Optimization-driven framework to understand health care network costs and resource allocation.

In the last several decades, the U.S. Health care industry has undergone a massive consolidation process that has resulted in the formation of large delivery networks. However, the integration of these networks into a unified operational system faces several challenges. Strategic problems, such as ensuring access, allocating resources and capacity efficiently, and defining case-mix in a multi-site network, require the correct modeling of network costs, network trade-offs, and operational constraints. Unfortunately, traditional practices related to cost accounting, specifically the allocation of overhead and labor cost to activities as a way to account for the consumption of resources, are not suitable for addressing these challenges; they confound resource allocation and network building capacity decisions. We develop a general methodological optimization-driven framework based on linear programming that allows us to better understand network costs and provide strategic solutions to the aforementioned problems. We work in collaboration with a network of hospitals to demonstrate our framework applicability and important insights derived from it.

Skeletal muscle PI3K p110ß regulates expression of AMP-activated protein kinase.

Skeletal muscle metabolic homeostasis is maintained through numerous biochemical and physiological processes. Two principal molecular regulators of skeletal muscle metabolism include AMP-activated protein kinase (AMPK) and phosphatidylinositol 3-kinase (PI3K); however, PI3K exists as multiple isoforms, and specific metabolic actions of each isoform have not yet been fully elucidated in skeletal muscle. Given this lack of knowledge, we performed a series of experiments to define the extent to which PI3K p110ß mediated expression and (or) activation of AMPK in skeletal muscle. To determine the effect of p110ß inhibition on AMPK expression and phosphorylation in cultured cells, C2C12 myoblasts were treated with a pharmacological inhibitor of p110ß (TGX-221), siRNA against p110ß, or overexpression of kinase-dead p110ß. Expression and phosphorylation of AMPK were unaffected in myoblasts treated with TGX-221 or expressing kinase-dead p110ß. However, expressions of total and phosphorylated AMPK at T172 were reduced in myoblasts treated with p110ß siRNA. When normalized to expression of total AMPK, phosphorylation of AMPK S485/491 was elevated in p110ß-deficient myoblasts. Similar results were observed in tibialis anterior muscle from mice with conditional deletion of p110ß (p110ß-mKO mice). Analysis of AMPK transcript expression revealed decreased expression of Prkaa2 in p110ß-deficient myoblasts and in p110ß-mKO muscle. Loss of p110ß had no effect on oligomycin-stimulated phosphorylation of AMPK or phosphorylated Acetyl-CoA carboxylase (ACC), although oligomycin-induced AMPK and ACC phosphorylation were increased in p110ß-deficient myoblasts compared to oligomycin-stimulated control myoblasts when normalized to levels of total AMPK or ACC. Overall, these results suggest that p110ß positively regulates expression of AMPK in cultured myoblasts and in skeletal muscle in vivo; moreover, despite the reduced abundance of AMPK in p110ß-deficient myoblasts, loss of p110ß does not appear to impair AMPK activation following stimulus. These findings thus reveal a novel role for p110ß in mediating skeletal muscle metabolic signaling.

Lysophosphatidic acid-stimulated phosphorylation of PKD2 is mediated by PI3K p110ß and PKCδ in myoblasts.

CONTEXT: G-protein coupled receptor (GPCR) signaling in skeletal muscle is incompletely understood; in particular, the signaling pathways that regulate GPCR-mediated signaling in skeletal muscle are only beginning to be established. Lysophosphatidic acid (LPA) is a GPCR agonist that has previously been shown to activate protein kinase D (PKD) in non-muscle cells; however, whether PKD is activated in response to LPA in skeletal muscle myoblasts, and the identities of signaling intermediates that regulate this activation, have not been defined. OBJECTIVE: To determine whether PKD is activated in response to LPA administration in myoblasts, and to define the signaling pathways that mediate LPA-stimulated PKD phosphorylation. METHODS: C2C12 myoblasts were treated with LPA and signaling pathways examined by means of Western immunoblotting and real-time PCR (RT-PCR). Pharmacological inhibition and RNA-interference were used to target specific molecules to determine their involvement in LPA-induced PKD phosphorylation. RESULTS: Treatment of myoblasts with exogenous LPA revealed that PI3K p110ß mediated PKD phosphorylation at Ser 748 and at Ser 916 through kinase-dependent and kinase-independent mechanisms. Loss of PKCδ, but not the loss of PKCα, prevented LPA-induced PKD phosphorylation. The PKD isoform responsive to LPA treatment was identified as PKD2. CONCLUSION: These results indicate that LPA-stimulated PKD2 phosphorylation requires PKCδ and non-catalytic actions of PI3K p110ß, and provide new information with respect to GPCR-mediated signal transduction in myoblasts.

Enhanced Akt phosphorylation and myogenic differentiation in PI3K p110ß-deficient myoblasts is mediated by PI3K p110α and mTORC2.

Phosphoinositide 3-kinase (PI3K) is a principal regulator of Akt activation and myogenesis; however, the function of PI3K p110ß in these processes is not well defined. To address this, we investigated the role of p110ß in Akt activation and skeletal muscle cell differentiation. We found that Akt phosphorylation was enhanced in p110ß-deficient myoblasts in response to Insulin-like Growth Factor-I (IGF-I), epidermal growth factor, or p110α overexpression, as compared to p110ß-sufficient cells. This effect was associated with increased mammalian target of rapamycin complex 2 activation, even in myoblasts deficient in mSin1 and rictor. Conversely, in response to the G-protein-coupled receptor agonist lysophosphatidic acid, Akt phosphorylation was attenuated in p110ß-deficient myoblasts. Loss of p110ß also enhanced the expression of myogenic markers at the myoblast stage and during the first 48 h of differentiation. These data demonstrate that reductions in p110ß are associated with agonist-specific Akt hyperactivation and accelerated myogenesis, thus revealing a negative role for p110ß in Akt activation and during myoblast differentiation.

Co-exposure to nickel and cobalt chloride enhances cytotoxicity and oxidative stress in human lung epithelial cells.

Nickel and cobalt are heavy metals found in land, water, and air that can enter the body primarily through the respiratory tract and accumulate to toxic levels. Nickel compounds are known to be carcinogenic to humans and animals, while cobalt compounds produce tumors in animals and are probably carcinogenic to humans. People working in industrial and manufacturing settings have an increased risk of exposure to these metals. The cytotoxicity of nickel and cobalt has individually been demonstrated; however, the underlying mechanisms of co-exposure to these heavy metals have not been explored. In this study, we investigated the effect of exposure of H460 human lung epithelial cells to nickel and cobalt, both alone and in combination, on cell survival, apoptotic mechanisms, and the generation of reactive oxygen species and double strand breaks. For simultaneous exposure, cells were exposed to a constant dose of 150 µM cobalt or nickel, which was found to be relatively nontoxic in single exposure experiments. We demonstrated that cells exposed simultaneously to cobalt and nickel exhibit a dose-dependent decrease in survival compared to the cells exposed to a single metal. The decrease in survival was the result of enhanced caspase 3 and 7 activation and cleavage of poly (ADP-ribose) polymerase. Co-exposure increased the production of ROS and the formation of double strand breaks. Pretreatment with N-acetyl cysteine alleviated the toxic responses. Collectively, this study demonstrates that co-exposure to cobalt and nickel is significantly more toxic than single exposure and that toxicity is related to the formation of ROS and DSB.

Alternative prey and farming system mediate predation of Colorado potato beetles by generalists.

BACKGROUND: Biological control by generalist predators can be mediated by the abundance and biodiversity of alternative prey. When alternative prey draw predator attacks away from the control target, they can weaken pest suppression. In other cases, a diverse prey base can promote predator abundance and biodiversity, reduce predator-predator interference, and benefit biocontrol. Here, we used molecular gut-content analysis to assess how community composition altered predation of Colorado potato beetle (Leptinotarsa decemlineata (Say)) by Nabis sp. and Geocoris sp. Predators were collected from organic or conventional potato (Solanum tuberosum L.) fields, encouraging differences in arthropod community composition. RESULTS: In organic fields, Nabis predation of potato beetles decreased with increasing arthropod richness and predator abundance. This is consistent with Nabis predators switching to other prey species when available and with growing predator-predator interference. In conventional fields these patterns were reversed, however, with potato beetle predation by Nabis increasing with greater arthropod richness and predator abundance. For Geocoris, Colorado potato beetle predation was more frequent in organic than in conventional fields. However, Geocoris predation of beetles was less frequent in fields with higher abundance of the detritus-feeding fly Scaptomyza pallida Zetterstedt, or of all arthropods, consistent with predators choosing other prey when available. CONCLUSION: Alternative prey generally dampened predation of potato beetles, suggesting these pests were less-preferred prey. Nabis and Geocoris differed in which alternative prey were most disruptive to feeding on potato beetles, and in the effects of farm management on predation, consistent with the two predator species occupying complementary feeding niches. © 2021 Society of Chemical Industry.

Alternative prey mediate intraguild predation in the open field.

BACKGROUND: Generalist predators that kill and eat other natural enemies can weaken biological control. However, pest suppression can be disrupted even if actual intraguild predation is infrequent, if predators reduce their foraging to lower their risk of being killed. In turn, predator-predator interference might be frequent when few other prey are available, but less common when herbivorous and detritus-feeding prey are plentiful. We used molecular gut-content analysis to track consumption of the predatory bug Geocoris sp. by the larger intraguild predator Nabis sp., in organic and conventional potato (Solanum tuberosum) fields. RESULTS: We found that higher densities of both aphids and thrips, two common herbivores, correlated with higher probability of detecting intraguild predation. Perhaps, Nabis foraging for these herbivores also encountered and ate more Geocoris. Surprisingly, likelihood of intraguild predation was not strongly linked to densities of either Nabis or Geocoris, or farming system, suggesting a greater importance for prey than predator community structure. Intriguingly, we found evidence that Geocoris fed more often on the detritus-feeding fly Scaptomyza pallida with increasing predator evenness. This would be consistent with Geocoris shifting to greater foraging on the ground, where S. pallida would be relatively abundant, in the face of greater risk of intraguild predation. CONCLUSION: Overall, our findings suggest that while herbivorous prey may heighten intraguild predation of Geocoris in the foliage, detritivores might support a shift to safer foraging on the ground. This provides further evidence that prey abundance and diversity can act to either heighten or relax predator-predator interference, depending on prey species identity and predator behavior. © 2022 Society of Chemical Industry.

Osteoclasts direct bystander killing of bone cancer.

Primary and metastatic bone cancers are difficult to eradicate and novel approaches are needed to improve treatment and extend life. As bone cancer grows, osteoclasts, the principal bone-resorbing cells of the body, are recruited to and activated at sites of cancer. In this investigation, we determined if osteoclast lineage cells could function as a cell-based gene delivery system to bone cancers. We used the cytosine deaminase (CD) 5-fluorocytosine (5-FC) enzyme/prodrug system and studied bone marrow and bones from transgenic mice expressing a novel CD gene regulated by the osteoclast tartrate-resistant acid phosphatase (TRAP) gene promoter (Tg/NCD). DsRed2-labeled 2472 sarcoma cells were placed in Tg/NCD osteoclastogenic cultures and treated with 5-FC. 5-FC treatment resulted in profound bystander killing (90%; P < 0.05). The effect of 5-FC treatment on osteoclast lineage cells was most dramatic when administered at the beginning of the 7-day cultures, suggesting that mature osteoclasts are less sensitive to 5-FC. Evaluation of osteoclast-directed bystander killing in vivo revealed dramatic killing of bone cancer with only a modest effect on osteoclast number. Specifically, 5-FC treatment of tumor-bearing Tg/NCD mice or Tg/NCD bone marrow transplanted C3H mice (Tg/NCD-C3H) resulted in 92% and 44% reductions in tumor area, respectively (P < 0.05). Eight of ten 5-FC-treated Tg/NCD mice had complete bone tumor killing and five of six 5-FC-treated Tg/NCD-C3H mice had reduced tumor compared with controls. In addition, Tg/NCD osteoclasts were resistant to 5-FC treatment in vivo, a very important feature, as it identifies osteoclasts as an ideal CD gene delivery system.

Novel cytosine deaminase fusion gene enhances the effect of radiation on breast cancer in bone by reducing tumor burden, osteolysis, and skeletal fracture.

BACKGROUND: Painful breast carcinoma metastases in bone are a common manifestation of malignant disease. Eradication of these tumors can be evasive, and as a result, skeletal morbidity increases with disease progression. EXPERIMENTAL DESIGN: The treatment potential of cytosine deaminase (CD) gene therapy combined with radiation treatment was evaluated in vitro and in vivo using a 4T1 murine breast carcinoma model. 4T1 carcinoma cells were transduced with a fusion gene encoding the extracellular and transmembrane domains of the human nerve growth factor receptor and the cytoplasmic portion of the yeast CD gene (NGFR-CD(y)). RESULTS AND CONCLUSIONS: CD-expressing tumor cells (4TCD(y)) were highly sensitive to treatment by 5-fluorocytosine prodrug (P < 0.0001). 5-Fluorocytosine treatment of 4TCD(y), but not 4T1 cells, enhanced the effects of radiation in vitro (P < 0.0001). 5-Fluorocytosine prodrug treatment also increased the therapeutic potential of radiation in vivo. Mice with 4TCD(y) intrafemoral tumors showed increased effectiveness of radiation based on improved reductions in tumor size, reductions in tumorigenic osteolysis, and a decrease in skeletal fractures (P < 0.01).

Direct and bystander killing of sarcomas by novel cytosine deaminase fusion gene.

Soft tissue and bone sarcomas of the extremities can be difficult to eradicate, and standard treatment may require limb amputation. New therapies to decrease tumor size could improve the effectiveness of treatment and decrease the frequency of limb amputation. Cytosine deaminase (CD)-based gene therapy has been shown to be effective in decreasing growth of solid tumors when animals with CD-expressing tumor cells are treated with 5 fluorocytosine (5FC), an inert prodrug that is converted to 5-fluorouracil (5FU) by CD. In this investigation, we used a novel CD-containing fusion gene to determine whether CD-based gene therapy affected soft tissue or bone sarcomas. The novel fusion gene (NGFR-CD) encodes for a protein with extracellular and transmembrane domains of human nerve growth factor receptor (NGFR) and cytoplasmic CD. Murine 2472 (2) sarcoma cells were transduced with fusion genes containing either the bacterial (NGFR-(b)CD) or yeast (NGFR-(y)CD) CD gene. 5FC treatment killed NGFR-(b)CD- and NGFR-(y)CD-transduced sarcoma cells in vitro through direct and bystander effects (P < 0.01). In contrast, 5FC treatment of mice with s.c. 2NGFR-(b)CD or 2NGFR-(y)CD tumors affected only 2NGFR-(y)CD tumors. 5FC had no effect on growth of NGFR-(b)CD tumors but caused significant decrease in the size of 2NGFR-(y)CD tumors (51 +/- 60 versus 938 +/- 767 mm(3), treated versus control, P < 0.01). Evaluation of bystander killing in vivo revealed significant tumor killing, with a 5-fold reduction in s.c. tumor volume evident in saline versus 5FC-treated mice when tumors were comprised of 90% 2472 cells and 10% 2NGFR-(y)CD selected for fluorescence-activated cell sorting (P < 0.01). Bone sarcomas were eliminated in 9 of 10 5FC-treated mice, compared with 11.8 +/- 6.0 mm(2) in saline-treated mice (P < 0.002). In addition, 5FC treatment of bone sarcomas caused a significant reduction in cancer-induced bone destruction (P < 0.002) and resulted in a reduction in the number of osteoclasts. Finally, 5FC treatment had no effect on animal weight or survival, whereas doses of 5FU providing equivalent tumor reduction as 5FC resulted in treatment-associated deaths and significant weight loss (P < 0.001).

Radiation treatment decreases bone cancer pain through direct effect on tumor cells.

The most used treatment for bone cancer pain is radiation; however, the mechanism responsible for analgesia after irradiation is unknown. The mechanistic influence of a single, localized 10-, 20- or 30-Gy dose of radiation on painful behaviors, osteolysis, histopathology and osteoclast number was evaluated in mice with painful femoral sarcomas. Dramatic reductions in pain behaviors (P < 0.05) and osteolysis (P < 0.0001) were seen in mice irradiated with 20 and 30 Gy. Irradiation reduced the tumor area by more than 75% (P < 0.05) but did not affect osteoclast frequency per mm2 tumor. Treatment with 20 Gy prior to tumor injection had no effect on tumor growth or pain behaviors, suggesting that radiation reduces osteolysis and pain through direct tumor effects. To demonstrate that tumor elimination was responsible for reduction in osteolysis and pain, sarcoma cells containing the suicide gene cytosine deaminase (CD) were inoculated into femora. After onset of bone cancer pain, mice were treated with the prodrug 5-fluorocytosine (5-FC). 5-FC treatment significantly reduced both osteolysis (P < 0.0005) and bone cancer pain (P < 0.05). The findings in this study demonstrate that one mechanism through which radiation decreases bone cancer pain is by direct effects on tumor cells.

Role of phosphoinositide 3-OH kinase p110ß in skeletal myogenesis.

Phosphoinositide 3-OH kinase (PI3K) regulates a number of developmental and physiologic processes in skeletal muscle; however, the contributions of individual PI3K p110 catalytic subunits to these processes are not well-defined. To address this question, we investigated the role of the 110-kDa PI3K catalytic subunit ß (p110ß) in myogenesis and metabolism. In C2C12 cells, pharmacological inhibition of p110ß delayed differentiation. We next generated mice with conditional deletion of p110ß in skeletal muscle (p110ß muscle knockout [p110ß-mKO] mice). While young p110ß-mKO mice possessed a lower quadriceps mass and exhibited less strength than control littermates, no differences in muscle mass or strength were observed between genotypes in old mice. However, old p110ß-mKO mice were less glucose tolerant than old control mice. Overexpression of p110ß accelerated differentiation in C2C12 cells and primary human myoblasts through an Akt-dependent mechanism, while expression of kinase-inactive p110ß had the opposite effect. p110ß overexpression was unable to promote myoblast differentiation under conditions of p110α inhibition, but expression of p110α was able to promote differentiation under conditions of p110ß inhibition. These findings reveal a role for p110ß during myogenesis and demonstrate that long-term reduction of skeletal muscle p110ß impairs whole-body glucose tolerance without affecting skeletal muscle size or strength in old mice.

Improving glycemic control in the acute care setting through nurse education.

Patients with a primary or secondary diagnosis of diabetes present unique challenges during an inpatient hospital stay to treat an acute or chronic illness. Upon review of current hospital practice, an interprofessional team embarked on a performance improvement project to improve outcomes for the complex medical-surgical diabetic patient. The methods detailed herein--a comprehensive education plan, preceptorship and peer accountability, active engagement and support by the unit nursing leadership team, and interprofessional collaboration--offer strategies any organization can implement to positively impact diabetes care.

Analysis of distinct tartrate-resistant acid phosphatase promoter regions in transgenic mice.

The tartrate-resistant acid phosphatase (TRAP) is present in multiple tissues, including kidney, liver, lung, spleen, and bone. Recent study of (TRAP) gene expression has provided evidence for distinct promoters within the (TRAP) gene, suggesting that the gene has alternative, tissue-preferred mRNA transcripts. Examination of endogenous (TRAP) exon 1B and 1C mRNA transcripts revealed tissue-preferred transcript abundance with increased exon 1B transcripts detected in liver and kidney and increased exon 1C transcripts detected in bone and spleen. In this investigation, we have made transgenic mice that express a marker gene driven by two candidate promoters, designated BC and C, within the (TRAP) gene. The BC and C promoters are 2.2 and 1.6 kb, respectively, measured from the translation initiation site. Evaluation of BC transgenic lines demonstrated robust expression in multiple tissues. In contrast, significant transgene expression was not detected in C transgenic lines. Evaluation of transgene mRNAs in BC transgenic lines revealed that virtually all expression was in the form of B transcripts, suggesting that the tissue-preferred pattern of endogenous (TRAP) was not replicated in the BC transgenic line. Likewise, osteoclastogenic cultures from BC, but not C, transgenic bone marrow cells expressed the transgene following receptor activator of NFkappaB ligand/macrophage colony-stimulating factor stimulation. In conclusion, when compared with the 2.2-kb BC portion of the (TRAP) promoter region, the 1.6-kb C portion does not account for significant gene expression in vivo or in vitro; production of the bone- and spleen-preferred (TRAP) C transcript must depend on regulatory elements outside of the 2.2-kb promoter. As the majority of currently investigated transcription factors that influence transcriptional regulation of osteoclast gene expression bind within the 1.6-kb C portion of the (TRAP) promoter, it is likely that transcription binding sites outside of the 2.2-kb region will have profound effects on regulation of the gene in vivo and in vitro.