechanism is not fully understood, the theory posits that PNS modulates electrical stimulation, hindering the signaling of nociceptive pain. PNS presents itself as an alternative to opioid therapy, holding promise to address the opioid epidemic by offering a nonpharmacologic approach for both acute and chronic pain states.

CRISPR/Cas-Mediated Knockdown of PD-L1 and KRAS in Lung Cancer Cells.

Cancer cells can escape death and surveillance by the host immune system in various ways. Programmed cell death ligand 1 (PD-L1) is a transmembrane protein that is expressed by most cell types, including cancer cells, and can provide an inhibitory signal to its receptor PD-1, which is expressed on the surface of activated T cells, impairing the immune response. PD-L1/PD-1-mediated immune evasion is observed in several KRAS-mutated cancers. In the current study, we used the CRISPR/Cas9 system to knock down PD-L1 and KRAS in adenocarcinoma lung cells (A549 and H1975). Knockdown of PD-L1 was validated by qPCR and coculture with lymphocytes. The cells were functionally analyzed for cell cycle, migration and apoptosis. In addition, the effects of PD-L1 and KRAS downregulation on chemotherapy sensitivity and expression of inflammatory markers were investigated. Suppression of PD-L1 and KRAS led to a slowdown of the cell cycle in the G0/G1 phase and reduced migration, increased sensitivity to chemotherapy and triggered apoptosis of cancer cells. In addition, the conditioned medium of the modulated cells significantly affected the native cancer cells and reduced their viability and drug resistance. Our study suggests that dual silencing of PD-L1 and KRAS by CRISPR/Cas9 may be a promising therapeutic approach for the treatment of lung cancer.

A short-term comparison of wheat straw and poplar wood chips used as litter in tiestalls on hygiene, milk, and behavior of lactating dairy cows.

A short-term study was conducted to compare the effect of using poplar wood chips (PWC) instead of wheat straw (WS) litter in dairy cows. A total of 38 lactating Holstein cows (204 ± 119 days in milk, 26.9 ± 6.5 kg of milk yield [MY]) were housed in a tiestall farm for a 10-d trial including 5 d of adaptation followed by 5 sampling days (from d 5 to 10). Cows were divided into 2 homogeneous groups: one group was bedded with WS, and the second with PWC. Both litter materials were provided in the amount of 7 kg/stall per d. Each group was composed of 3 subgroups of 6 or 7 cows; the subgroups were physically separated along the feeding line by wooden boards. During the sampling days, fecal composition, used litter composition, and bacterial count (Clostridium spp., Salmonella spp., Escherichia coli, Lactobacillus, and total bacterial count) were analyzed by subgroup twice a day. On d 1 and from d 5 to 10, udder hygiene score and cow cleanliness score were also evaluated individually twice a day. Meanwhile MY, milk hygiene (total bacterial count [TBC], coliform bacterial count [CBC], and spore-forming units [SFU]) and quality were measured and analyzed from 9 animals per group. Moreover, individual animal behavior (body position and behavioral traits) and subgroup dry matter intake were measured on d 9 and 10. Fecal dry matter did not differ between groups, PWC had the lowest used litter moisture and N content favoring the highest clean cow frequency, but also gave rise to the greatest used litter microbial contamination. The MY, milk quality, TBC, SFU, and CBC were similar. The lying behavior frequency was similar between groups. However, the PWC group showed the lowest sleeping frequency, the highest frequency of other behaviors (including discomfort signs), and the lowest dry matter intake. However, despite this apparent reduction in cow comfort, no biologically important differences were observed in this short-term study between cows on PWC and WS in milk production or hygiene.

Why haploinsufficiency persists.

Haploinsufficiency describes the decrease in organismal fitness observed when a single copy of a gene is deleted in diploids. We investigated the origin of haploinsufficiency by creating a comprehensive dosage sensitivity data set for genes under their native promoters. We demonstrate that the expression of haploinsufficient genes is limited by the toxicity of their overexpression. We further show that the fitness penalty associated with excess gene copy number is not the only determinant of haploinsufficiency. Haploinsufficient genes represent a unique subset of genes sensitive to copy number increases, as they are also limiting for important cellular processes when present in one copy instead of two. The selective pressure to decrease gene expression due to the toxicity of overexpression, combined with the pressure to increase expression due to their fitness-limiting nature, has made haploinsufficient genes extremely sensitive to changes in gene expression. As a consequence, haploinsufficient genes are dosage stabilized, showing much more narrow ranges in cell-to-cell variability of expression compared with other genes in the genome. We propose a dosage-stabilizing hypothesis of haploinsufficiency to explain its persistence over evolutionary time.

Emergency Nurse Perceptions of Pain and Opioids in the Emergency Department.

The opioid crisis is a national health emergency with immense morbidity, mortality, and socioeconomic cost. Emergency department (ED) pain management is tightly linked to the issue of opioid use disorder (OUD), because opioid exposure is necessary for development of OUD. Emergency nurses are on the frontlines of this complex problem, yet little, if any, attention has been paid to the role they play in the prevention and management of either pain or OUD in this unique and important setting. A framework that conceptualizes and optimizes emergency nurses as change agents in the opioid epidemic is urgently needed. While ED pain management and OUD prevention is dependent on the entire care team, this innovative study qualitatively characterizes emergency nurse perceptions of pain management, OUD prevention, and their potential role in each. Content analysis produced 14 categories that were clustered into two themes, "nurses influence ED pain management" and "adjustments in ED pain management", and an overarching message that "pain management depends on the care team." By generating a more comprehensive and nuanced understanding of the role played by emergency nurses, our findings provide essential insights into potential interventions and frameworks.

Enhanced Osteogenic Differentiation of Pluripotent Stem Cells via γ-Secretase Inhibition.

Bone healing is a complex, well-organized process. Multiple factors regulate this process, including growth factors, hormones, cytokines, mechanical stimulation, and aging. One of the most important signaling pathways that affect bone healing is the Notch signaling pathway. It has a significant role in controlling the differentiation of bone mesenchymal stem cells and forming new bone. Interventions to enhance the healing of critical-sized bone defects are of great importance, and stem cell transplantations are eminent candidates for treating such defects. Understanding how Notch signaling impacts pluripotent stem cell differentiation can significantly enhance osteogenesis and improve the overall healing process upon transplantation. In Rancourt's lab, mouse embryonic stem cells (ESC) have been successfully differentiated to the osteogenic cell lineage. This study investigates the role of Notch signaling inhibition in the osteogenic differentiation of mouse embryonic and induced pluripotent stem cells (iPS). Our data showed that Notch inhibition greatly enhanced the differentiation of both mouse embryonic and induced pluripotent stem cells.

Antibiotic Treatment Prior to Injury Improves Post-Traumatic Osteoarthritis Outcomes in Mice.

Osteoarthritis (OA) is a painful and debilitating disease characterized by the chronic and progressive degradation of articular cartilage. Post-traumatic OA (PTOA) is a secondary form of OA that develops in ~50% of cases of severe articular injury. Inflammation and re-occurring injury have been implicated as contributing to the progression of PTOA after the initial injury. However, there is very little known about external factors prior to injury that could affect the risk of PTOA development. To examine how the gut microbiome affects PTOA development we used a chronic antibiotic treatment regimen starting at weaning for six weeks prior to ACL rupture, in mice. A six-weeks post-injury histological examination showed more robust cartilage staining on the antibiotic (AB)-treated mice than the untreated controls (VEH), suggesting slower disease progression in AB cohorts. Injured joints also showed an increase in the presence of anti-inflammatory M2 macrophages in the AB group. Molecularly, the phenotype correlated with a significantly lower expression of inflammatory genes Tlr5, Ccl8, Cxcl13, and Foxo6 in the injured joints of AB-treated animals. Our results indicate that a reduced state of inflammation at the time of injury and a lower expression of Wnt signaling modulatory protein, Rspo1, caused by AB treatment can slow down or improve PTOA outcomes.

Stereodivergent, Chemoenzymatic Synthesis of Azaphilone Natural Products.

Selective access to a targeted isomer is often critical in the synthesis of biologically active molecules. Whereas small-molecule reagents and catalysts often act with anticipated site- and stereoselectivity, this predictability does not extend to enzymes. Further, the lack of access to catalysts that provide complementary selectivity creates a challenge in the application of biocatalysis in synthesis. Here, we report an approach for accessing biocatalysts with complementary selectivity that is orthogonal to protein engineering. Through the use of a sequence similarity network (SSN), a number of sequences were selected, and the corresponding biocatalysts were evaluated for reactivity and selectivity. With a number of biocatalysts identified that operate with complementary site- and stereoselectivity, these catalysts were employed in the stereodivergent, chemoenzymatic synthesis of azaphilone natural products. Specifically, the first syntheses of trichoflectin, deflectin-1a, and lunatoic acid A were achieved. In addition, chemoenzymatic syntheses of these azaphilones supplied enantioenriched material for reassignment of the absolute configuration of trichoflectin and deflectin-1a based on optical rotation, CD spectra, and X-ray crystallography.

Chemoenzymatic o-Quinone Methide Formation.

Generation of reactive intermediates and interception of these fleeting species under physiological conditions is a common strategy employed by Nature to build molecular complexity. However, selective formation of these species under mild conditions using classical synthetic techniques is an outstanding challenge. Here, we demonstrate the utility of biocatalysis in generating o-quinone methide intermediates with precise chemoselectivity under mild, aqueous conditions. Specifically, α-ketoglutarate-dependent non-heme iron enzymes, CitB and ClaD, are employed to selectively modify benzylic C-H bonds of o-cresol substrates. In this transformation, biocatalytic hydroxylation of a benzylic C-H bond affords a benzylic alcohol product which, under the aqueous reaction conditions, is in equilibrium with the corresponding o-quinone methide. o-Quinone methide interception by a nucleophile or a dienophile allows for one-pot conversion of benzylic C-H bonds into C-C, C-N, C-O, and C-S bonds in chemoenzymatic cascades on preparative scale. The chemoselectivity and mild nature of this platform is showcased here by the selective modification of peptides and chemoenzymatic synthesis of the chroman natural product (-)-xyloketal D.

A phase Ib study of entinostat plus lapatinib with or without trastuzumab in patients with HER2-positive metastatic breast cancer that progressed during trastuzumab treatment.

BACKGROUND: Human epidermal growth factor 2 (HER2) is an effective therapeutic target in breast cancer; however, resistance to anti-HER2 agents such as trastuzumab and lapatinib develops. In a preclinical model, an HDAC inhibitor epigenetically reversed the resistance of cancer cells to trastuzumab and showed synergistic efficacy with lapatinib in inhibiting growth of trastuzumab-resistant HER2-positive (HER2+) breast cancer. METHODS: A phase 1b, dose escalation study was performed to assess maximum tolerated dose, safety/toxicity, clinical efficacy and explored pharmacodynamic biomarkers of response to entinostat combined with lapatinib with or without trastuzumab. RESULTS: The combination was safe. The MTD was lapatinib, 1000 mg daily; entinostat, 12 mg every other week; trastuzumab, 8 mg/kg followed by 6 mg/kg every 3 weeks. Adverse events included diarrhoea (89%), neutropenia (31%), and thrombocytopenia (23%). Neutropenia, thrombocytopenia and hypokalaemia were noted. Pharmacodynamic assessment did not yield conclusive results. Among 35 patients with evaluable response, PR was observed in 3 patients and CR in 3 patients, 1 maintained SD for over 6 months. DISCUSSION: This study identified the MTD of the entinostat, lapatinib, and trastuzumab combination that provided acceptable tolerability and anti-tumour activity in heavily pre-treated patients with HER2+ metastatic breast cancer, supporting a confirmatory trial.

Flavin-dependent biocatalysts in synthesis.

The diverse chemistry possible with flavin cofactors positions flavin-dependent enzymes as versatile synthetic tools. This focused review highlights applications of flavin-dependent enzymes in organic synthesis. Select examples of monoamine oxidases, ene-reductases, monooxygenases and halogenases in target-oriented synthesis are presented.

Detailed macro- and micromineral profile of milk: Effects of herd productivity, parity, and stage of lactation of cows of 6 dairy and dual-purpose breeds.

The aim of this study was to quantify the major sources of variation in the levels of 15 minerals in individual milk samples collected from cows raised in multibreed dairy herds. The herds (n = 27) were classified into 2 categories, according to milk productivity. Milk productivity was based on the net energy of lactating cows' average daily milk yield. Milk samples were collected from 240 cows of 6 different breeds: 3 specialized dairy (Holstein-Friesian, Brown Swiss, and Jersey) and 3 dual-purpose (Simmental, Rendena, and Alpine Grey). The samples were analyzed for macro-elements (Na, Mg, P, S, K, and Ca), essential micro-elements (Mn, Fe, Cu, Zn, and Se), and environmental micro-elements (B, Si, Sr, and Sn), using inductively coupled plasma-optical emission spectrometry. Data were analyzed using a linear mixed model that included fixed effects of days in milk (DIM), parity, breed, and herd productivity, and a random effect of herd-date within productivity level. Results showed that the effect of herd-date varied across minerals. It was especially large for environmental minerals (ranging from 47 to 91% of total variance) and ranged from 11 to 61% for macrominerals and essential microminerals. Milk samples collected from farms with a high level of herd productivity had a richer mineral profile than samples from low-productivity herds. Parity only influenced macrominerals, with the exception of S and Ca, while DIM influenced almost all minerals, with a few exceptions among the environmental elements. Differences in mineral profile were small between specialized and dual-purpose breeds, but they were large within the group of the specialized cows. These breed differences were reduced after adjusting for milk quality and yield, particularly in the case of milk Mg, S, Ca, Mn, and Zn levels. Milk samples from the Jersey and Brown Swiss cows had higher mineral levels (Sn excluded) than milk from the Holstein-Friesian cows; the other breeds of Alpine origin produced milk of intermediate quality. Our findings suggest that breed has a stronger effect on macrominerals and some of the essential microminerals than herd productivity, parity, and DIM. The modification of the mineral profile in milk seems possible for many minerals, but it likely depends on genetics (e.g., breed, selection) and on environmental and management factors in variable proportions according to the mineral considered.

DNA Instability Maintains the Repeat Length of the Yeast RNA Polymerase II C-terminal Domain.

The C-terminal domain (CTD) of RNA polymerase II in eukaryotes is comprised of tandemly repeating units of a conserved seven-amino acid sequence. The number of repeats is, however, quite variable across different organisms. Furthermore, previous studies have identified evidence of rearrangements within the CTD coding region, suggesting that DNA instability may play a role in regulating or maintaining CTD repeat number. The work described here establishes a clear connection between DNA instability and CTD repeat number in Saccharomyces cerevisiae First, analysis of 36 diverse S. cerevisiae isolates revealed evidence of numerous past rearrangements within the DNA sequence that encodes the CTD. Interestingly, the total number of CTD repeats was relatively static (24-26 repeats in all strains), suggesting a balancing act between repeat expansion and contraction. In an effort to explore the genetic plasticity within this region, we measured the rates of repeat expansion and contraction using novel reporters and a doxycycline-regulated expression system for RPB1 In efforts to determine the mechanisms leading to CTD repeat variability, we identified the presence of DNA secondary structures, specifically G-quadruplex-like DNA, within the CTD coding region. Furthermore, we demonstrated that mutating PIF1, a G-quadruplex-specific helicase, results in increased CTD repeat length polymorphisms. We also determined that RAD52 is necessary for CTD repeat expansion but not contraction, identifying a role for recombination in repeat expansion. Results from these DNA rearrangements may help explain the CTD copy number variation seen across eukaryotes, as well as support a model of CTD expansion and contraction to maintain CTD integrity and overall length.

Evaluation of fever in the emergency department.

BACKGROUND: Fever is one of the most common complaints in the emergency department (ED) and is more complex than generally appreciated. The broad differential diagnosis of fever includes numerous infectious and non-infectious etiologies. An essential skill in emergency medicine is recognizing the pitfalls in fever evaluation. OBJECTIVE OF REVIEW: This review provides an overview of the complaint of fever in the ED to assist the emergency physician with a structured approach to evaluation. DISCUSSION: Fever can be due to infectious or non-infectious etiology and results from the body's natural response to a pyrogen. Adjunctive testing including C-reactive protein, erythrocyte sedimentation rate, and procalcitonin has been evaluated in the literature, but these tests do not have the needed sensitivity and specificity to definitively rule in a bacterial cause of fever. Blood cultures should be obtained in septic shock or if the results will change clinical management. Fever may not be always present in true infection, especially in elderly and immunocompromised patients. Oral temperatures suffer from poor sensitivity to diagnose fever, and core temperatures should be utilized if concern for fever is present. Consideration of non-infectious causes of elevated temperature is needed based on the clinical situation. CONCLUSION: Any fever evaluation must rigorously maintain a broad differential to avoid pitfalls that can have patient care consequences. Fever is complex and due to a variety of etiologies. An understanding of the pathophysiology, causes, and assessment is important for emergency physicians.

Prevalence of Sickle Cell Disease among Newborns in St Vincent and the Grenadines: A Retrospective Study.

Objective: In the United States of America (USA), sickle cell disease (SCD) occurs in 1:375 African-American births. However, published data from the Caribbean have revealed higher numbers for some Caribbean islands. St Vincent and the Grenadines (SVG) is a multi-island nation in the Caribbean, and there are currently no data on the incidence or prevalence of the disease in this population. The objective of this study was to obtain birth prevalence estimates for SCD in SVG. Methods: A retrospective review of haemoglobin electrophoresis test results at the laboratory of the main hospital in SVG for the period of October 1, 2005 to December 31, 2013 was done. Test results and demographic data were extracted to determine the estimated birth prevalence of SCD. Results: The estimated birth prevalence of SCD was found to be 1:172 live births, and 86% of the patients were diagnosed after one year of age. Conclusion: The birth prevalence of SCD in SVG was higher than those in the USA, but was similar to the numbers in other Caribbean populations.

Objetivo: En los Estados Unidos de América (EE.UU.), la enfermedad de células falciformes (ECF) ocurre en 1:375 de los nacimientos de afroamericanos. Sin embargo, los datos publicados en el Caribe revelan un número mayor para algunas islas del Caribe. San Vicente y las Granadinas (SVG) es una nación formada por varias islas en el Caribe, y actualmente no existen datos sobre la incidencia o prevalencia de la enfermedad en esta población. El objetivo de este estudio fue obtener estimados de la prevalencia de nacimientos con ECF en SVG. Métodos: Se realizó una revisión retrospectiva de los resultados de pruebas de electroforesis de hemoglobina en el laboratorio del hospital principal de SVG, correspondientes al período de 1 de octubre de 2005 a 31 de diciembre de 2013. Los resultados de la prueba y los datos demográfcos se obtuvieron para hacer un estimado de la prevalencia de nacimientos con ECF. Resultados: Se halló que la prevalencia estimada de nacimientos con ECF fue de 1:172 por nacidos vivos, y que el 86% de los pacientes fueron diagnosticados después de un año de edad. Conclusión: La prevalencia de nacimientos con EFC en SVG fue más alta que la de los EE.UU., pero similar a las estadísticas en otras poblaciones del Caribe.

Gender-specific abnormalities in the serotonin transporter system in panic disorder.

The central serotonergic system has been implicated in the pathophysiology of panic disorder (PD) by evidence of abnormally elevated serotonin-turnover, reduced pre- and post-synaptic 5-HT(1A)-receptor sensitivity and binding and clinical improvement during administration of agents that enhance serotonergic transmission. Polymorphisms in genes that putatively influence serotonergic neurotransmission increase the vulnerability for developing PD specifically in males. We tested the hypotheses that serotonin transporter (5-HTT) binding is elevated in PD subjects vs. healthy controls in regions where in vivo evidence exists for both elevated 5-HTT and 5-HT(1A) receptor levels in PD and investigated whether the extent of this difference depends upon gender. Volunteers were out-patients with current PD (n=24) and healthy controls (n=24). The non-displaceable component of 5-HTT binding-potential (BP(ND)) was measured using positron emission tomography and the 5-HTT selective radioligand, [(11)C]DASB. PD severity was assessed using the PD Severity Scale. The 5-HTT-BP(ND) was increased in males with PD relative to male controls in the anterior cingulate cortex (F=8.96, p(FDR)=0.01) and midbrain (F=5.09, p(FDR)=0.03). In contrast, BP(ND) did not differ between females with PD and female controls in any region examined. The finding that 5-HTT-binding is elevated in males but not in females with PD converges with other evidence suggesting that dysfunction within the central serotonergic system exists in PD, and also indicates that such abnormalities are influenced by gender. These findings conceivably may reflect a sexual dimorphism that underlies the greater efficacy of serotonin reuptake inhibitor treatment in females vs. males with PD.

Kinetic studies on the reaction of chlorosulfonyl isocyanate with monofluoroalkenes: experimental evidence for both stepwise and concerted mechanisms and a pre-equilibrium complex on the reaction pathway.

Chlorosulfonyl isocyanate (CSI) is reported to react with hydrocarbon alkenes by a stepwise dipolar pathway to give N-chlorosulfonyl-ß-lactams that are readily reduced to ß-lactams. Substitution of a vinyl hydrogen for a vinyl fluorine changes the dynamics for reaction with CSI so that a concerted pathway is favored. Rate constants were measured for reactions of CSI with monofluoroalkenes and some hydrocarbon alkenes. Activation parameters for two hydrocarbon alkenes and two monofluoroalkenes support this change in mechanism. A plot generated from the natural log of rate constants vs ionization potentials (IP) indicates that fluoroalkenes with IP values >8.9 eV react by a concerted process. Electron-rich monofluoroalkenes with IP values <8.5 eV were found to react by a single-electron transfer (SET) pathway. Hydrocarbon alkenes were also found to react by this dipolar stepwise SET intermediate rather than the previously accepted stepwise dipolar pathway. Data support a pre-equilibrium complex on the reaction pathway just before the rate-determining step of the concerted pathway and a SET intermediate for the stepwise reactions. When the reactions are carried out at lower temperatures, the equilibrium shifts toward the complex or SET intermediate enhancing the synthetic utility of these reactions. Kinetic data also support formation of a planar transition state rather than the orthogonal geometry as reported for ketene [2 + 2] cycloadditions.

Analysis of 5-year Mortality following Lower Extremity Amputation due to Vascular Disease.

Mortality rates following major lower extremity amputations (LEAs) 30 days-365 days postoperative have decreased, but 5-year rates remain high at 40.4%-70%. These data may not reflect recent advances in peripheral arterial disease (PAD) care, and comorbidities of chronic PAD may lead to mortality more frequently than the amputation itself. Mortality rates between diabetic and nondiabetic patients were also analyzed. Methods: The California Office of Statewide Health Planning and Development hospital database was queried for patients admitted January 1, 2007-December 31, 2018. ICD-9-CM codes identified patients with vascular disease and an amputation procedure. Results: There were 26,669 patients. The 30-day, 90-day, 1-year, and 5-year major LEA mortality rates were 4.82%, 8.62%, 12.47%, and 18.11%, respectively. Weighted averages of 30-day, 90-day, 1-year, and 5-year major LEA mortality rates in the literature are 13%, 15.40%, 47.93%, and 60.60%, respectively. Mortality risk associated with vascular disease after amputation (hazard ratio = 22.07) was 11 times greater than risk associated with amputation-specific complications from impaired mobility (hazard ratio = 1.90; P < 0.01). Having diabetes was associated with lower mortality at 30 days, 90 days, and 1 year (P < 0.01) but not at 5 years (P = 0.22). Conclusions: This study suggests that people may be living longer after their major LEA than was previously thought. This study suggests that patients' PAD may play a bigger role in contributing to their mortality than complications from loss of mobility postamputation. Although having diabetes was associated with lower postamputation mortality, the difference was no longer significant by 5 years.

Expression of epithelial-mesenchymal transition-inducing transcription factors in primary breast cancer: The effect of neoadjuvant therapy.

Epithelial cancer cells are likely to undergo epithelial-mesenchymal transition (EMT) prior to entering the peripheral circulation. By undergoing EMT, circulating tumor cells (CTCs) lose epithelial markers and may escape detection by conventional methods. Therefore, we conducted a pilot study to investigate mRNA transcripts of EMT-inducing transcription factors (TFs) in tumor cells from the peripheral blood (PB) of patients with primary breast cancer (PBC). PB mononuclear cells were isolated from 52 patients with stages I-III PBC and 30 healthy donors (HDs) and were sequentially depleted of EpCAM(+) cells and CD45(+) leukocytes, henceforth referred to as CD45(-). The expression levels of EMT-inducing TFs (TWIST1, SNAIL1, SLUG, ZEB1 and FOXC2) in the CD45(-) cells were determined using quantitative real-time polymerase chain reaction. The highest level of expression by the CD45(-) cell fraction of HD was used as "cutoff" to determine if samples from patients with PBC overexpressed any EMT-inducing TFs. In total, 15.4% of patients with PBC overexpressed at least one of the EMT-inducing TF transcripts. Overexpression of any EMT-inducing TF transcripts was more likely to be detected in patients with PBC who received neoadjuvant therapies (NAT) than patients who received no NAT (p = 0.003). Concurrently, CTCs were detected in 7 of 38 (18.4%) patients by CellSearch® and in 15 of 42 (35.7%) patients by AdnaTest™. There was no association between the presence of CTCs measured by CellSearch® or AdnaTest™. In summary, our results demonstrate that CTCs with EMT phenotype may occur in the peripheral circulation of patients with PBC and that NAT is unable to eliminate CTCs undergoing EMT.

Impact of Medication Reconciliation by a Dialysis Pharmacist.

Integrating a pharmacist into a hemodialysis unit significantly reduced medication discrepancies and medication-related problems over time.Medication reconciliation for the Centers for Medicare and Medicaid Services End-Stage Renal Disease Quality Incentive Program can be optimally performed by a dialysis pharmacist.