Acute Rheumatic Fever.

Acute rheumatic fever (ARF) and its sequela rheumatic heart disease remain significant causes of cardiovascular morbidity and mortality worldwide. When caring for patients originating from a geographic setting where ARF is endemic, a high index of suspicion for ARF is indicated. Early recognition of ARF with the initiation of treatment and secondary prevention is vital to prevent irreversible cardiac valve damage. This article covers the epidemiology, clinical manifestations, and diagnostic considerations of ARF. Specifically, the differing diagnostic criteria between high- and low-risk populations are emphasized. It will also review management and prevention strategies for ARF. [Pediatr Ann. 2022;51(12):e457-e460.].

Nondihydropyridine Calcium Channel Blockers for the Treatment of Proteinuria: A Review of the Literature.

Objective: To review the use of nondihydropyridine calcium channel blockers (non-DHP CCBs) for the treatment of proteinuria in diabetic and nondiabetic kidney disease. Data Sources: A search using PubMed and MEDLINE, Scopus, and Google Scholar was performed from 1964 through February 2019 using the following search terms alone or in combination: verapamil, diltiazem, non-dihydropyridine calcium channel blocker, proteinuria, albuminuria, microalbuminuria, kidney disease, renal disease. Study Selection and Data Extraction: All prospective English-language trials examining one or more non-DHP CCB for the treatment of proteinuria were evaluated. Data Synthesis: A total of 13 clinical trials examining the use of non-DHP CCBs to treat proteinuria alone or in combination with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) were included in the evaluation. Most studies evaluated patients with macroalbuminuria secondary to diabetes and hypertension. Verapamil was the most common agent studied. Non-DHP CCBs were effective in reducing proteinuria in diabetic kidney disease but did not reduce renal or cardiovascular outcomes in the one trial that evaluated clinical end points. They were generally well tolerated, with the most common adverse effect reported being constipation. Relevance to Patient Care and Clinical Practice: This review evaluates and summarizes the available evidence on non-DHP CCBs for treatment of proteinuria in patients with existing kidney disease. Conclusion: Non-DHP CCBs may be a reasonable therapeutic option for patients with diabetic kidney disease and persistent proteinuria despite maximum doses of ACE inhibitors or ARBs. Additionally, they may be reasonable alternatives to ACE inhibitors or ARBs if a contraindication or intolerance exists.

Greening the Operating Room: Results of a Scalable Initiative to Reduce Waste and Recover Supply Costs.

Operating rooms generate 42% of a hospital's revenue and 30% of hospital waste. Supply costs are 56% of a total operating room (OR) budget. US academic medical centers use 2 million pounds ($15 million) of recoverable medical supplies annually. Forming a multidisciplinary leadership team, we analyzed sources of waste focusing on our Department of Neurosurgery. We developed an 8-wk pilot project to recycle "blue wrap," the number 5 plastic polypropylene material that is ubiquitously used in ORs across the country to wrap instrument pans and implant trays for sterilization. Blue wrap can be baled and sold to recyclers where the material is pelletized and transformed into plastic products. During the 39 d of the pilot, we collected 1247 pounds of blue wrap (32 lbs collected daily). The cost of the pilot was $14 987 that includes a new baler ($11 200) and 5 transport carts ($3697). The revenue received from baled blue wrap was 8 cents per pound. Cost avoidance yielded $31 680.00 in savings. Implementation of this pilot across our main hospital would yield $5000 in revenue annually and $174 240 in cost avoidance. This project can be replicated at other centers and not only reduces the environmental footprint, but also helps generate additional revenue by recycling a necessary packing material that would otherwise require payment for disposal.

Decisional Capacity in Amyotrophic Lateral Sclerosis.

The cognitive and behavioral changes that can be observed in the neurodegenerative terminal disease amyotrophic lateral sclerosis (ALS), once characterized as purely a motor neuron disease, have become increasingly recognized over the past century. Detecting cognitive deficits earlier and identifying continued changes at regular intervals can lead to improved care, proactive treatments, and earlier discussions about end-of-life wishes. Although medical decisional capacity is required for every treatment decision made, its importance becomes paramount when making decisions on complex medical treatments that will invariably and significantly affect quality of life or life itself. In this review, we conducted a critical analysis of the evidence-based literature on the cognitive and behavioral impairments in ALS that can compromise medical decisional capacity. We review specific ALS-related clinical scenarios in which decisional capacity is of utmost importance and discuss a practical framework for cognitive and behavioral assessment that can be routinely and efficiently used, while being mindful of the confounding factors associated with ALS. Finally, we review models for preserving patient choices that can be used in patients with ALS to help safeguard autonomy and retain dignity toward the end of life.

Allosteric interaction of nucleotides and tRNA(ala) with E. coli alanyl-tRNA synthetase.

Alanyl-tRNA synthetase, a dimeric class 2 aminoacyl-tRNA synthetase, activates glycine and serine at significant rates. An editing activity hydrolyzes Gly-tRNA(ala) and Ser-tRNA(ala) to ensure fidelity of aminoacylation. Analytical ultracentrifugation demonstrates that the enzyme is predominately a dimer in solution. ATP binding to full length enzyme (ARS875) and to an N-terminal construct (ARS461) is endothermic (ΔH = 3-4 kcal mol(-1)) with stoichiometries of 1:1 for ARS461 and 2:1 for full-length dimer. Binding of aminoacyl-adenylate analogues, 5'-O-[N-(L-alanyl)sulfamoyl]adenosine (ASAd) and 5'-O-[N-(L-glycinyl)sulfamoyl]adenosine (GSAd), are exothermic; ASAd exhibits a large negative heat capacity change (ΔC(p) = 0.48 kcal mol(-1) K(-1)). Modification of alanyl-tRNA synthetase with periodate-oxidized tRNA(ala) (otRNA(ala)) generates multiple, covalent, enzyme-tRNA(ala) products. The distribution of these products is altered by ATP, ATP and alanine, and aminoacyl-adenylate analogues (ASAd and GSAd). Alanyl-tRNA synthetase was modified with otRNA(ala), and tRNA-peptides from tryptic digests were purified by ion exchange chromatography. Six peptides linked through a cyclic dehydromoropholino structure at the 3'-end of tRNA(ala) were sequenced by mass spectrometry. One site lies in the N-terminal adenylate synthesis domain (residue 74), two lie in the opening to the editing site (residues 526 and 585), and three (residues 637, 639, and 648) lie on the back side of the editing domain. At least one additional modification site was inferred from analysis of modification of ARS461. The location of the sites modified by otRNA(ala) suggests that there are multiple modes of interaction of tRNA(ala) with the enzyme, whose distribution is influenced by occupation of the ATP binding site.