Improving healthcare professionals' ultrasound-guided peripheral vascular access ability utilizing self-assembled ultrasound phantoms: A prospective, observational quality improvement project.

BACKGROUND: Ultrasound guidance can reduce the number of attempts to gain peripheral IV access while improving the success rate and satisfaction in patients with difficult IV access. Education and simulation are effective tools for improving the skills and knowledge related to ultrasound-guided peripheral IV access. Ultrasound phantom models allow for skill development without the risk of patient harm. METHODS: Twenty-nine registered nurses and nurse practitioners were recruited for education and simulation regarding ultrasound-guided peripheral IV (USGPIV) placement. Participants completed a survey evaluating the efficacy of the phantom models in addition to pre- and post-intervention confidence, perceived competence, knowledge surveys, and a Directly Observed Procedural Skills Evaluation (DOPSE). The intervention included an educational PowerPoint and open practice session using the phantom models. RESULTS: Statistically significant improvements were found in participants' confidence (p < 0.001; 95% CI: 5.287, 9.499; d = 1.31), perceived competence (p < 0.001; 95% CI: 1.231, 2.742; d = 1.20), knowledge (p < 0.001; 95% CI: 1.079, 2.163; d = 1.47), and skills (p < 0.001; 95% CI: 2.499; 5.501; d = 1.29). Participants improved in maintaining needle visualization (p < 0.001; 95% CI: 0.272, 0.9; d = 0.79) and decreasing their cannulation attempts (0.045; 95% CI: 0.013, 1.022; d = 0.48). Participants with no and novice experience saw statistically significant improvement across all categories (p < 0.02) compared to those with intermediate, advanced, or expert experience with ultrasound. 96.5% of participants could perform ultrasound-guided peripheral IV cannulation independently or with indirect supervision following the intervention. CONCLUSIONS: At $36.52 per model, the self-assembled ultrasound phantom models provided a cost-effective and sustainable solution to teaching ultrasound-guided peripheral IV cannulations. Education and simulation for ultrasound-guided peripheral vascular access may benefit individuals with no or novice ultrasound experience.

The Effects of Exercise on Telomere Length in Persons With Heart Failure.

BACKGROUND: Telomere length is reduced in persons with heart failure (HF). Inflammation is a putative mechanism contributing to telomere shortening. Although physical activity is known to increase telomere length, its effects in HF are unknown. OBJECTIVE: The aim of this study was to examine the effects of exercise on telomere length and its relationship with interleukin (IL)-1ß in persons with HF. METHODS: This secondary analysis of a 3-month home-based aerobic exercise intervention measured total telomere length and IL-1ß levels in persons with HF (69% with reduced ejection fraction). RESULTS: Total telomere length increased and plasma IL-1ß levels decreased in the exercise group from baseline to 3 months. Total telomere length was negatively associated with IL-1ß at baseline (r = -0.441 P = .001). CONCLUSIONS: The association between telomere length and IL-1ß suggests a relationship between inflammation and cellular aging. Moderate-intensity exercise may help maintain cellular functions. Further research is needed to examine the effects on outcomes in persons with HF.

Growth-uncoupled propanediol production in a Thermoanaerobacterium thermosaccharolyticum strain engineered for high ethanol yield.

Cocultures of engineered thermophilic bacteria can ferment lignocellulose without costly pretreatment or added enzymes, an ability that can be exploited for low cost biofuel production from renewable feedstocks. The hemicellulose-fermenting species Thermoanaerobacterium thermosaccharolyticum was engineered for high ethanol yield, but we found that the strains switched from growth-coupled production of ethanol to growth uncoupled production of acetate and 1,2-propanediol upon growth cessation, producing up to 6.7 g/L 1,2-propanediol from 60 g/L cellobiose. The unique capability of this species to make 1,2-propanediol from sugars was described decades ago, but the genes responsible were not identified. Here we deleted genes encoding methylglyoxal reductase, methylglyoxal synthase and glycerol dehydrogenase. Deletion of the latter two genes eliminated propanediol production. To understand how carbon flux is redirected in this species, we hypothesized that high ATP levels during growth cessation downregulate the activity of alcohol and aldehyde dehydrogenase activities. Measurements with cell free extracts show approximately twofold and tenfold inhibition of these activities by 10 mM ATP, supporting the hypothesized mechanism of metabolic redirection. This result may have implications for efforts to direct and maximize flux through alcohol dehydrogenase in other species.

Establishment of an Alternate Care Site (ACS) in Imperial County During COVID-19.

Imperial County is in southern California, one of the state's two counties at the international United States-Mexico border. The county is one of the most resource-limited in the state, with only two hospitals serving its 180,000 citizens, and no tertiary care centers. A significant portion of the population cared for at the local hospitals commutes from Mexicali, a large city of 1.2 million persons, just south of Imperial County's ports of entry. Since May 2020, following an outbreak in Mexicali, Imperial County has seen a significant increase in the number of COVID-19 patients, quickly outpacing its local resources. In response to this surge an alternate care site (ACS) was created as part of a collaboration between the California State Emergency Medical Service Authority (EMSA) and the county. In the first month of operations (May 26-June 26, 2020) the ACS received 106 patients with an average length of stay of 3.6 days. The average patient age was 55.5 years old with a range of 19-95 years. Disposition of patients included 25.5% sent to the emergency department for acute care needs, 1.8% who left against medical advice, and 72.7% who were discharged home or to a skilled nursing facility. There were no deaths on site. This study shares early experiences, challenges, and innovations created with the implementation of this ACS. Improving communication with local partners was the single most significant step in overcoming initial barriers.

The role of small molecules in cell and gene therapy.

Cell and gene therapies have achieved impressive results in the treatment of rare genetic diseases using gene corrected stem cells and haematological cancers using chimeric antigen receptor T cells. However, these two fields face significant challenges such as demonstrating long-term efficacy and safety, and achieving cost-effective, scalable manufacturing processes. The use of small molecules is a key approach to overcome these barriers and can benefit cell and gene therapies at multiple stages of their lifecycle. For example, small molecules can be used to optimise viral vector production during manufacturing or used in the clinic to enhance the resistance of T cell therapies to the immunosuppressive tumour microenvironment. Here, we review current uses of small molecules in cell and gene therapy and highlight opportunities for medicinal chemists to further consolidate the success of cell and gene therapies.

Coculture with hemicellulose-fermenting microbes reverses inhibition of corn fiber solubilization by Clostridium thermocellum at elevated solids loadings.

BACKGROUND: The cellulolytic thermophile Clostridium thermocellum is an important biocatalyst due to its ability to solubilize lignocellulosic feedstocks without the need for pretreatment or exogenous enzyme addition. At low concentrations of substrate, C. thermocellum can solubilize corn fiber > 95% in 5 days, but solubilization declines markedly at substrate concentrations higher than 20 g/L. This differs for model cellulose like Avicel, on which the maximum solubilization rate increases in proportion to substrate concentration. The goal of this study was to examine fermentation at increasing corn fiber concentrations and investigate possible reasons for declining performance. RESULTS: The rate of growth of C. thermocellum on corn fiber, inferred from CipA scaffoldin levels measured by LC-MS/MS, showed very little increase with increasing solids loading. To test for inhibition, we evaluated the effects of spent broth on growth and cellulase activity. The liquids remaining after corn fiber fermentation were found to be strongly inhibitory to growth on cellobiose, a substrate that does not require cellulose hydrolysis. Additionally, the hydrolytic activity of C. thermocellum cellulase was also reduced to less-than half by adding spent broth. Noting that > 15 g/L hemicellulose oligosaccharides accumulated in the spent broth of a 40 g/L corn fiber fermentation, we tested the effect of various model carbohydrates on growth on cellobiose and Avicel. Some compounds like xylooligosaccharides caused a decline in cellulolytic activity and a reduction in the maximum solubilization rate on Avicel. However, there were no relevant model compounds that could replicate the strong inhibition by spent broth on C. thermocellum growth on cellobiose. Cocultures of C. thermocellum with hemicellulose-consuming partners-Herbinix spp. strain LL1355 and Thermoanaerobacterium thermosaccharolyticum-exhibited lower levels of unfermented hemicellulose hydrolysis products, a doubling of the maximum solubilization rate, and final solubilization increased from 67 to 93%. CONCLUSIONS: This study documents inhibition of C. thermocellum with increasing corn fiber concentration and demonstrates inhibition of cellulase activity by xylooligosaccharides, but further work is needed to understand why growth on cellobiose was inhibited by corn fiber fermentation broth. Our results support the importance of hemicellulose-utilizing coculture partners to augment C. thermocellum in the fermentation of lignocellulosic feedstocks at high solids loading.

Development of a thermophilic coculture for corn fiber conversion to ethanol.

The fiber in corn kernels, currently unutilized in the corn to ethanol process, represents an opportunity for introduction of cellulose conversion technology. We report here that Clostridium thermocellum can solubilize over 90% of the carbohydrate in autoclaved corn fiber, including its hemicellulose component glucuronoarabinoxylan (GAX). However, Thermoanaerobacterium thermosaccharolyticum or several other described hemicellulose-fermenting thermophilic bacteria can only partially utilize this GAX. We describe the isolation of a previously undescribed organism, Herbinix spp. strain LL1355, from a thermophilic microbiome that can consume 85% of the recalcitrant GAX. We sequence its genome, and based on structural analysis of the GAX, identify six enzymes that hydrolyze GAX linkages. Combinations of up to four enzymes are successfully expressed in T. thermosaccharolyticum. Supplementation with these enzymes allows T. thermosaccharolyticum to consume 78% of the GAX compared to 53% by the parent strain and increases ethanol yield from corn fiber by 24%.

Virtual Orientation of Volunteer Short-Term International Health Teams to Increase Self-Confidence and Cultural and Global Health Competence.

International health team volunteers frequently arrive at service sites with considerable lack of confidence and knowledge gaps because of poor preparation. Preservice orientation has been shown to improve knowledge, confidence, and competence, but current practices fall short of meeting most needs. This health care improvement project was aimed to improve self-confidence and cultural and global health competence using a virtual preservice orientation format. The virtual innovation significantly narrowed the difference in confidence between new and experienced team members. Significant increases were observed in knowledge of global health and health equities for new and experienced team members. Following the orientation, a significant difference in global health skills for the entire team also was observed. Many Americans leave the United States annually attempting to help those in need. This effort is hindered by poor preparation and unreal expectations. Improving health team member confidence and competence is one way to address this concern. [J Contin Educ Nurs. 2019;50(1):35-40.].

Strain and bioprocess improvement of a thermophilic anaerobe for the production of ethanol from wood.

BACKGROUND: The thermophilic, anaerobic bacterium Thermoanaerobacterium saccharolyticum digests hemicellulose and utilizes the major sugars present in biomass. It was previously engineered to produce ethanol at yields equivalent to yeast. While saccharolytic anaerobes have been long studied as potential biomass-fermenting organisms, development efforts for commercial ethanol production have not been reported. RESULTS: Here, we describe the highest ethanol titers achieved from T. saccharolyticum during a 4-year project to develop it for industrial production of ethanol from pre-treated hardwood at 51-55 °C. We describe organism and bioprocess development efforts undertaken to improve ethanol production. The final strain M2886 was generated by removing genes for exopolysaccharide synthesis, the regulator perR, and re-introduction of phosphotransacetylase and acetate kinase into the methyglyoxal synthase gene. It was also subject to multiple rounds of adaptation and selection, resulting in mutations later identified by resequencing. The highest ethanol titer achieved was 70 g/L in batch culture with a mixture of cellobiose and maltodextrin. In a "mock hydrolysate" Simultaneous Saccharification and Fermentation (SSF) with Sigmacell-20, glucose, xylose, and acetic acid, an ethanol titer of 61 g/L was achieved, at 92 % of theoretical yield. Fungal cellulases were rapidly inactivated under these conditions and had to be supplemented with cellulosomes from C. thermocellum. Ethanol titers of 31 g/L were reached in a 100 L SSF of pre-treated hardwood and 26 g/L in a fermentation of a hardwood hemicellulose extract. CONCLUSIONS: This study demonstrates that thermophilic anaerobes are capable of producing ethanol at high yield and at titers greater than 60 g/L from purified substrates, but additional work is needed to produce the same ethanol titers from pre-treated hardwood.

Clostridium thermocellum releases coumaric acid during degradation of untreated grasses by the action of an unknown enzyme.

Clostridium thermocellum is an anaerobic thermophile with the ability to digest lignocellulosic biomass that has not been pretreated with high temperatures. Thermophilic anaerobes have previously been shown to more readily degrade grasses than wood. Part of the explanation for this may be the presence of relatively large amounts of coumaric acid in grasses, with linkages to both hemicellulose and lignin. We found that C. thermocellum and cell-free cellulase preparations both release coumaric acid from bagasse and switchgrass. Cellulase preparations from a mutant strain lacking the scaffoldin cipA still showed activity, though diminished. Deletion of all three proteins in C. thermocellum with ferulic acid esterase domains, either singly or in combination, did not eliminate the activity. Further work will be needed to identify the novel enzyme(s) responsible for the release of coumaric acid from grasses and to determine whether these enzymes are important factors of microbial biomass degradation.

Genome-scale resources for Thermoanaerobacterium saccharolyticum.

BACKGROUND: Thermoanaerobacterium saccharolyticum is a hemicellulose-degrading thermophilic anaerobe that was previously engineered to produce ethanol at high yield. A major project was undertaken to develop this organism into an industrial biocatalyst, but the lack of genome information and resources were recognized early on as a key limitation. RESULTS: Here we present a set of genome-scale resources to enable the systems level investigation and development of this potentially important industrial organism. Resources include a complete genome sequence for strain JW/SL-YS485, a genome-scale reconstruction of metabolism, tiled microarray data showing transcription units, mRNA expression data from 71 different growth conditions or timepoints and GC/MS-based metabolite analysis data from 42 different conditions or timepoints. Growth conditions include hemicellulose hydrolysate, the inhibitors HMF, furfural, diamide, and ethanol, as well as high levels of cellulose, xylose, cellobiose or maltodextrin. The genome consists of a 2.7 Mbp chromosome and a 110 Kbp megaplasmid. An active prophage was also detected, and the expression levels of CRISPR genes were observed to increase in association with those of the phage. Hemicellulose hydrolysate elicited a response of carbohydrate transport and catabolism genes, as well as poorly characterized genes suggesting a redox challenge. In some conditions, a time series of combined transcription and metabolite measurements were made to allow careful study of microbial physiology under process conditions. As a demonstration of the potential utility of the metabolic reconstruction, the OptKnock algorithm was used to predict a set of gene knockouts that maximize growth-coupled ethanol production. The predictions validated intuitive strain designs and matched previous experimental results. CONCLUSION: These data will be a useful asset for efforts to develop T. saccharolyticum for efficient industrial production of biofuels. The resources presented herein may also be useful on a comparative basis for development of other lignocellulose degrading microbes, such as Clostridium thermocellum.

Development of a regulatable plasmid-based gene expression system for Clostridium thermocellum.

Clostridium thermocellum can rapidly solubilize cellulose and produces ethanol as an end product of its metabolism. As such, it is a candidate for bioethanol production from plant matter. In this study, we developed an inducible expression system for C. thermocellum based on its native celC operon. We enhanced expression over the native operon structure by placing the repressor gene, glyR3, immediately after the celC promoter, and expressing the target gene after glyR3. Upon the addition of the inducer substrate, laminaribiose, an approximately 40-fold increase in gene expression was obtained using the test gene spo0A. Furthermore, induction of the sporulation histidine kinase, clo1313_1942, increased sporulation frequency by approximately 10,000-fold relative to an uninduced control. We have also shown that the laminaribiose (ß1-3-linked carbon source) utilization pathway is not catabolite repressed by cellobiose, a ß1-4-linked carbon source frequently used for C. thermocellum cultivation in laboratory conditions. Selective expression of target genes has the potential to inform metabolic engineering strategies as well as increase fundamental understanding of C. thermocellum biology.

Anaerobic detoxification of acetic acid in a thermophilic ethanologen.

BACKGROUND: The liberation of acetate from hemicellulose negatively impacts fermentations of cellulosic biomass, limiting the concentrations of substrate that can be effectively processed. Solvent-producing bacteria have the capacity to convert acetate to the less toxic product acetone, but to the best of our knowledge, this trait has not been transferred to an organism that produces ethanol at high yield. RESULTS: We have engineered a five-step metabolic pathway to convert acetic acid to acetone in the thermophilic anaerobe Thermoanaerobacterium saccharolyticum. The first steps of the pathway, a reversible conversion of acetate to acetyl-CoA, are catalyzed by the native T. saccharolyticum enzymes acetate kinase and phosphotransacetylase. ack and pta normally divert 30% of catabolic carbon flux to acetic acid; however, their re-introduction in evolved ethanologen strains resulted in virtually no acetic acid production. Conversion between acetic acid and acetyl-CoA remained active, as evidenced by rapid (13)C label transfer from exogenous acetate to ethanol. Genomic re-sequencing of six independently evolved ethanologen strains showed convergent mutations in the hfs hydrogenase gene cluster, which when transferred to wildtype T. saccharolyticum conferred a low acid production phenotype. Thus, the mutated hfs genes effectively separate acetic acid production and consumption from central metabolism, despite their intersecting at the common intermediate acetyl-CoA. To drive acetic acid conversion to a less inhibitory product, the enzymes thiolase, acetoacetate:acetate CoA-transferase, and acetoacetate decarboxylase were assembled in T. saccharolyticum with genes from thermophilic donor organisms that do not natively produce acetone. The resultant strain converted acetic acid to acetone and ethanol while maintaining a metabolic yield of 0.50 g ethanol per gram carbohydrate. CONCLUSIONS: Conversion of acetic acid to acetone results in improved ethanol productivity and titer and is an attractive low-cost solution to acetic acid inhibition.

Functional heterologous expression of an engineered full length CipA from Clostridium thermocellum in Thermoanaerobacterium saccharolyticum.

BACKGROUND: Cellulose is highly recalcitrant and thus requires a specialized suite of enzymes to solubilize it into fermentable sugars. In C. thermocellum, these extracellular enzymes are present as a highly active multi-component system known as the cellulosome. This study explores the expression of a critical C. thermocellum cellulosomal component in T. saccharolyticum as a step toward creating a thermophilic bacterium capable of consolidated bioprocessing by employing heterologously expressed cellulosomes. RESULTS: We developed an inducible promoter system based on the native T. saccharolyticum xynA promoter, which was shown to be induced by xylan and xylose. The promoter was used to express the cellulosomal component cipA*, an engineered form of the wild-type cipA from C. thermocellum. Expression and localization to the supernatant were both verified for CipA*. When a ΔcipA mutant C. thermocellum strain was cultured with a CipA*-expressing T. saccharolyticum strain, hydrolysis and fermentation of 10 grams per liter SigmaCell 101, a highly crystalline cellulose, were observed. This trans-species complementation of a cipA deletion demonstrated the ability for CipA* to assemble a functional cellulosome. CONCLUSION: This study is the first example of an engineered thermophile heterologously expressing a structural component of a cellulosome. To achieve this goal we developed and tested an inducible promoter for controlled expression in T. saccharolyticum as well as a synthetic cipA. In addition, we demonstrate a high degree of hydrolysis (up to 93%) on microcrystalline cellulose.

Redirecting carbon flux through exogenous pyruvate kinase to achieve high ethanol yields in Clostridium thermocellum.

In Clostridium thermocellum, a thermophilic anaerobic bacterium able to rapidly ferment cellulose to ethanol, pyruvate kinase (EC 2.7.1.40) is absent based on both the genome sequence and enzymatic assays. Instead, a new pathway converting phosphoenolpyruvate to pyruvate via a three-step pathway involving phosphoenolpyruvate carboxykinase, NADH-linked malate dehydrogenase, and NADP-dependent malic enzyme has been found. We examined the impact of targeted modification of enzymes associated with this pathway, termed the "malate shunt", including expression of the pyruvate kinase gene from Thermoanaerobacterium saccharolyticum, mutation of the phosphoenolpyruvate carboxykinase and deletion of malic enzyme gene. Strain YD01 with exogenous pyruvate kinase, in which phosphoenolpyruvate carboxykinase expression was diminished by modifying the start codon from ATG to GTG, exhibited 3.25-fold higher ethanol yield than the wild-type strain. A second strain, YD02 with exogenous pyruvate kinase, in which the gene for malic enzyme and part of malate dehydrogenase were deleted, had over 3-fold higher ethanol yield than the wild-type strain.

Carbon catabolite repression in Thermoanaerobacterium saccharolyticum.

BACKGROUND: The thermophilic anaerobe Thermoanaerobacterium saccharolyticum is capable of directly fermenting xylan and the biomass-derived sugars glucose, cellobiose, xylose, mannose, galactose and arabinose. It has been metabolically engineered and developed as a biocatalyst for the production of ethanol. RESULTS: We report the initial characterization of the carbon catabolite repression system in this organism. We find that sugar metabolism in T. saccharolyticum is regulated by histidine-containing protein HPr. We describe a mutation in HPr, His15Asp, that leads to derepression of less-favored carbon source utilization. CONCLUSION: Co-utilization of sugars can be achieved by mutation of HPr in T. saccharolyticum. Further manipulation of CCR in this organism will be instrumental in achieving complete and rapid conversion of all available sugars to ethanol.

Urease expression in a Thermoanaerobacterium saccharolyticum ethanologen allows high titer ethanol production.

Genes encoding the enzyme urease were integrated in a Thermoanaerobacterium saccharolyticum ethanologen. The engineered strain hydrolyzed urea, as evidenced by increased cellular growth and elevated final pH in urea minimal medium and urease activity in cell free extracts. Interestingly, replacement of ammonium salts with urea resulted in production of 54 g/L ethanol, one of the highest titers reported for Thermoanaerobacterium. The observed increase in ethanol titer may result from reduced pH, salt, and osmolality stresses during fermentation. Urea utilization is attractive for industrial scale fermentation, where pH control is technically challenging and increased ethanol titer is desirable.

Ethanol and anaerobic conditions reversibly inhibit commercial cellulase activity in thermophilic simultaneous saccharification and fermentation (tSSF).

BACKGROUND: A previously developed mathematical model of low solids thermophilic simultaneous saccharification and fermentation (tSSF) with Avicel was unable to predict performance at high solids using a commercial cellulase preparation (Spezyme CP) and the high ethanol yield Thermoanaerobacterium saccharolyticum strain ALK2. The observed hydrolysis proceeded more slowly than predicted at solids concentrations greater than 50 g/L Avicel. Factors responsible for this inaccuracy were investigated in this study. RESULTS: Ethanol dramatically reduced cellulase activity in tSSF. At an Avicel concentration of 20 g/L, the addition of ethanol decreased conversion at 96 hours, from 75% in the absence of added ethanol down to 32% with the addition of 34 g/L initial ethanol. This decrease is much greater than expected based on hydrolysis inhibition results in the absence of a fermenting organism. The enhanced effects of ethanol were attributed to the reduced, anaerobic conditions of tSSF, which were shown to inhibit cellulase activity relative to hydrolysis under aerobic conditions. Cellulose hydrolysis in anaerobic conditions was roughly 30% slower than in the presence of air. However, this anaerobic inhibition was reversed by exposing the cellulase enzymes to air. CONCLUSION: This work demonstrates a previously unrecognized incompatibility of enzymes secreted by an aerobic fungus with the fermentation conditions of an anaerobic bacterium and suggests that enzymes better suited to industrially relevant fermentation conditions would be valuable. The effects observed may be due to inactivation or starvation of oxygen dependent GH61 activity, and manipulation or replacement of this activity may provide an opportunity to improve biomass to fuel process efficiency.

Marker removal system for Thermoanaerobacterium saccharolyticum and development of a markerless ethanologen.

Marker removal strategies were developed for Thermoanaerobacterium saccharolyticum to select against the pyrF gene and the pta and ack genes. The pta- and ack-based haloacetate selective strategy was subsequently used to create strain M0355, a markerless Δldh Δpta Δack strain that produces ethanol at a high yield.

Off-label prescribing during pregnancy in the UK: an analysis of 18,000 prescriptions in Liverpool Women's Hospital.

OBJECTIVE: Large numbers of drugs are prescribed antenatally, many of which are off-label or unlicensed. An off-label medication is one which does have a market authorization, but for a different indication, dose, route or patient group than that for which it is prescribed. The purpose of this study was to determine how commonly these prescriptions are written at Liverpool Women's Hospital (LWH), a unit with 8000 deliveries per annum. METHODS: All inpatient prescriptions received from antenatal areas at LWH during a 3-month period were analysed. The drugs were divided into categories according to their licence, FDA class and degree of clinical risk. KEY FINDINGS: Some 17 694 prescriptions of 235 different drugs were prescribed during this period. Thirty-seven (16%) drugs and 4445 (25%) medications prescribed were licensed for use in pregnancy; 57 (24%) drugs and 3363 (19%) of the total prescriptions were off-label but considered safe by the manufacturers (e.g. erythromycin, prochlorperazine and clotrimazole); 138 (58%) drugs and 9722 (55%) prescriptions were cautioned or contraindicated by the manufacturer in pregnancy (e.g. cefalexin, magnesium sulphate and nifedipine). After further investigation into the safety of the off-label medications from the FDA safety profile and with the opinion of a multidisciplinary team, we were able to draw up a list of high-risk off-label medicines. This consisted of 38 drugs (16% of total) and 1735 (10%) of the total prescriptions (e.g. lisinopril, diazepam and morphine). CONCLUSIONS: A significant number of prescriptions being used in an off-label manner at LWH are high risk. Prescribers need to be aware of the risks associated with these drugs and the possible legal consequences of prescribing and administering them.