PKCα Is Required for Inflammation-Induced Trafficking of Extrasynaptic AMPA Receptors in Tonically Firing Lamina II Dorsal Horn Neurons During the Maintenance of Persistent Inflammatory Pain

Persistent inflammation promotes internalization of synaptic GluR2-containing, Ca²⁺-impermeable AMPA receptors (AMPARs) and insertion of GluR1-containing, Ca²⁺-permeable AMPARs at extrasynaptic sites in dorsal horn neurons. Previously we have shown that internalization of synaptic GluR2-containing AMPARs requires activation of spinal cord protein kinase C alpha (PKCα), but molecular mechanisms that underlie altered trafficking of extrasynaptic AMPARs are unclear. Here, using antisense (AS) oligodeoxynucleotides (ODN) that specifically knock down PKCα, we found that a decrease in dorsal horn PKCα expression prevents complete Freund's adjuvant (CFA)-induced increase in functional expression of extrasynaptic Ca²⁺-permeable AMPARs in substantia gelatinosa (SG) neurons of the rat spinal cord. Augmented AMPA-induced currents and associated [Ca²⁺]_i transients were abolished, and the current rectification 1 day post-CFA was reversed. These changes were observed specifically in SG neurons characterized by intrinsic tonic firing properties, but not in those that exhibited strong adaptation. Finally, dorsal horn PKCα knockdown produced an antinociceptive effect on CFA-induced thermal and mechanical hypersensitivity during the maintenance period of inflammatory pain, indicating a role for PKCα in persistent inflammatory pain maintenance. Our results indicate that inflammation-induced trafficking of extrasynaptic Ca²⁺-permeable AMPARs in tonically firing SG neurons depends on PKCα, and that this PKCα-dependent trafficking may contribute to persistent inflammatory pain maintenance.PerspectiveThis study shows that PKCα knockdown blocks inflammation-induced upregulation of extrasynaptic Ca²⁺-permeable AMPARs in dorsal horn neurons and produces an antinociceptive effect during the maintenance period of inflammatory pain. These findings have potential implications for use of PKCα gene-silencing therapy to prevent and/or treat persistent inflammatory pain.     

Is intraoperative ultrasound (IOUS) still useful for the detection of liver metastases?

Purpose

To evaluate the clinical impact of intraoperative ultrasound (IOUS) in the detection of liver metastases during the years, as compared with those of other imaging modalities.

Materials and methods

All IOUS scans performed for detection of liver metastases from 2000 to 2006 were retrospectively reviewed and compared with the results of preoperative imaging modalities: Ultrasound (US), Computed Tomography (CT), and/or Magnetic Resonance (MR). The number of cases in which IOUS and preoperative imaging studies produced discordant results, in terms of presence/absence of focal liver lesions, was calculated per year. Statistical analysis was performed using the McNemar test. A p value < 0.05 was considered statistically significant.

Results

Eighty-three IOUS scans performed in 2000–2003 were reviewed, and discordance with preoperative imaging findings was found in 19/83 (23%) cases. Of the 42 IOUS scans done during the 2004–2006 period, 10/42 (24%) showed discordance with preoperative studies. All metastases diagnosed with imaging studies were pathologically confirmed. The number of discordant cases in the two periods were not significantly different (p = 0.2).

Conclusion

IOUS is still useful in the detection of liver metastases. Its decreased use is probably due to the improved accuracy of preoperative imaging modalities.     

Is current serologic RhD typing of blood donors sufficient for avoiding immunization of recipients? (CME)

BACKGROUND: Avoiding immunization with clinically important antibodies is a primary objective in transfusion medicine. Therefore, it is central to identify the extent of D antigens that escape routine RhD typing of blood donors and to improve methodology if necessary. STUDY DESIGN AND METHODS: We screened 5058 D? donors for the presence of the RHD gene, targeting Exons 5, 7, and 10 with real‐time polymerase chain reaction. Samples that were positive in the screen test were investigated further by adsorption‐elution, antibody consumption, flow cytometry, and sequencing of all RHD exons with intron‐specific primers. Lookback was performed on all recipients of RBCs from RHD+ donors. RESULTS: We found 13 RHD+ samples (0.26%). No variants or chimeras were found. Characterization of DNA revealed a novel DEL type (IVS2‐2 A>G). In the lookback of the 136 transfusions with subsequent antibody follow‐up, of which 13 were from DEL donors, one recipient developed anti‐D. However, in this case, a competing and more likely cause of immunization was the concurrent transfusion of D+ platelets. Eleven recipients were immunized with 13 antibodies different from anti‐D, of which five were anti‐K. CONCLUSION: In our laboratory, serologic RhD typing was safe. We detected all D variants and only missed DEL types. In assessing the immunization risk we included a DEL donor, found previous to this study, that did immunize a recipient with anti‐D. We conclude that inadvertent immunization with D antigens in our setting was rare and in the order of 1.4 in 100,000 D? transfusions.     

Low-Molecular-Mass Penicillin Binding Protein 6b (DacD) Is Required for Efficient GOB-18 Metallo-β-Lactamase Biogenesis in Salmonella enterica and Escherichia coli

Metallo-β-lactamases (MBLs) are Zn²⁺-containing secretory enzymes of clinical relevance, whose final folding and metal ion assembly steps in Gram-negative bacteria occur after secretion of the apo form to the periplasmic space. In the search of periplasmic factors assisting MBL biogenesis, we found that dacD null (ΔdacD) mutants of Salmonella enterica and Escherichia coli expressing the pre-GOB-18 MBL gene from plasmids showed significantly reduced resistance to cefotaxime and concomitant lower accumulation of GOB-18 in the periplasm. This reduced accumulation of GOB-18 resulted from increased accessibility to proteolytic attack in the periplasm, suggesting that the lack of DacD negatively affects the stability of secreted apo MBL forms. Moreover, ΔdacD mutants of S. enterica and E. coli showed an altered ability to develop biofilm growth. DacD is a widely distributed low-molecular-mass (LMM) penicillin binding protein (PBP6b) endowed with low dd-carboxypeptidase activity whose functions are still obscure. Our results indicate roles for DacD in assisting biogenesis of particular secretory macromolecules in Gram-negative bacteria and represent to our knowledge the first reported phenotypes for bacterial mutants lacking this LMM PBP.     

Development of the Basic Knowledge Assessment Tool for Medical-Surgical Nursing (MED-SURG BKAT) © and implications for in-service educators and managers

BACKGROUND OF THE PROBLEM. Medical‐surgical nursing is now the largest specialty in acute care, and needs an objective measure of basic knowledge necessary to provide safe care to patients. The Joint Commission on Accreditation of Healthcare Organizations noted that healthcare organizations have in the past relied on education and experience to support competence, but an increasing number are seeking objective measures of a nurse's knowledge that is required for safe practice. The American Nurses Association adds that safe practice is both a professional and a moral responsibility. PROBLEM. A review of the literature failed to locate a standardized test of basic knowledge in medical‐surgical nursing. In‐service educators and managers need such a test to facilitate orientation programs, and as a way to safely decrease the length of orientation for new employees with previous experience in medical‐surgical nursing. METHODS. The purpose of the study was to develop a valid and reliable test to measure basic knowledge in medical‐surgical nursing. FINDINGS. The Basic Knowledge Assessment Tool for Medical‐Surgical nursing was developed with support for its validity and reliability.     

Development of the assessment for collaborative environments (ACE-15): A tool to measure perceptions of interprofessional “teamness”

As interprofessional education moves from classroom to clinical settings, assessing clinical training sites for a high level of “teamness” to ensure optimal learning environments is critical but often problematic ahead of student placement. We developed a tool (Assessment for Collaborative Environments, or ACE), suitable for a range of clinical settings and health professionals, that allows rapid assessment of a clinical practice’s teamwork qualities. We collected evidence of tool validity including content, response process, internal structure, and convergent validity. Expert review and cognitive interviews allowed reduction of the initial 30-item tool to 15 items (the ACE-15). Data from 192 respondents from 17 clinical professions and varied clinical settings (inpatient, ambulatory, urban, and rural) were used for factor analysis, which resulted in a single factor solution. Internal consistency reliability Cronbach’s alpha was high at 0.91. Subgroup analysis of 121 respondents grouped by their clinical teams (n = 16 teams) showed a wide range of intra-team agreement. Data from a subsequent sample of 54 clinicians who completed the ACE-15 and a measure of team cohesion indicated convergent validity, with a correlation of the tools at r = 0.81. We conclude that the ACE-15 has acceptable psychometric properties and promising utility for assessing interprofessional teamness in clinical training sites that are settings for learners, and, in addition may be useful for team development.     

Health-related quality of life before and during adjuvant interferon-α treatment for patients with malignant melanoma (DeCOG-trial)

Adjuvant treatment with interferon-α (IFN-α) for patients with malignant melanoma can improve relapse-free and overall survival, but IFN-associated side effects may reduce patient's quality of life. The aim of the study was to prospectively evaluate health-related quality of life (HRQoL) in patients with melanoma before and during Low-Dose IFN-α therapy. In a prospective multicenter trial conducted by the Dermatologic Cooperative Oncology Group, 850 patients with cutaneous stage II malignant melanoma received a standard Low-Dose of IFN-α-2a. We evaluated HRQoL using the European Organization for Research and Treatment of Cancer Quality of Life Core 30 questionnaire at baseline and after 3, 6, and 12 months of IFN-α treatment in 282 patients. Nine of 15 subscales showed significant poorer results after 3 months of adjuvant IFN treatment. Symptoms included reduced physical functioning, reduced cognitive functioning, fatigue, nausea, pain, dyspnea, insomnia, diarrhea, and loss of appetite. We did not find a significant change over time for role, emotional, or social functioning. Only cognitive functioning and dyspnea continuously worsened through the twelfth month. At baseline women had significantly lower scores for physical and emotional functioning and for fatigue compared with men. During treatment, women scored significantly poorer on physical functioning, emotional functioning, fatigue, pain, and constipation subscales. Patients who reported having a bad or very bad QoL before treatment were 5.8 times more likely to discontinue treatment early because of psychiatric problems. We conclude that adjuvant low-dose IFN treatment is associated with significant deterioration of HRQoL. Specific psychosocial care should be offered especially for patients who report lower HRQoL and emotional problems before treatment to prevent early discontinuation.     

Development and Psychometric Evaluation of the HPV Clinical Trial Survey for Parents (CTSP‐HPV) Using Traditional Survey Development Methods and Community Engagement Principles

Objective

This study describes the development and psychometric evaluation of HPV Clinical Trial Survey for Parents with Children Aged 9 to 15 (CTSP‐HPV) using traditional instrument development methods and community engagement principles.

Methods

An expert panel and parental input informed survey content and parents recommended study design changes (e.g., flyer wording). A convenience sample of 256 parents completed the final survey measuring parental willingness to consent to HPV clinical trial (CT) participation and other factors hypothesized to influence willingness (e.g., HPV vaccine benefits). Cronbach''s a, Spearman correlations, and multiple linear regression were used to estimate internal consistency, convergent and discriminant validity, and predictively validity, respectively.

Results

Internal reliability was confirmed for all scales (a ≥ 0.70.). Parental willingness was positively associated (p < 0.05) with trust in medical researchers, adolescent CT knowledge, HPV vaccine benefits, advantages of adolescent CTs (r range 0.33–0.42), supporting convergent validity. Moderate discriminant construct validity was also demonstrated. Regression results indicate reasonable predictive validity with the six scales accounting for 31% of the variance in parents’ willingness.

Conclusions

This instrument can inform interventions based on factors that influence parental willingness, which may lead to the eventual increase in trial participation. Further psychometric testing is warranted.     

Is triple combination of different neurohormonal modulators recommended for treatment of mild-to-moderate congestive heart failure patients? (Results of Sadko-CHF study)

AIM: To assess effects of different variants of neurohormonal (NH) modulation with angiotensin converting enzyme (ACE-I) quinapril (Q), angiotensin-receptor blocker (ARB) valsartan (V) and their combination in addition to beta-adrenergic blocker bisoprolol (B) on functional status, quality of life (QOL), parameters of left ventricular (LV) remodeling, main indices of 24-h heart rate variability (HRV) and NH profile in patients with stable mild-to-moderate congestive heart failure (CHF). MATERIAL AND METHODS: Sixty three patients with CHF (NYHA class II-III) as a result of ischemic heart disease and dilated cardiomyopathy with LV EF < 40% were randomly assigned to one of the treatment variants on 1:1:1 basis: B+Q (n = 22), B+V (n = 23) and combination of B+Q + V (n = 18). At baseline, all the patients in this study were on background B treatment and according to the study design Q or V were then added to B at randomization. NYHA FC, 6-min walking test (6MT), QOL, 2D-echocardiography, plasma renin activity (PRA), angiotensin II (AT-II), aldosterone (Ald), norepinephrine (NE), epinephrine (E), brain natriuretic peptide (BNP) concentrations and 24-hour HRV parameters were investigated at baseline, 3 and 6 months after randomization. RESULTS: During the study NYHA FC improvement was revealed in all three treatment groups with comparative significant changes in 6MT distance by 20.4%, 19.1% and 19.4% in B+Q, B+V and B+Q+V groups, respectively. QOL maximally decreased in B+V combination (from 45 to 21 points). LV volumes significantly decreased and LV ejection fraction (EF) increased in all groups to the end of the study. Triple combination had no additional effect on LV volumes and LVEF changes compared to B+Q and B+V groups. Plasma NE concentrations decreased maximally in B+Q group (from 650 to 430 pg/ml, p = 0.007). The lesser effect was observed in the combination of B+Q+V, with any NE changes in B+ V group. The E concentration increased significantly (from 215 to 295 pg/ml, p = 0.024) in the B+Q+V group at the end of the study. Plasma A-II concentration did not differ from the baseline during the study in B+Q group, but significantly increased in B+V group and maximally in B+Q+V group (from 11.4 to 23.5 pg/ml, p = 0.009). To the end of the study plasma Ald concentrations remain reduced significantly only in B+V group. The level of BNP significantly decreased in all 3 treatment groups. Significant changes in HRV indices, both in time and frequency domain, were revealed in the B+Q group at 3-month follow-up and SDNN increased on month 24 (p = 0.039). These changes became insignificant at the end of the study. The lesser effect was revealed in B+Q+V group, with insignificant trend toward an increase of SDNN to the end of the study. HRV indices did not improve in the B+V group. CONCLUSION: During long-term treatment the triple combination of B+Q+ V has no significant advantages over B+Q and B+V by the functional status, QOL and parameters of LV remodeling in patients with mild-to-moderate CHF. The combination of B+Q has more potent effect on 24-hour HRV parameters, sympatho-adrenal activity and renal function compared to B+V and B+Q+V groups in CHF patients in our study. The combination B+Q+V may have a negative effect on NH profile (excessive activation of ATII and E) in CHF patients. The triple combination is not recommended for therapy of stable mild-to-moderate CHF patients.     

Development of a measure of therapy provision for spasticity management in the paretic lower limb – the Leg Therapy recording Schedule (LegTS)

Purpose: In rehabilitation studies, it is critical to understand the constituents of interventions. First, to enable replication of the work and second, to identify what treatments work best. The development of a tool to describe and quantify therapy interventions in the context of focal spasticity management is presented.

Methods: Potential intervention categories were identified from: (a) retrospective analysis of prospectively collected data from a cohort of patients (n?=?62) receiving physical interventions in the context of botulinum toxin (BoNT) injection for leg spasticity and (b) cognitive de-briefing with Patient and Carer Advisory Group (PCAG) of patient and carer dyads (n?=?8). Item reduction was achieved through consultation with a purposively-selected group of physiotherapists and occupational therapists (n?=?16) in a two-round Delphi process. This was followed by review of findings by PCAG members.

Results: A list of 24 possible therapy categories were identified and then reduced, resulting in a tool with two domains: (1) postural management; four categories and (2) exercise and retraining; four categories. The Leg Therapy recording Schedule (LegTS) wording and presentation were refined for clinical and research use.

Conclusions: The LegTS is designed to record therapy interventions for the paretic lower limb in the context of spasticity intervention. Content and face validity have initially been addressed within the development process.

• Implications for Rehabilitation

• Clinicians need to understand intervention effectiveness, and to do so, it is critical to capture all the components of a complex intervention.

• In clinical practice or research, patient experience measures are required to capture the complexity of intervention provided and monitor intervention effectiveness on a case by case basis.

• Clinicians involved in rehabilitation and management of focal spasticity in the leg can use the Leg Therapy recording Schedule (LegTS) to enable an understanding of the entirety of the intervention package provided.

     

Development and validation of an instrument for measuring junior nurses’ recognition and response abilities to clinical deterioration (RRCD)

BackgroundNurses of all levels are expected to be competent in managing clinical deterioration. Given their limited experience and basic-level knowledge, there is a concern about junior nurses' clinical and patient management skills. However, junior nurses’ abilities to recognise and respond to clinical deterioration have not been adequately explored because of the absence of a comprehensive tool.ObjectivesThe aim of this study was to develop a new self-assessment scale to assess the junior nurses’ recognition and response abilities to clinical deterioration and to examine its reliability and validity.MethodsScale items were based on literature reviews and interviews. The preliminary scale was generated through two rounds of expert review. A panel of five experts evaluated content validity. After a pilot study, the questionnaire was distributed to 168 junior nurses via convenience sampling. Subsequent statistical analysis of results included construct validity, internal consistency, and test–retest reliability.ResultsSix factors were included, and 69.310% of the total variance was explained by the 25 items comprising the scale. The Cronbach's alpha coefficient was 0.905 (95% confidence interval [CI]: 0.812–0.979) for the overall scale and 0.655–0.838 for its subscales. The Guttman split-half reliability was 0.856 (95% CI: 0.806–0.894). The test–retest reliability of the scale was 0.878 (95% CI: 0.836–0.911).ConclusionWe developed a scale for measuring the abilities of junior nurses to recognise and respond to clinical deterioration and confirmed its reliability and validity. More experimental studies are needed to further evaluate this instrument.     

Development of the Psychosocial Distress Questionnaire��Breast Cancer (PDQ-BC): a breast cancer-specific screening instrument for psychosocial problems

Purpose  

The aim of the present study was to develop a short, easy-to-use, and acceptable psychosocial screening instrument specific for breast cancer patients.     

The reference range for complexed α2-macroglobulin human plasma: Development of a new enzyme linked in immunosorbent assay (ELISA) for quantitation of complexed α2-macroglobulin

Jespersen MH, Jensen J, Rasmussen LH, Ejlersen E, M0ller-Petersen J, Sperlitig-Petersen HU. The reference range for complexed a₂-macroglobulin in human plasma: development of a new enzyme-linked immunosorbent assay (ELISA) for quantitation of complexed a₂-macroglobulin. Scand J Clin Lab Invest 1993; 53: 639-648.

Purified α₂-macroglobulin was complexed by reaction with methylamine and used to raise monoclonal murine antibodies. A four-step enzyme linked immunosorbent assay (ELISA) was developed to determine the antibody-specificity of the produced monoclonal murine antibodies towards human native and complexed α₂-macroglobulin.

Two monoclonal antibodies were selected, HI 1 All (specific towards complexed a₂-macroglobulin) and 1CG4 (recognizes both forms of the molecule), and purified by affinity chromatography on protein G. The purified antibodies were used to develop a fast three-step ELISA for exact quantitation of complexed and total a₂-macroglobulin in human plasma. The intra-assay coefficient of variation (CV) for measurement of complexed a₂-macroglobulin is 2.2-9.9%, whereas the inter-assay CV was determined to be 3.7-10.5% and the recovery of the assay is 93-108%. The assay for total a₂-macroglobulin has an intra-assay CV of 3.0-15.5%, an interassay CV of 5.1-21.2% and a recovery of 91-116%.

Citrated plasma samples from 139 healthy blood donors were examined, resulting in a reference range for complexed a₂-macroglobulin of 13.5 31.1 mgl^?1 “with a median value of 21.7mgl”. The concentration of total a₂-macroglobulin was measured by the same assay using the monoclonal antibodies 1CG4. For total a₂-macroglobulin we determined the reference range to be 1.12-3.54g 1^_1 with a median value of 2.14g 1^_1. Based on these results the reference range for complexed a₂-macroglobulin as a percentage of total a₂-macroglobulin was calculated to be 0.8-1.9% with a median value of 1.0%.     

Is Hysterosalpingo-Contrast Sonography (HyCoSy) Using Sulfur Hexafluoride Microbubbles (SonoVue) Sufficient for the Assessment of Fallopian Tube Patency? A Systematic Review and Meta-Analysis

This study aimed to evaluate the diagnostic value of HyCoSy using sulfur hexafluoride microbubbles for fallopian tubal patency assessment in infertile females. Twenty-four studies, including 1358 females with 2661 detected fallopian tubes published from January 2003 to May 2019, were identified. The pooled sensitivity was 93% (95% CI: 90–95%), while the specificity was 90% (95% CI: 87–92%). The area under the receiver-operating characteristic curve was 0.96 (95% CI: 94–98%). The specificity of the four-dimensional HyCoSy subgroup was higher than the 2D/3D subgroup; an increased dose of contrast agent did not affect the specificity, with only a slightly reduced sensitivity.