Battling professional self-sabotage: Embracing standard of care as the future of pharmacy regulation

Laws and regulations are intended to protect the public; however, overregulation of the profession can block initiatives focused on patient safety and public health. This article discusses the 3 main regulatory approaches to pharmacy practice: standard of care (SOC), bright line, and right touch. An SOC regulatory model supports practitioners delivering patient care within their scope of practice and clinical training. Patient safety is maintained by measuring care against other practitioners within the same practice setting while supporting practitioners practicing at the top of their clinical ability. Compared with bright line and right touch approaches, the SOC regulatory model provides the adaptability needed to respond to different practice scenarios and settings, thus increasing access to health care and opportunities for innovation. To have a lasting impact on the profession and support patients, all pharmacy professionals must be fluent in regulatory approaches and advocate for states to transition to SOC regulatory models.

Community Pharmacy Credentialing for Medical Insurance to Facilitate Sustainability in COVID-19 Testing

Background: In April 2020, pharmacists were added as medical providers under Idaho Medicaid in response to recent scope expansion for pharmacists and to increase beneficiaries' access to coronavirus disease 2019 (COVID-19) testing and services. The COVID-19 pandemic prompted expedited Medicaid enrollment for pharmacists but did not address coverage of medical services provided to privately insured individuals for pharmacy-based testing services. Objective: This study aimed to describe processes used by independently owned, community-based pharmacies in Idaho to credential with private insurers and report outcomes. Methods: Relevant information and forms required to credential with the four major payers in the state of Idaho were collected. Packets were obtained via medical insurers' websites and by direct contact. Questions that arose from community pharmacists during the submission process were collected and answered on a shared spreadsheet, and insurance representatives were contacted directly to resolve questions. Results: Eight out of 13 participating pharmacies submitted an average of three credentialing packets for their facilities. Thirty-five pharmacists also submitted an average of four credentialing packets for themselves. As of mid-May 2021, nearly 20 weeks after submission, only 67 out of 129 pharmacists had received word regarding the status of their applications. Less than half of all pharmacist applications were approved (after their first attempt). Conclusion: Efforts to support the education of both pharmacists and medical insurers may streamline the credentialing processes in the future.

AACP Strategic Engagement Committee Report: Report of the 2022-2023 Strategic Engagement Standing Committee

The American Association of Colleges of Pharmacy recognizes strategic engagement as critical to the success of pharmacy education, contributing to the expansion of pharmacy and public health practice, the fulfillment of institutional missions, and the meeting of programmatic needs. The 2022-2023 Strategic Engagement Committee or the Committee was charged with identifying ways professional advocacy is being emphasized in Doctor of Pharmacy and graduate education curricula to optimize active student engagement and share new resources for the ongoing resource guide being developed by the association. The Committee was also tasked with identifying advocacy champions at each member institution, integrating them into the work of the American Association of Colleges of Pharmacy Policy Advisory Task Force, and identifying strong advocacy partnerships between colleges and schools of pharmacy and state pharmacy organizations that can be replicated to advance the legislative or regulatory priorities of the profession. The Committee conducted a 2-part, sequential advocacy survey to identify advocacy champions at member institutions and to gain better insight into the breadth and depth of current advocacy efforts within pharmacy programs. The Committee also developed suggestions for the advocacy activities that should be required in pharmacy curricula, as well as exemplary activities identified through surveying advocacy champions.

Doom or Deliciousness: Challenges and Opportunities for Visualization in the Age of Generative Models

Generative text-to-image models (as exemplified by DALL-E, MidJourney, and Stable Diffusion) have recently made enormous technological leaps, demonstrating impressive results in many graphical domains-from logo design to digital painting to photographic composition. However, the quality of these results has led to existential crises in some fields of art, leading to questions about the role of human agency in the production of meaning in a graphical context. Such issues are central to visualization, and while these generative models have yet to be widely applied in visualization, it seems only a matter of time until their integration is manifest. Seeking to circumvent similar ponderous dilemmas, we attempt to understand the roles that generative models might play across visualization. We do so by constructing a framework that characterizes what these technologies offer at various stages of the visualization workflow, augmented and analyzed through semi-structured interviews with 21 experts from related domains. Through this work, we map the space of opportunities and risks that might arise in this intersection, identifying doomsday prophecies and delicious low-hanging fruits that are ripe for research.

Our Patients Need Empathy Training across Healthcare Professions

Vulnerable populations are those who experience disparity at a disproportionate rate. For this article, specific vulnerable populations of interest include people who experience intellectual or developmental disorders, mental illness, or substance misuse. Vulnerable populations are some of the most stigmatized populations in our society. Research shows that vulnerable populations receive less empathic care than general health care populations, resulting in reduced quality of care and disparities in health outcomes. Empathy, a necessary health care competency, is associated with improved patient outcomes, enhanced job satisfaction, and increased retention and resilience across health care professions. However, there is no current standard for how empathy is taught, assessed, or sustained. Even when empathy education is implemented in healthcare professions curricula, research has demonstrated that it appears to erode with experience and time. In addition, the COVID-19 pandemic has exacerbated inequities in health care systems, with consequences for both patients and providers. There is an urgent need to develop efficacious training in empathy across health care professions to foster and sustain a robust workforce and improve health care experiences and outcomes.

A case of annular erythema of infancy accompanied by elevated tryptase

Annular erythema of infancy (AEI) is characterized by self-limited eruptions of erythematous, annular to polycyclic patches and plaques, the etiology of which is thought to involve a hypersensitivity reaction to an unknown antigen. We present a case of AEI mistaken for systemic mastocytosis due to elevated serum tryptase. We were unable to find prior reports of an association between AEI and elevated tryptase in the literature.

Pharmacy-Based Point-of-Care Testing: How a “Standard of Care” Approach Can Facilitate Sustainability

COVID-19 spurred rapid expansion of pharmacy-based point-of-care testing (POCT). This growth was aided, in part, by federal guidance that removed state-level regulatory uncertainty surrounding the ability of pharmacists to administer, interpret, and act on the results of tests. Surveys suggest there is considerable confusion about the legality of these services by state regulators. To ensure the sustainability of POCT services over time, states should consider adopting a standard of care approach to regulation, allowing a flexible framework for practice innovation and expansion over time.

Report of the 2020-2021 Strategic Engagement Standing Committee

EXECUTIVE SUMMARY For the American Association of Colleges of Pharmacy (AACP), strategic engagement is critical to the success of colleges and schools of pharmacy in expanding pharmacy and public health practice, meeting programmatic needs, and fulfilling institutional missions. The 2020-2021 Strategic Engagement Standing Committee was charged with identifying effective strategies to leverage the temporary expansion of pharmacist practice capabilities granted during the COVID-19 pandemic for sustained practice. The group was also tasked with looking at ways to partner with the Association of American Medical Colleges (AAMC), our medicine counterparts to develop a plan for collaborating with them to advance interprofessional practice. In this unique year, all standing committees were charged with reading all the reports last year to put President Lin's charges into perspective with the hopes of carrying over the overall theme and work of the previous years committee. Overall, throughout the COVID-19 pandemic, there have been several expansions on the scope of practice for pharmacists and vary by state. We hope to draw out some of those expansions to see how we can build upon efforts to make those permanent.

Developing sustainable workflows for community pharmacy-based SARS-CoV-2 testing

Background

The coronavirus disease Rapid Antigen Testing Expansion Program (Program) employed a drive-thru model to maximize pharmacy staff and the public’s safety.

Objectives

To quickly design, implement, and disseminate a pharmacy-based point-of-care testing program during a public health crisis.

Practice description

Community pharmacies in Idaho were engaged in the state’s public health efforts to boost severe acute respiratory syndrome coronavirus 2 testing statewide. Geographic location was a major recruitment factor. Two recruitment periods were held to extend the Program’s reach into more remote underserved communities.

Practice innovation

Program and pharmacy staff developed workflows and materials in an iterative process. Pharmacies received testing supplies. Program staff created e-Care plans for documentation and reimbursement and designed a Web portal for state reporting of positive rapid antigen test results.

Evaluation methods

Testing data (pharmacy location, patient insurance status, test type and results, number of submitted Medicaid claims) were captured in an online form.

Results

From September to December 2020, 13 pharmacies opted into a drive-thru, rapid antigen point-of-care testing and nasal swab for offsite testing program. A total of 2425 tests were performed. Approximately 29.4% of point-of-care tests were positive, and 70.6% required backup polymerase chain reaction confirmatory analysis. Patient insurance breakdown was 72.1% private, 8% Medicare, 11.4% Medicaid, and 8.5% uninsured. On average, pharmacies tested patients an average of 2.3 hours/day and 2.6 days/week. As a group, they provided 77.5 hours of testing per week statewide. Program pharmacies accounted for an average of 5.1% of testing across the entire state at the end of December 2020.

Conclusion

Independent community-based pharmacies should be considered as partners in public health initiatives.

The impact of the COVID-19 pandemic on addressing common barriers to pharmacy-based point-of-care testing

Introduction: Pharmacy-based point-of-care testing has long had the potential to improve patient access to timely care, but adoption has been slowed by financial and regulatory barriers. The COVID-19 pandemic reduced or temporarily eliminated many of the barriers to pharmacy-based testing. This review examines how the changes brought on by may impact pharmacy-based testing after the pandemic.Areas covered: This review searched peer-reviewed, lay, and regulatory literature to explore the implementation of pharmacy-based COVID-19 testing. This includes a review of regulatory and financial changes that removed barriers to testing. Additionally, it reviews the literature related to the growth of pharmacy-based testing.Expert opinion: It is clear that the COVID-19 pandemic created an awareness and opportunity for pharmacy-based point-of-care testing. The changes made in response to the pandemic have the potential to increase the role of pharmacy-based testing, but additional regulatory changes and wider pharmacy adoption are still needed to maximize the value of such services.

Gianotti-crosti syndrome in the setting of recent coronavirus disease-19 infection

Since the onset of the COVID-19 pandemic, the growing body of literature has largely focused on the adult population. Reported symptoms among children appear to be consistent with those in adults, including fever, respiratory symptoms, and gastrointestinal symptoms, though children may experience an overall milder disease course. Viral exanthems with possible association to COVID-19 have been reported in pediatric patients. We describe a 10-month-old boy with Gianotti-Crosti syndrome in the setting of recent SARS-CoV-2 RT-PCR positive testing to increase physician awareness and add to the collection of cutaneous manifestations of COVID-19.

Impact of COVID-19 on prevalence of community pharmacies as CLIA-Waived facilities

Background

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) enabled greater access to low-risk tests by allowing their use in facilities with a Certificate of Waiver in the U.S. Recently, the 2019 novel coronavirus (COVID-19) pandemic has shined a spotlight on CLIA-waived diagnostic testing. To meet this increased patient demand for diagnostic testing, the U.S. Department of Health and Human Services (HHS) authorized licensed pharmacists to order and administer FDA authorized COVID-19 tests.

Objective

This study aims to update the previous national benching report and examine both the number of pharmacies in the United States with CLIA Certificates of Waiver before and after the SARS-CoV-2 pandemic and the state-by-state differences in the percentage of pharmacies with CLIA Certificates of Waiver.

Methods

Data were collected from the U.S. Centers for Disease Control and Prevention CLIA Laboratory Search website May 3rd, 2015, August 4th, 2019 and November 26th, 2020. The website allows for exportation of demographic data on all CLIA-waived facilities by state.

Results

Pharmacies exhibited the largest growth both in number (4865 new locations) and by percent (45%) of CLIA-waived facilities between 2015 and 2020. The total number of pharmacies with a CLIA-waiver grew from 10,626 (17.94%) locations in 2015 to 12,157 (21.43%) locations in 2019, to 15,671 (27.63%) locations in 2020. States demonstrated considerable variability in the percentage of pharmacies with a CLIA-waiver, with a range of 2.92%–56.52%.

Conclusions

Pharmacies have become an increasingly important location for patients to access CLIA-waived tests in the United States, now serving as the second largest provider of CLIA-waived tests by the total number of locations. Most of this growth occurred between 2019 and 2020 due to the COVID-19 pandemic, and concentrated efforts will be necessary to sustain this momentum.

Comparative effectiveness of antiretroviral drug classes for the treatment of HIV infection in patients with high viral loads: a multicentre retrospective cohort study

OBJECTIVES

We aimed to compare the effectiveness of antiretroviral therapy (ART) classes for achieving HIV RNA suppression to < 50 HIV-1 RNA copies/mL within 6 months of initiation with high viral loads (VLs). Secondary objectives were to compare viral suppression (VS) at 12 weeks and 12 months, partial HIV RNA suppression to < 200 copies/mL, time to VS, time to rebound, and change in CD4 cell count.

METHODS

This was a multicentre, retrospective, observational study. Adult patients were included if they initiated ART between January 2005 and December 2016 with a VL ≥ 100 000 copies/mL.

RESULTS

There were 220 patients included in the study. The median VL was 252 919 [interquartile range (IQR) 149 472-500 000] copies/mL. Nonnucleoside reverse transcriptase inhibitor (NNRTI) recipients were more likely to achieve VS by 6 months compared to those initiating ART containing protease inhibitors (PIs) [75.4% vs. 44.1%, respectively; odds ratio (OR) 3.34; 95% confidence interval (CI) 1.62-6.90] or integrase strand transfer inhibitors (INSTIs) (75.4% vs. 55.8%, respectively; OR 2.40; 95% CI 1.03-5.58). VS at 12 weeks was more frequent with INSTI-containing regimens than with PIs (28.9% vs. 9.0%, respectively; OR 4.10; 95% CI 1.69-9.92). VS at 12 months did not significantly differ between treatment regimens. Median time to complete VS for INSTI, PI and NNRTI recipients was 22.3 (95% CI 13.4-33), 30.1 (95% CI 25-36) and 19.9 (95% CI 16-22.3) weeks, respectively. There were no significant differences in time to viral rebound or change in CD4 cell counts.

CONCLUSIONS

Patients with high VLs initiated on NNRTIs were more likely to achieve VS by 6 months on ART compared to INSTI and PI recipients.

The intersection of professionalism and interprofessional care: development and initial testing of the interprofessional professionalism assessment (IPA)

Valid assessment of interprofessional education and collaborative practice (IPECP) is challenging. The number of instruments that measure various aspects of IPECP, or in various sites is growing, however. The Interprofessional Professionalism Assessment (IPA) measures observable behaviors of health care professionals-in-training that demonstrate professionalism and collaboration when working with other health care providers in the context of people-centered care. The IPA instrument was created by the Interprofessional Professionalism Collaborative (IPC), a national group representing 12 entry-level health professions and one medical education assessment organization. The instrument was created and evaluated over several years through a comprehensive, multi-phasic process: 1) development of construct and observable behaviors, 2) instrument design, expert review and cognitive interviews, and 3) psychometric testing. The IPA contains 26 items representing six domains of professionalism (altruism and caring, excellence, ethics, respect, communication, accountability), and was tested by 233 preceptors rating health profession learners in the final year of their practical training. These preceptors represented 30 different academic institutions across the U.S., worked in various types of practice sites, and evaluated learners representing 10 different entry-level health professions. Exploratory factor analysis suggested four factors (communication, respect, excellence, altruism and caring) using 21 items with the least amount of missing data, and confirmed, for the most part, a priori expectations. Internal consistency reliability coefficients for the entire instrument and its four subscales were high (all greater than 0.9). Psychometric results demonstrate aspects of the IPA's reliability and validity and its use across multiple health professions and in various practice sites.

Report of the 2016-2017 Student Affairs Standing Committee

The 2016-2017 AACP Student Affairs Standing Committee addressed charges related to recruitment to the profession of pharmacy and a national awareness campaign for pharmacy careers, as well as promotion of student wellness and stress management. The Committee report provides six recommendations to the American Association of Colleges of Pharmacy (AACP) and one proposed policy statement for the AACP House of Delegates related to recruitment to the pharmacy profession. The Committee report also provides three recommendations to AACP and one proposed policy statement for the AACP House of Delegates related to student wellness and stress management. In addition, this report provides recommendations for future AACP Student Affairs Standing Committee work.

AACP Special Taskforce White Paper on Diversifying Our Investment in Human Capital

The 2015-2017 American Association of Colleges of Pharmacy (AACP) Special Taskforce on Diversifying our Investment in Human Capital was appointed for a two-year term, due to the rigors and complexities of its charges. This report serves as a white paper for academic pharmacy on diversifying our investment in human capital. The Taskforce developed and recommended a representation statement that was adapted and adopted by the AACP House of Delegates at the 2016 AACP Annual Meeting. In addition, the Taskforce developed a diversity statement for the Association that was adopted by the AACP Board of Directors in 2017. The Taskforce also provides recommendations to AACP and to academic pharmacy in this white paper.

Productivity in a dominant herbaceous species is largely unrelated to soil macronutrient stocks

To predict ecosystem responses to anthropogenic change it is important to understand how and where plant productivity is limited by macronutrient availability. Nitrogen (N) is required in large quantities for plant growth, and is readily lost through leaching or gas fluxes, but reactive nitrogen can be obtained through dinitrogen fixation, and phosphorus (P) is often considered a more fundamental long-term constraint to growth and carbon sequestration in terrestrial ecosystems. Phosphorus limitation may be becoming more prevalent due to widespread pollution by atmospheric N. Assessments of the effects of macronutrient availability on productivity in natural ecosystems are however scarce. We measured standing biomass of bracken Pteridium aquilinum as a proxy for productivity across sites with similar climate but varied geology. Total above-ground biomass varied from 404 to 1947gm^-2, yet despite 12-fold to 281-fold variation in soil macronutrient stocks these were remarkably poor at explaining variation in productivity. Soil total nitrogen, organic phosphorus, calcium, magnesium and zinc had no relationship with productivity, whether expressed as concentrations, stocks or element/C ratios, and nor did foliar N/P. Soil potassium (K) and molybdenum stocks both showed weak relationships with productivity. The stock of K in bracken biomass was considerably greater as a proportion of soil stock than for other nutrient elements, suggesting that this nutrient element can be important in determining productivity. Moisture availability, as indicated by environmental trait scores for plant species present, explained considerably more of the variation in productivity than did K stock, with less production in wetter sites. Soil N/C ratio and organic P stock were relatively unimportant in determining productivity across these bracken sites. It is possible that more-direct measures of N and P availability would explain variation in productivity, but the study shows the importance of considering other essential elements and other environmental factors when predicting productivity.

Association between osteoporosis treatment change and adherence, incident fracture, and total healthcare costs in a Medicare Advantage Prescription Drug plan

We examined the association between osteoporosis treatment change and adherence, incident fractures, and healthcare costs among Medicare Advantage Prescription Drug (MAPD) plan members. Treatment change was associated with a small but significant increase in adherence, but was not associated with incident fracture or total healthcare costs. Overall adherence remained low.

INTRODUCTION

We examined the association between osteoporosis treatment change and adherence, incident fractures, and healthcare costs among MAPD plan members in a large US health plan.

METHODS

We conducted a retrospective cohort study of MAPD plan members aged≥50 years newly initiated on an osteoporosis medication between 1 January 2006 and 31 December 2008. Members were identified as having or not having an osteoporosis treatment change within 12 months after initiating osteoporosis medication. Logistic regression analyses and difference-in-difference (DID) generalized linear models were used to investigate the association between osteoporosis treatment change and (1) adherence to treatment, (2) incident fracture, and (3) healthcare costs at 12 and 24 months follow-up.

RESULTS

Of the 33,823 members newly initiated on osteoporosis treatment, 3,573 (10.6%) changed osteoporosis treatment within 12 months. After controlling for covariates, osteoporosis treatment change was associated with significantly higher odds of being adherent (medication possession ratio [MPR]≥0.8) at 12 months (odds ratio [OR]=1.18) and 24 months (OR=1.13) follow-up. However, overall adherence remained low (MPR=0.59 and 0.51 for the change cohort and MPR=0.51 and 0.44 for the no-change cohort at 12 and 24 months, respectively). Osteoporosis treatment change was not significantly associated with incident fracture (OR=1.00 at 12 months and OR=0.98 at 24 months) or total direct healthcare costs (p>0.4) in the DID analysis, but was associated with higher pharmacy costs (p<0.004).

CONCLUSIONS

Osteoporosis treatment change was associated with a small but significant increase in adherence, but was not associated with incident fracture or total healthcare costs in the MAPD plan population. Overall adherence to therapy remained low.

Pharmacokinetics of two common antiretroviral regimens in older HIV-infected patients: a pilot study

OBJECTIVES

The pharmacokinetics (PK) of antiretrovirals (ARVs) in older HIV-infected patients are poorly described. Here, the steady-state PK of two common ARV regimens [tenofovir (TFV)/emtricitabine (FTC)/efavirenz (EFV) and TFV/FTC/atazanavir (ATV)/ritonavir (RTV)] in older nonfrail HIV-infected patients are presented.

METHODS

HIV-infected subjects ≥ 55 years old not demonstrating the frailty phenotype were enrolled in an unblinded, intensive-sampling PK study. Blood plasma (for TFV, FTC, EFV, ATV and RTV concentrations) and peripheral blood mononuclear cells [PBMCs; for tenofovir diphosphate (TFV-DP) and emtricitabine triphosphate (FTC-TP) concentrations] were collected at 11 time-points over a 24-hour dosing interval. Drug concentrations were analysed using validated liquid chromatography-ultraviolet detection (LC-UV) or liquid chromatography tandem mass spectrometry (LC-MS/MS) methods. Noncompartmental pharmacokinetic analysis was used to estimate PK parameters [area under the concentration-time curve over 24 h (AUC0-24h ) and maximal concentration (Cmax )]. These parameters were compared with historical values from the general HIV-infected population.

RESULTS

Six subjects on each regimen completed the study. Compared with the general population, these elderly subjects had 8-13% decreased TFV AUC0-24h and Cmax , and 19-78% increased FTC and RTV AUC0-24h and Cmax . Decreased ATV AUC0-24h (12%) and increased Cmax (9%) were noted, while EFV exposure was unchanged (5%) with a 16% decrease in Cmax . Intracellular nucleoside/tide metabolite concentrations and AUC are also reported for these subjects.

CONCLUSIONS

This study demonstrates that the PK of these ARVs are altered by 5-78% in an older HIV-infected population. Implications of PK differences for clinical outcomes, particularly with the active nucleoside metabolites, remain to be explored. This study forms the basis for further study of ARV PK, efficacy, and toxicity in older HIV-infected patients.

Effect of metabolic inhibitors on ATP and citrate content in PC3 prostate cancer cells

BACKGROUND

In normal prostate epithelial cells low m-aconitase activity decreases citrate oxidation leading to citrate accumulation. In prostate cancer cells m-aconitase activity is increased and citrate content is lower. The effect of inhibition of m-aconitase on ATP production by prostate cancer cells (PC3) is not known nor is the contribution of glycolysis versus respiration.

METHODS

ATP content of PC3 cells as affected by inhibition of m-aconitase (fluoroacetate (FA), zinc), inhibition of glycolysis (2DxG), or respiration (DNP, oligomycin) was determined. The ability to maintain ATP using glucose or glutamine as sole substrate was also determined. Intermediates including ATP, lactate, glucose, and glutamine were assayed in neutralized perchloric acid (PCA) cell extracts, virgin, and conditioned medium by enzymatic fluorometry.

RESULTS

Data show that inhibition of m-aconitase, glycolysis, or respiration alone did not decrease ATP content. Inhibition of both glycolysis and respiration were required to decrease ATP content. PC3 cells were able to produce ATP with either glucose or glutamine as sole substrate. Though FA clearly inhibited m-aconitase there was no evidence that zinc had a similar effect.

CONCLUSION

PC3 cells can support ATP production when m-aconitase is inhibited by using glycolysis or oxidation of substrate (e.g., glutamine) entering the TCA cycle distal to citrate.

Leap for Life: innovative patient education to optimize outcomes among patients with cardiovascular disease

OBJECTIVE

To evaluate the Leap for Life cardiovascular risk factor education program based on outcome measurements of self-reported hospital readmission, goal achievement, satisfaction, and educational model preference.

SETTING

Four hospitals and one senior center of Baylor Health Care System in the Dallas, Texas, area.

DESIGN

Administration of a satisfaction questionnaire and resurvey of participants by telephone at 3, 6, and 12 months.

PATIENTS

161 patients with cardiovascular disease enrolled in the Leap for Life program during calendar year 1997. Patients were primarily male (59%), with an average age of 66 years; they had an average of 4 cardiovascular disease risk factors.

RESULTS

Of the 152 participants who took part in the telephone follow-up, 19% reported a hospital admission with a cardiovascular diagnosis during the 12-month follow-up period. Twenty-one percent reported meeting all of their goals; 56%, some of their goals; and 23%, none of their goals. All stated that the educational sessions met their informational needs, and 75% preferred the Leap for Life setting over other educational settings. CONCLUSION AND NEXT STEPS: These data provide initial validation of the program and are being used as a starting point for another assessment that involves individualized health enhancement measures and 6- and 12-month follow-up of participants using a survey designed to assess readiness, lifestyle changes, and quality of life.

Effect of hydraulic retention time on inorganic nutrient recovery and biodegradable organics removal in a biofilm reactor treating plant biomass leachate

A fixed-film (biofilm) reactor was designed and its performance was determined at various retention times. The goal was to find the optimal retention time for recycling plant nutrients in an advanced life support system, to minimize the size, mass, and volume (hold-up) of a production model. The prototype reactor was tested with aqueous leachate from wheat crop residue at 24, 12, 6, and 3 h hydraulic retention times (HRTs). Biochemical oxygen demand (BOD), nitrates and other plant nutrients, carbohydrates, total phenolics, and microbial counts were monitored to characterize reactor performance. BOD removal decreased significantly from 92% at the 24 h HRT to 73% at 3 h. Removal of phenolics was 62% at the 24 h retention time, but 37% at 3 h. Dissolved oxygen concentrations, nitric acid consumption, and calcium and magnesium removals were also affected by HRT. Carbohydrate removals, carbon dioxide (CO2) productions, denitrification, potassium concentrations, and microbial counts were not affected by different retention times. A 6 h HRT will be used in future studies to determine the suitability of the bioreactor effluent for hydroponic plant production.

Pyrimidinylimidazole inhibitors of p38: cyclic N-1 imidazole substituents enhance p38 kinase inhibition and oral activity

Optimization of a series of N-1-cycloalkyl-4-aryl-5-(pyrimidin-4-yl)imidazole inhibitors of p38 kinase is reported. Oral administration of inhibitors possessing a cyclohexan-4-ol or piperidin-4-yl group at N-1 in combination with alkoxy, amino(alkyl), phenoxy and anilino substitution at the 2-position of the pyrimidine was found to potently inhibit LPS-induced TNF in mice and rats. The selectivity of these new inhibitors for p38 kinase versus eight other protein kinases is high and in all cases exceeds that of SB 203580.

Hypertensive end-organ damage and premature mortality are p38 mitogen-activated protein kinase-dependent in a rat model of cardiac hypertrophy and dysfunction

BACKGROUND

Numerous pathological mediators of cardiac hypertrophy (eg, neurohormones, cytokines, and stretch) have been shown to activate p38 MAPK. The purpose of the present study was to examine p38 MAPK activation and the effects of its long-term inhibition in a model of hypertensive cardiac hypertrophy/dysfunction and end-organ damage.

METHODS AND RESULTS

In spontaneously hypertensive stroke-prone (SP) rats receiving a high-salt/high-fat diet (SFD), myocardial p38 MAPK was activated persistently during the development of cardiac hypertrophy and inactivated during decompensation. Long-term oral treatment of SFD-SP rats with a selective p38 MAPK inhibitor (SB239063) significantly enhanced survival over an 18-week period compared with the untreated group (100% versus 50%). Periodic echocardiographic analysis revealed a significant reduction in LV hypertrophy and dysfunction in the SB239063-treatment groups. Little or no difference in blood pressure was noted in the treatment or vehicle groups. Basal and stimulated (lipopolysaccharide) plasma tumor necrosis factor-alpha concentrations were reduced in the SB239063-treatment groups. In vitro vasoreactivity studies demonstrated a significant preservation of endothelium-dependent relaxation in animals treated with the p38 MAPK inhibitor without effects on contraction or NO-mediated vasorelaxation. Proteinuria and the incidence of stroke (53% versus 7%) were also reduced significantly in the SB239063-treated groups.

CONCLUSIONS

These results demonstrate a crucial role for p38 MAPK in hypertensive cardiac hypertrophy and end-organ damage. Interrupting its function with a specific p38 MAPK inhibitor halts clinical deterioration.

Culturability as an indicator of succession in microbial communities

Successional theory predicts that opportunistic species with high investment of energy in reproduction and wide niche width will be replaced by equilibrium species with relatively higher investment of energy in maintenance and narrower niche width as communities develop. Since the ability to rapidly grow into a detectable colony on nonselective agar medium could be considered as characteristic of opportunistic types of bacteria, the percentage of culturable cells may be an indicator of successional state in microbial communities. The ratios of culturable cells (colony forming units on R2A agar) to total cells (acridine orange direct microscopic counts) and culturable cells to active cells (reduction of 5-cyano-2,3-ditolyl tetrazolium chloride) were measured over time in two types of laboratory microcosms (the rhizosphere of hydroponically grown wheat and aerobic, continuously stirred tank reactors containing plant biomass) to determine the effectiveness of culturabilty as an index of successional state. The culturable cell:total cell ratio in the rhizosphere decreased from approximately 0.25 to less than 0.05 during the first 30-50 days of plant growth, and from 0.65 to 0.14 during the first 7 days of operation of the bioreactor. The culturable cell:active cell ratio followed similar trends, but the values were consistently greater than the culturable cell:total cell ratio, and even exceeded I in early samples. Follow-up studies used a cultivation-independent method, terminal restriction fragment length polymorphisms (TRFLP) from whole community DNA, to assess community structure. The number of TRFLP peaks increased with time, while the number of culturable types did not, indicating that the general decrease in culturability is associated with a shift in community structure. The ratio of respired to assimilated C-14-labeled amino acids increased with the age of rhizosphere communities, supporting the hypothesis that a shift in resource allocation from growth to maintenance occurs with time. Results from this work indicate that the percentage of culturable cells may be a useful method for assessing the successional state of microbial communities.

Potent and selective nonpeptide inhibitors of caspases 3 and 7

5-Dialkylaminosulfonylisatins have been identified as potent, nonpeptide inhibitors of caspases 3 and 7. The most active compound within this series (34) inhibited caspases 3 and 7 in the 2-6 nM range and exhibited approximately 1000-fold selectivity for caspases 3 and 7 versus a panel of five other caspases (1, 2, 4, 6, and 8) and was at least 20-fold more selective versus caspase 9. Sequence alignments of the active site residues of the caspases strongly suggest that the basis of this selectivity is due to binding in the S2 subsite comprised of residues Tyr204, Trp206, and Phe256 which are unique to caspases 3 and 7. These compounds inhibit apoptosis in three cell-based models: human Jurkat T cells, human chondrocytes, and mouse bone marrow neutrophils.

Identification of a selective nonpeptide antagonist of the anaphylatoxin C3a receptor that demonstrates antiinflammatory activity in animal models

The anaphylatoxin C3a is a potent chemotactic peptide and inflammatory mediator released during complement activation which binds to and activates a G-protein-coupled receptor. Molecular cloning of the C3aR has facilitated studies to identify nonpeptide antagonists of the C3aR. A chemical lead that selectively inhibited the C3aR in a high throughput screen was identified and chemically optimized. The resulting antagonist, N(2)-[(2,2-diphenylethoxy)acetyl]-L-arginine (SB 290157), functioned as a competitive antagonist of (125)I-C3a radioligand binding to rat basophilic leukemia (RBL)-2H3 cells expressing the human C3aR (RBL-C3aR), with an IC(50) of 200 nM. SB 290157 was a functional antagonist, blocking C3a-induced C3aR internalization in a concentration-dependent manner and C3a-induced Ca(2+) mobilization in RBL-C3aR cells and human neutrophils with IC(50)s of 27.7 and 28 nM, respectively. SB 290157 was selective for the C3aR in that it did not antagonize the C5aR or six other chemotactic G protein-coupled receptors. Functional antagonism was not solely limited to the human C3aR; SB 290157 also inhibited C3a-induced Ca(2+) mobilization of RBL-2H3 cells expressing the mouse and guinea pig C3aRS: It potently inhibited C3a-mediated ATP release from guinea pig platelets and inhibited C3a-induced potentiation of the contractile response to field stimulation of perfused rat caudal artery. Furthermore, in animal models, SB 290157, inhibited neutrophil recruitment in a guinea pig LPS-induced airway neutrophilia model and decreased paw edema in a rat adjuvant-induced arthritis model. This selective antagonist may be useful to define the physiological and pathophysiological roles of the C3aR.

Phenoxypyrimidine inhibitors of p38α kinase

As a continuation of our work with 1,4,5 substituted imidazole inhibitors of p38alpha, we report a series of 1-(4-piperidinyl)-4-(4-fluorophenyl)-5-(2-phenoxy-4-pyrimidinyl) imidazoles related to 7. The compounds have IC50's for inhibition of p38alpha ranging from 6.0 to 650nM. Statistical analysis of the p38beta inhibitor potencies shows a correlation of IC50's with the electron donating strength of low molecular weight substituents.

Inhibition of p38 mitogen-activated protein kinase provides neuroprotection in cerebral focal ischemia

Mitogen-activated protein kinases (MAPKs) are involved in many cellular processes. The stress-activated MAPK, p38, has been linked to inflammatory cytokine production and cell death following cellular stress. Here, we demonstrate focal ischemic stroke-induced p38 enzyme activation (i.e., phosphorylation) in the brain. The second generation p38 MAPK inhibitor SB 239063 was identified to exhibit increased kinase selectivity and improved cellular and in vivo activity profiles, and thus was selected for evaluation in two rat models of permanent focal ischemic stroke. SB 239063 was administered orally pre- and post-stroke and intravenously post-stroke. Plasma concentration levels were achieved in excess of those that effectively inhibit p38 activity. In both moderate and severe stroke, SB 239063 reduced infarct size by 28-41%, and neurological deficits by 25-35%. In addition, neuroprotective plasma concentrations of SB 239063 that reduced p38 activity following stroke also reduced the stroke-induced expression of IL-1beta and TNFalpha (i.e., cytokines known to contribute to stroke-induced brain injury). SB 239063 also provided direct protection of cultured brain tissue to in vitro ischemia. This robust SB 239063-induced neuroprotection emphasizes a significant opportunity for targeting MAPK pathways in ischemic stroke injury, and also suggests that p38 inhibition be evaluated for protective effects in other experimental models of nervous system injury and neurodegeneration.

SB 239063, a second-generation p38 mitogen-activated protein kinase inhibitor, reduces brain injury and neurological deficits in cerebral focal ischemia

The stress-activated mitogen-activated protein kinase (MAPK) p38 has been linked to the production of inflammatory cytokines/mediators/inflammation and death/apoptosis following cell stress. In these studies, a second-generation p38 MAPK inhibitor, SB 239063 (IC(50) = 44 nM), was found to exhibit improved kinase selectivity and increased cellular (3-fold) and in vivo (3- to 10-fold) activity over first-generation inhibitors. Oral SB 239063 inhibited lipopolysaccharide-induced plasma tumor necrosis factor production (IC(50) = 2.6 mg/kg) and reduced adjuvant-induced arthritis (51% at 10 mg/kg) in rats. SB 239063 reduced infarct volume (48%) and neurological deficits (42%) when administered orally (15 mg/kg, b.i.d.) before moderate stroke. Intravenous SB 239063 exhibited a clearance of 34 ml/min/kg, a volume of distribution of 3 l/kg, and a plasma half-life of 75 min. An i.v. dosing regimen that provided effective plasma concentrations of 0.38, 0.75, or 1.5 microg/ml (i.e., begun 15 min poststroke and continuing over the initial 6-h p38 activation period) was used. Significant and dose-proportional brain penetration of SB 239063 was demonstrated during these infusion periods. In both moderate and severe stroke, intravenous SB 239063 produced a maximum reduction of infarct size by 41 and 27% and neurological deficits by 35 and 33%, respectively. No effects of the drug were observed on cerebral perfusion, hemodynamics, or body temperature. Direct neuroprotective effects from oxygen and glucose deprivation were also demonstrated in organotypic cultures of rat brain tissue. This robust in vitro and in vivo SB 239063-induced neuroprotection emphasizes the potential role of MAPK pathways in ischemic stroke and also suggests that p38 inhibition warrants further study, including protection in other models of nervous system injury and neurodegeneration.

Measuring the incremental cost of clinical cancer research

PURPOSE

To summarize evidence on the costs of treating patients in clinical trials and to describe the Cost of Cancer Treatment Study, an ongoing effort to produce generalizable estimates of the incremental costs of government-sponsored cancer trials.

METHODS

A retrospective study of costs will be conducted with 1,500 cancer patients recruited from a randomly selected sample of institutions in the United States. Patients accrued to either phase II or phase III National Cancer Institute-sponsored clinical trials during a 15-month period will be asked to participate in a study of their health care utilization (n = 750). Costs will be measured approximately 1 year after their trial enrollment from a combination of billing records, medical records, and an in-person survey questionnaire. Similar data will be collected for a comparable group of cancer patients not in trials (n = 750) to provide an estimate of the incremental cost.

RESULTS

Evidence suggests insurers limit access to trials because of cost concerns. Public and private efforts are underway to change these policies, but their permanent status is unclear. Previous studies found that treatment costs in clinical trials are similar to costs of standard therapy. However, it is difficult to generalize from these studies because of the unique practice settings, insufficient sample sizes, and the exclusion of potentially important costs.

CONCLUSION

Denials of coverage for treatment in a clinical trial limit patient access to trials and could impede clinical research. Preliminary estimates suggest changes to these policies would not be expensive, but these results are not generalizable. The Cost of Cancer Treatment Study is an ongoing effort to provide generalizable estimates of the incremental treatment cost of phase II and phase III cancer trials. The results should be of great interest to insurers and the research community as they consider permanent ways to finance cancer trials.

SB 239063, a p38 MAPK inhibitor, reduces neutrophilia, inflammatory cytokines, MMP-9, and fibrosis in lung

The effects of a second generation p38 mitogen-activated protein kinase (MAPK) inhibitor, SB 239063 [trans-1-(4-hydroxycyclohexyl)-4-(4-fluorophenyl)-5-(2-methoxypyridim idi n-4-yl)imidazole; IC(50) = 44 nM vs. p38 alpha], were assessed in models that represent different pathological aspects of chronic obstructive pulmonary disease (COPD) [airway neutrophilia, enhanced cytokine formation and increased matrix metalloproteinase (MMP)-9 activity] and in a model of lung fibrosis. Airway neutrophil infiltration and interleukin (IL)-6 levels, assessed by bronchoalveolar lavage 48 h after lipopolysaccharide (LPS) inhalation, were inhibited dose dependently by 3-30 mg/kg of SB 239063 given orally twice a day. In addition, SB 239063 (30 mg/kg orally) attenuated IL-6 bronchoalveolar lavage fluid concentrations (>90% inhibition) and MMP-9 activity (64% inhibition) assessed 6 h after LPS exposure. In guinea pig cultured alveolar macrophages, SB 239063 inhibited LPS-induced IL-6 production (IC(50) of 362 nM). In a bleomycin-induced pulmonary fibrosis model in rats, treatment with SB 239063 (2.4 or 4.8 mg/day via osmotic pump) significantly inhibited bleomycin-induced right ventricular hypertrophy (indicative of secondary pulmonary hypertension) and increases in lung hydroxyproline synthesis (indicative of collagen synthesis and fibrosis). Therefore, SB 239063 demonstrates activity against a range of sequelae commonly associated with COPD and fibrosis, supporting the therapeutic potential of p38 MAPK inhibitors such as SB 239063 in chronic airway disease.

Role of p38 mitogen-activated protein kinase in rhinovirus-induced cytokine production by bronchial epithelial cells

The stress-activated protein kinase p38 plays a central role in the regulation of cytokine biosynthesis by various cell types in response to a wide range of stimuli. Because the local inflammatory response and the infiltration of neutrophils is thought to contribute to the symptoms and sequelae of rhinovirus infection, we investigated the role of p38 kinase in cytokine and chemokine elaboration in airway epithelial cells infected with human rhinovirus. Rhinovirus-39 infection of BEAS-2B cells resulted in synthesis of cytokines (IL-1, IL-6, G-CSF, and GM-CSF) and CXC chemokines (IL-8, epithelial neutrophil-activating protein-78, and growth-related oncogene-alpha), evident 24-72 h postinfection. Rhinovirus infection induced a time- and dose-dependent increase in tyrosine phosphorylation of p38 kinase, which peaked 30 min postinfection and remained elevated for 1 h. Treatment of infected cells with SB 239063, a potent pyridinyl imidazole inhibitor of p38 kinase, resulted in up to 100% inhibition of mediator production and partially reduced levels of IL-8 mRNA as determined by quantitative RT-PCR. Treatment with SB 239063 had no effect on virus replication and was not cytotoxic at concentrations </= 70 microM. These studies provide the first evidence that early activation of p38 kinase by rhinovirus infection is a key event in regulation of virus-induced cytokine transcription, and may provide a new target for inhibition of symptoms and airway inflammation associated with rhinovirus infection.

Evidence for new isotopes of element 107: 266Bh and 267Bh

New neutron rich isotopes 267107Bh and 266107Bh were produced in bombardments of a 249Bk target with 117-MeV and 123-MeV 22Ne ions at the Lawrence Berkeley National Laboratory 88-Inch Cyclotron. Identification was made by observation of correlated alpha-particle decays between the Bh isotopes and their Db and Lr daughters using a rotating wheel system. 267Bh was produced with a cross section of approximately 70 pb and decays with a 17(+14)(-6) s half life by emission of alpha particles with an average energy of 8.83+/-0.03 MeV. One atom of 266Bh was observed, decaying within 1 s by emission of a 9.29-MeV alpha particle.

Potent and selective nonpeptide inhibitors of caspases 3 and 7 inhibit apoptosis and maintain cell functionality

Caspases have been strongly implicated to play an essential role in apoptosis. A critical question regarding the role(s) of these proteases is whether selective inhibition of an effector caspase(s) will prevent cell death. We have identified potent and selective non-peptide inhibitors of the effector caspases 3 and 7. The inhibition of apoptosis and maintenance of cell functionality with a caspase 3/7-selective inhibitor is demonstrated for the first time, and suggests that targeting these two caspases alone is sufficient for blocking apoptosis. Furthermore, an x-ray co-crystal structure of the complex between recombinant human caspase 3 and an isatin sulfonamide inhibitor has been solved to 2.8-A resolution. In contrast to previously reported peptide-based caspase inhibitors, the isatin sulfonamides derive their selectivity for caspases 3 and 7 by interacting primarily with the S(2) subsite, and do not bind in the caspase primary aspartic acid binding pocket (S(1)). These inhibitors blocked apoptosis in murine bone marrow neutrophils and human chondrocytes. Furthermore, in camptothecin-induced chondrocyte apoptosis, cell functionality as measured by type II collagen promoter activity is maintained, an activity considered essential for cartilage homeostasis. These data suggest that inhibiting chondrocyte cell death with a caspase 3/7-selective inhibitor may provide a novel therapeutic approach for the prevention and treatment of osteoarthritis, or other disease states characterized by excessive apoptosis.

Inhibition of p38 MAP kinase as a therapeutic strategy

Since the discovery of p38 MAP kinase in 1994, our understanding of its biology has progressed dramatically. The key advances include (1) identification of p38 MAP kinase homologs and protein kinases that act upstream and downstream from p38 MAP kinase, (2) identification of interesting and potentially important substrates, (3) elucidation of the role of p38 MAP kinase in cellular processes and (4) the establishment of the mechanism by which the pyridinylimidazole p38 MAP kinase inhibitors inhibit enzyme activity. It is now known that there are four members of the p38 MAP kinase family. They differ in their tissue distribution, regulation of kinase activation and subsequent phosphorylation of downstream substrates. They also differ in terms of their sensitivities toward the p38 MAP kinase inhibitors. The best-studied isoform is p38 alpha, whose activation has been observed in many hematopoietic and non-hematopoietic cell types upon treatment with appropriate stimuli. The pyridinylimidazole compounds, exemplified by SB 203580, were originally prepared as inflammatory cytokine synthesis inhibitors that subsequently were found to be selective inhibitors of p38 MAP kinase. SB 203580 inhibits the catalytic activity of p38 MAP kinase by competitive binding in the ATP pocket. X-ray crystallographic studies of the target enzyme complexed with inhibitor reinforce the observations made from site-directed mutagenesis studies, thereby providing a molecular basis for understanding the kinase selectivity of these inhibitors. The p38 MAP kinase inhibitors are efficacious in several disease models, including inflammation, arthritis and other joint diseases, septic shock, and myocardial injury. In all cases, p38 activation in key cell types correlated with disease initiation and progression. Treatment with p38 MAP kinase inhibitors attenuated both p38 activation and disease severity. Structurally diverse p38 MAP kinase inhibitors have been tested extensively in preclinical studies.

A systematic review of patient information leaflets for hypertension

OBJECTIVE

To review patient information leaflets on hypertension to determine the quality of information currently available to patients.

DESIGN AND SETTING

A standardised systematic rating of patient information leaflets for hypertension in the UK.

MAIN OUTCOME MEASURE

A quality score per leaflet based on a pre-determined rating scale. using recognised criteria with marks allocated for content, writing style, readability and design.

RESULTS

Sixty-one leaflets were received, 42 from the Internet and 19 from other sources. Leaflets could achieve a maximum of 84 points. Scores ranged from 30 to 70 for non-Internet leaflets and 28 to 67 for Internet leaflets. Leaflets produced by Boeringer Ingelheim for the British Hypertension Society and Greenlines Publishing (with a medical education grant from Knoll Ltd) scored highest overall. A detailed analysis of the non-Internet leaflets showed that few leaflets contained the full range of information considered important though most should be readable by the majority of the adult population and are written using appropriate language and typeface.

CONCLUSION

High quality information is available for patients, though some leaflets fall below an adequate standard. Professionals providing advice to patients should have some knowledge of what constitutes good quality information and be critical of the resources they use. Ideally surgeries and clinics should stock a range of the best information available so that patients can chose the leaflet most appropriate to their needs.

SB 239063, a potent p38 MAP kinase inhibitor, reduces inflammatory cytokine production, airways eosinophil infiltration, and persistence

The anti-inflammatory/antiallergic activity of a novel second-generation p38 mitogen-activated protein kinase inhibitor, SB 239063[trans-1-(4-hydroxycyclohexyl) -4-(4-fluorophenyl)-5-(2-methoxypyridimidin-4-yl)imidazole], was investigated in vivo and in vitro. SB 239063 had an IC(50) of 44 nM for inhibition of recombinant purified human p38alpha. In lipopolysaccharide-stimulated human peripheral blood monocytes, SB 239063 inhibited interleukin-1 and tumor necrosis factor-alpha production (IC(50) values = 0.12 and 0.35 microM, respectively). A role for p38 kinase in cytokine-associated inflammation in the mouse was shown by p38 activation in the lung and inhibition of lipopolysaccharide-induced tumor necrosis factor-alpha production by SB 239063 (ED(50) = 5.8 mg/kg p.o.). Antiallergic activity was demonstrated by essential abolition (approximately 93% inhibition) of inhaled ovalbumin (OA)-induced airway eosinophilia by SB 239063 (12 mg/kg p.o.), measured by bronchoalveolar lavage (BAL) in OA-sensitized mice. In addition, p38 kinase was found by Western analysis to be activated in guinea pig lung. Administration of SB 239063 (10 or 30 mg/kg p.o.) in conscious guinea pigs markedly reduced ( approximately 50% inhibition) OA-induced pulmonary eosinophil influx, measured by BAL 24 h after antigen. SB 239063 (10 mg/kg b.i.d. p.o.) administered after leukotriene D(4) inhalation, reduced by 60% the persistent airway eosinophilia seen at 4 days. Apoptosis of cultured eosinophils isolated from guinea pig BAL was increased by SB 239063 (1-10 microM) in the presence of interleukin-5. These results indicate that SB 239063 is a potent inhibitor of inflammatory cytokine production, inhibits eosinophil recruitment, in addition to enhancing apoptosis of these cells. Collectively, the results support the potential utility of p38 kinase inhibitors, such as SB 239063, for the treatment of asthma and other inflammatory disorders.

Disease-modifying activity of SB 242235, a selective inhibitor of p38 mitogen-activated protein kinase, in rat adjuvant-induced arthritis

OBJECTIVE

To evaluate the effects of SB 242235, a potent and selective inhibitor of p38 mitogen-activated protein (MAP) kinase, on joint integrity in rats with adjuvant-induced arthritis (AIA).

METHODS

Male Lewis rats with AIA were orally treated either prophylactically (days 0-20) or therapeutically (days 10-20) with SB 242235. Efficacy was determined by measurements of paw inflammation, dual-energy x-ray absorptiometry for bone-mineral density (BMD), magnetic resonance imaging (MRI), microcomputed tomography (CT), and histologic evaluation. Serum tumor necrosis factor alpha (TNFalpha) in normal (non-AIA) rats and serum interleukin-6 (IL-6) levels in rats with AIA were measured as markers of the antiinflammatory effects of the compound.

RESULTS

SB 242235 inhibited lipopolysaccharide-stimulated serum levels of TNFalpha in normal rats, with a median effective dose of 3.99 mg/kg. When SB 242235 was administered to AIA rats prophylactically on days 0-20, it inhibited paw edema at 30 mg/kg and 10 mg/kg per day by 56% and 33%, respectively. Therapeutic administration on days 10-20 was also effective, and inhibition of paw edema was observed at 60, 30, and 10 mg/kg (73%, 51%, and 19%, respectively). Significant improvement in joint integrity was demonstrated by showing normalization of BMD and also by MRI and micro-CT analysis. Protection of bone, cartilage, and soft tissues was also shown histologically. Serum IL-6 levels were decreased in AIA rats treated with the 60 mg/kg dose of compound.

CONCLUSION

Symptoms of AIA in rats were significantly reduced by both prophylactic and therapeutic treatment with the p38 MAP kinase inhibitor, SB 242235. Results from measurements of paw inflammation, assessment of BMD, MRI, and micro-CT indicate that this compound exerts a protective effect on joint integrity, and thus appears to have disease-modifying properties.

Pyridinylimidazole compound SB 203580 inhibits the activity but not the activation of p38 mitogen-activated protein kinase

p38 MAPK is a Ser/Thr protein kinase activated by various inflammatory cytokines and a variety of stress stimuli. It is involved in many physiological processes, including the production of inflammatory cytokines. We have previously reported the design and synthesis of a series of pyridinylimidazole compounds that are selective inhibitors of p38 MAPK. These compounds, exemplified by SB 203580, are exceptionally effective in cell-based assays, including the inhibition of inflammatory cytokine production. SB 203580 is widely used as a tool to dissect the role of p38 MAPK in various physiological processes. It has previously been established that SB 203580 acts primarily to block the catalytic activity of p38 MAPK. However, it has been suggested that in cells, the compounds could also inhibit p38 MAPK activation by virtue of their ability to bind to the inactive enzyme. We undertook careful studies to definitively demonstrate that treatment with SB 203580 had no effect on Thr(180) and Tyr(182) phosphorylation, and hence activation of p38 in vivo. SB 203580, however, potently inhibited the activity of p38 MAPK as demonstrated by the inhibition of the activation of MAPKAP K2, a specific physiological substrate of p38 MAPK. This was observed regardless of stimuli or cell type. Identical results were obtained when the p38 MAPK cascade was partially reconstituted in vitro. Thus, our data clearly indicate that SB 203580 specifically inhibits the activity of p38 MAPK but not its activation by upstream MAPKK.

Impact of rpoS deletion on Escherichia coli biofilms

Slow growth has been hypothesized to be an essential aspect of bacterial physiology within biofilms. In order to test this hypothesis, we employed two strains of Escherichia coli, ZK126 (DeltalacZ rpoS(+)) and its isogenic DeltarpoS derivative, ZK1000. These strains were grown at two rates (0.033 and 0.0083 h(-1)) in a glucose-limited chemostat which was coupled either to a modified Robbins device containing plugs of silicone rubber urinary catheter material or to a glass flow cell. The presence or absence of rpoS did not significantly affect planktonic growth of E. coli. In contrast, biofilm cell density in the rpoS mutant strain (ZK1000), as measured by determining the number of CFU per square centimeter, was reduced by 50% (P < 0.05). Deletion of rpoS caused differences in biofilm cell arrangement, as seen by scanning confocal laser microscopy. In reporter gene experiments, similar levels of rpoS expression were seen in chemostat-grown planktonic and biofilm populations at a growth rate of 0.033 h(-1). Overall, these studies suggest that rpoS is important for biofilm physiology.

Infusion protocol improves delivery of enteral tube feeding in the critical care unit

BACKGROUND

Numerous factors may impede the delivery of enteral tube feedings (ETF) in the intensive care unit (ICU). We designed a prospective study to determine whether the use of an infusion protocol could improve the delivery of ETF in the ICU.

METHODS

In a prior prospective study, we monitored all patients admitted to the medical intensive care unit (MICU) or cardiac care unit (CCU) who were made nil per os and placed on ETF (control group). We found that critically ill patients received only 52% of their goal calories, primarily due to physician underordering (66% of goal), frequent cessations of ETF (22% of the time), and slow advancement (14% at goal by 72 hours). Based on these findings, we developed an ETF protocol that incorporated standardized physician ordering and nursing procedures, rapid advancement, and limited ETF interruption. After extensive educational sessions, the ETF protocol was begun. Again, all patients admitted to the MICU or CCU who were made nil per os and placed on ETF were prospectively followed (protocol group).

RESULTS

Thirty-one patients in the protocol group were followed during 312 days of ETF and compared with the control group (44 patients with 339 days of ETF). Despite efforts by the nutritional support team, the infusion protocol was used in only 18 patients (58%). The main reasons for noncompliance with the protocol were physician preference and system failure (ETF order sheet not placed in chart). When used, the infusion protocol improved physician ordering (control 66% of goal volume, noncompliant 68%, compliant 82%, p < .05); delivery of calories (control 52% of goal, noncompliant 55%, compliant 68%, p < .05); and advancement of ETF (control 14% at goal by 72 hours, noncompliant 31%, compliant 56%, p < .05). Although significant reduction in ETF cessation due to nursing care was noted, it represented only a fraction of the total time ETF were stopped. Cessation due to residual volumes, patient tolerance, and procedure continued to be a frequent occurrence and was often avoidable.

CONCLUSIONS

An evidence-based infusion protocol improved the delivery of ETF in the ICU, primarily because of better physician ordering and more rapid advancement. The nursing staff rapidly assimilated these changes. However, physicians' reluctance to use the protocol limited its efficacy and will need continued educational efforts.

Enteral tube feeding in the intensive care unit: factors impeding adequate delivery

OBJECTIVE

To evaluate those factors that impact on the delivery of enteral tube feeding.

DESIGN

Prospective study.

SETTING

Medical intensive care units (ICU) and coronary care units at two university-based hospitals.

PATIENTS

Forty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male) who were to receive nothing by mouth and were placed on enteral tube feeding.

INTERVENTIONS

Rate of enteral tube feeding ordered, actual volume delivered, patient position, residual volume, flush volume, presence of blue food coloring in oropharynx, and stool frequency were recorded every 4 hrs. Duration and reason for cessation of enteral tube feeding were documented.

MEASUREMENTS AND MAIN RESULTS

Physicians ordered a daily mean volume of enteral tube feeding that was 65.6% of goal requirements, but an average of only 78.1% of the volume ordered was actually infused. Thus, patients received a mean volume of enteral tube feeding for all 339 days of infusion that was 51.6% of goal (range, 15.1% to 87.1%). Only 14% of patients reached > or = 90% of goal feeding (for a single day) within 72 hrs of the start of enteral tube feeding infusion. Of 24 patients weighed before and after, 54% were noted to lose weight on enteral tube feeding. Declining albumin levels through the enteral tube feeding period correlated significantly with decreasing percent of goal calories infused (p = .042; r2 = .13). Diarrhea occurred in 23 patients (52.3%) for a mean 38.2% of enteral tube feeding days. In >1490 bedside evaluations, patients were observed to be in the supine position only 0.45%, residual volume of >200 mL was found 2.8%, and blue food coloring was found in the oropharynx 5.1% of the time. Despite this, cessation of enteral tube feeding occurred in 83.7% of patients for a mean 19.6% of the potential infusion time. Sixty-six percent of the enteral tube feeding cessations was judged to be attributable to avoidable causes.

CONCLUSIONS

The current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support. Barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings.

A substrate combinatorial array for caspases

An efficient strategy for the synthesis of a tetrapeptidyl substrate combinatorial array directed toward the caspases is described. Testing of this array with caspases 1 and 4 gave substrate hydrolytic profiles characteristic of each caspase, and permitted the identification of efficiently processed substrates. A comparison of this approach to that using a positional scanning library is presented.