Engaging patients and families to transform heart failure care.

For patients with advanced heart failure involvement as a member of the healthcare team is critical to safe, high-quality and goal-directed care. While recognized as an important aspect of care, patient engagement is not yet a standard practice. This presents an opportunity for professional education and development in team-based care. This short report describes the development of a Community and Patient Advisory Team (CPAT) formed to support patient involvement in interprofessional collaborative practice. The CPAT, composed of patient and family advisors, researchers, care team members, and grant operations staff, served as a core team within the structure of a project to shape a new vision of care delivery. This was accomplished through participation in quarterly leadership workshops and facilitation of team training focused on patient-provider communication strategies to improve patient safety. The advisory team led the co-development of patient materials to support patient engagement during the new implementation of structured interprofessional bedside rounds. Involving community members as partners helped shape our work to more effectively and directly address gaps in current patient care.

Clinical decision-making as the basis for assessing agreement between measures of the International Normalized Ratio.

BACKGROUND: The now classic approach of Bland and Altman is often used to assess the level of agreement between International Normalized Ratio (INR) measures. However, we are concerned that this method does not define agreement in a clinically meaningful way. Agreement between measures should be characterized explicitly in terms of clinical decisions that result from INR measures. OBJECTIVES: To develop and validate an extension of the Bland-Altman method to assess agreement between INR measures, based explicitly on the way clinicians make decisions. METHODS AND RESULTS: We developed a clinically based graphical method to estimate the level of agreement between measures of INR. We identified clinically relevant INR ranges using epidemiologic and clinical evidence regarding risk and expected outcome at different INR ranges. Clinical decisions were expected to agree within these INR ranges and, therefore, the ranges became the basis for establishing agreement between measures. We used paired INR measures and resultant clinical decisions measured during a previous prospective study to validate and compare the accuracy of our model to those of Bland and Altman's and other published models. Our method more accurately predicts when warfarin dosing decisions differ than the Bland-Altman method (P < 0.02). Our method is also superior to other published methods, particularly at the important task of identifying when measures lead to discrepant clinical decisions. CONCLUSIONS: We introduced and validated an improvement of the Bland-Altman method to assess agreement between INR measures. Our model is superior because it is based explicitly on factors that influence clinical decision-making.

Dynamics of Saturn's magnetosphere from MIMI during Cassini's orbital insertion.

The Magnetospheric Imaging Instrument (MIMI) onboard the Cassini spacecraft observed the saturnian magnetosphere from January 2004 until Saturn orbit insertion (SOI) on 1 July 2004. The MIMI sensors observed frequent energetic particle activity in interplanetary space for several months before SOI. When the imaging sensor was switched to its energetic neutral atom (ENA) operating mode on 20 February 2004, at approximately 10(3) times Saturn's radius RS (0.43 astronomical units), a weak but persistent signal was observed from the magnetosphere. About 10 days before SOI, the magnetosphere exhibited a day-night asymmetry that varied with an approximately 11-hour periodicity. Once Cassini entered the magnetosphere, in situ measurements showed high concentrations of H+, H2+, O+, OH+, and H2O+ and low concentrations of N+. The radial dependence of ion intensity profiles implies neutral gas densities sufficient to produce high loss rates of trapped ions from the middle and inner magnetosphere. ENA imaging has revealed a radiation belt that resides inward of the D ring and is probably the result of double charge exchange between the main radiation belt and the upper layers of Saturn's exosphere.

A new global mode of Earth deformation: seasonal cycle detected.

We have detected a global mode of Earth deformation that is predicted by theory. Precise positioning of Global Positioning System sites distributed worldwide reveals that during February to March, the Northern Hemisphere compresses (and the Southern Hemisphere expands), such that sites near the North Pole move downward by 3.0 millimeters, and sites near the equator are pulled northward by 1.5 millimeters. The opposite pattern of deformation occurs during August to September. We identify this pattern as the degree-one spherical harmonic response of an elastic Earth to increased winter loading of soil moisture, snow cover, and atmosphere. Data inversion shows the load moment's trajectory as a great circle traversing the continents, peaking at 6.9 x 10(22) kilogram meters near the North Pole in winter, indicating interhemispheric mass exchange of 1.0 x 10(16) +/- 0.2 x 10(16) kilograms.

Preparation and biodistribution of copper-67-labeled porphyrins and porphyrin-A6H immunoconjugates.

The synthetic porphyrins, N-benzyl-5,10,15,20-tetrakis (4-carboxyphenyl) porphine (N-bzHTCPP) and N-4-nitrobenzyl-5-(4-carboxyphenyl)-10,15,20-tris(4-sulfophenyl) porphine (N-bzHCS3P), represent excellent radiocopper chelating agents that may find utility in antibody-mediated diagnosis and/or therapy. N-bzHCS3P was conjugated to an anti-renal cell carcinoma (RCC) antibody, A6H, and labeled with copper-67. 67CuCS3P-A6H was studied for its biodistribution in human RCC xenograft-bearing nude mice, along with the radiolabeled free porphyrins. The porphyrins resulted in tumor:blood ratios in the range of 3 to 4 after 48 h. The radiolabeled antibody achieved a tumor:blood ratio of over 16 after 45 h, indicating accumulation at the desired site. However, unwanted localization also occurred in the liver and spleen, which will have to be rectified before realizing the full potential of this approach.

Dissociation between behavioral and hormonal responses to the forced swim stress in lactating rats.

Retention of immobility in the Porsolt forced swim test is believed to be dependent upon glucocorticoid secretion in male rats. Because lactating females exhibit increased basal glucocorticoid secretion and blunted stress responses, we tested the hypothesis that lactation-induced changes in adrenal glucocorticoid and in circulating estrogen and progesterone levels would improve retention and/or acquisition of immobility. Immobility was recorded during 3 intervals of 5 min on day 1 (acquisition) and one 5 min interval 24 h later (retention). Blood samples were collected before the swim test and at various times after the onset of stress for plasma ACTH and corticosterone (B) determinations. Male rats (young=200 g, old=325 g) were compared to virgin females (V) and to lactating females in early (day 8-10, EL) and late (day 17-19, LL) lactation. Adrenalectomy (ADX) and ovariectomy (OVX) were performed 5 and 10 days prior to testing, respectively. All animals acquired immobility at the end of the 15 min swim on day 1, but only the young male group exhibited a significant retention of immobility on day 2. Total immobility was higher in males than females (V) although basal and stress-induced ACTH and B secretion were comparable on both testing days. Lactational status did not affect immobility in either the acquisition or retention phases. However, stress-induced ACTH secretion was greatly diminished in intact and ADX lactating females (EL and LL) compared to virgins (LL < EL < virgin), demonstrating a clear dissociation between behavioral and neuroendocrine responses. Following ADX, immobility in the retention phase was either decreased in males or increased in lactating females. Finally, OVX decreased immobility in both lactating (EL) and virgin females without significantly altering the magnitude of the ACTH and B responses to stress. In summary, our results demonstrated both sex-related and lactation-related differences in the behavioral and endocrine responses to he forced swim test of Porsolt. Although retention of the immobile response is thought to involve glucocorticoids and/or opioids secreted during the first testing session, we did not find evidence for a direct relationship between basal or stress-induced total corticosterone secretion, the magnitude of ACTH response to stress and behavioral scores in the retention period. However, experimental variables such as body weight, sex and water depth could significantly modify the outcome of behavioral testing and question the validity of glucocorticoid-mediated retention processes. Since the effect of ADX was reversed in lactating females compared to male rats, we hypothesize that glucocorticoid sensitivity of cognitive processes controlling behavioral reactivity is different from that controlling hypothalamic-adrenocortical function. Our results also demonstrated a clear dissociation between behavioral and neuroendocrine responses to the swim test, in particular during lactation. In early and late lactation, blunted responsiveness to stress was not caused by enhanced glucocorticoid feedback but might result from modifications in the inhibitory and/or stimulatory inputs to hypothalamic neurons controlling adrenocortical activity.

Catheter cleaning for re-use in intermittent catheterization: new light on an old problem.

Clean intermittent catheterization is a common method of urinary elimination for people with Spinal Cord Injuries. The methods of catheter cleaning for re-use, however, have not been validated with research studies. This study compared the effectiveness of Hydrogen Peroxide, vinegar, dishwashing detergent, and tap water alone to clean catheters contaminated with Pseudomonas aeruginosa and Escherichia coli. The effect of rinsing and drying before cleaning was also examined, as well as the effect of storage in paper or plastic bags after cleaning. Results indicated that rinsing and drying catheters immediately after use was the most effective at reducing bacteria to very near zero. Elements of a procedure are outlined, as well as plans for further development and testing of a rinse & dry procedure for catheter cleaning and re-use.

Characterization of a common VIP-PACAP receptor in human small intestinal epithelium.

Vasoactive intestinal peptide (VIP) receptors were characterized in epithelial plasma membranes from human small intestine. Native VIP inhibited the binding of 125I-labeled VIP to jejunal membranes, and Scatchard analysis of these data was consistent with the existence of one class of receptor with a dissociation constant of 42 pM and a maximal binding of 256 fmol/mg membrane protein. VIP stimulated adenylyl cyclase activity in human jejunal membranes in the 0.01 nM-1 microM range [half-maximal effective dose = 0.7 nM]. Coupling of VIP receptors with a Gs protein was further assessed by the ability of GTP (10(-8) to 10(-3) M) to inhibit 125I-VIP binding to membranes. 125I-VIP binding was seven to eight times higher in villus cells than in crypt cells. Finally, 125I-VIP binding was detectable throughout the small and large intestines with the highest binding in jejunum. Among the natural peptides structurally related to VIP, some inhibited 125I-VIP binding with the following order of potency: VIP = pituitary adenylate cyclase-activating peptide (PACAP)-27 = PACAP-38 > helodermin >> peptide histidine methionineamide = human growth hormone-releasing factor > secretin. The same order of potency of peptides for inhibiting 125I-VIP or 125I-labeled PACAP was observed, supporting that the two tracers bound to a common VIP-PACAP receptor site. This order of potency was also observed for the stimulation of adenylyl cyclase activity by these peptides. 125I-VIP was cross-linked to membranes using disuccinimidyl suberate. After sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis, one single band of 70,000 mol wt was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Using starburst dendrimers as linker molecules to radiolabel antibodies.

Starburst dendrimers, spherical polymers constructed from methyl acrylate and ethylenediamine, were successfully used to covalently couple synthetic porphyrins to antibody molecules. The dendrimers, as linker molecules, have great potential for increasing the specific activity of radiolabeled antibodies for tumor therapy and diagnosis.

Mn (III) hematoporphyrin. A potential MR contrast agent.

Manganese (III) hematoporphyrin (MnHP), a new and stable complex, was prepared, and its toxicity and magnetic resonance (MR) imaging properties were evaluated. In tests of acute and subacute toxicity, no deaths resulted from bolus intravenous injections of 13 or 19 mumols/kg of MnHP, but there was a 33% mortality when the dose was 38 mumols/kg. Laboratory results were normal in the surviving rats. Ultraviolet- visible spectroscopy of the urine and serum of two rats injected 24 hours previously with 38 mumols/kg MnHP revealed no free HP, suggesting in vivo stability of MnHP. Finally, using a standardized imaging protocol, there was a mean increase of 37% in the liver-to-muscle intensity ratios in four rats injected 24 hours previously with 25 mumols/kg MnHP when compared to paired controls (P less than .005). In addition, obvious visual increase in the signal intensity of the liver on T1-weighted images was seen in animals tested with 13 and 19 mumols/kg of MnHP. The results suggest that further evaluation of MnHP as an MR contrast agent for the liver is warranted.

The biological characteristics of a water soluble porphyrin in rat lymph nodes.

The biological characteristics of a radiolabeled metalloporphyrin, 5,10,15,20-tetrakis(4-carboxyphenyl)-porphinato [67Cu]copper (II) [( 67Cu]TCPP), in rat lymph nodes, surrounding muscle, fat, and blood were determined. Lymphatic tissue localized greater amounts of [67Cu]TCPP than did surrounding muscle and fat. Inflamed lymph nodes localized greater amounts of [67Cu]TCPP than did noninflamed lymph nodes. Time course studies suggest that the uptake of [67Cu]TCPP in noninflamed and in inflamed lymph nodes may involve different biological processes. The affinity of [67Cu]TCPP for inflamed lymph nodes may be influenced by the degree of inflammation. If further studies confirm these results, [67Cu]TCPP may be useful as a potential radiopharmaceutical for imaging inflamed lymph nodes.

Labeling antibodies with copper radionuclides using N-4-nitrobenzyl-5-(4-carboxyphenyl)-10,15,20-tris(4-sulfophenyl) porphine.

Antibody conjugates labeled with copper-64 and -67 (64Cu and 67Cu) were prepared using the porphyrin chelator N-4-nitrobenzyl-5-(4-carboxyphenyl)-10,15,20-tris(4-sulfophenyl) porphine (N-bzHCS3P). N-bzHCS3P was chosen because it has only one carboxylate group available for activation and coupling to antibody. The conjugates were characterized with respect to (1) the location of the porphyrin on the antibody, (2) the retention of immunoreactivity, and (3) the serum stability of the amide bond linking porphyrin to antibody. These studies showed that porphyrin attachment on the antibody surface is random. The conjugates exhibited high retention of immunoreactivity and reasonable serum stability for potential application in nuclear medicine.

The biodistribution of radiocopper-labeled compounds.

Porphyrins form extremely stable chelates with Cu2+. Two copper radionuclides, 67Cu and 64Cu, have attractive nuclear decay properties for use in nuclear medicine applications. We have investigated the use of radiocopper-labeled porphyrins for localization in inflamed tissue and for attachment to antibodies for tumor imaging and therapy. We have examined the biodistribution of a 67Cu labeled porphyrin, [5, 10, 15, 20-tetrakis(4-carboxyphenyl) porphinato [67Cu] copper (II)], 67 CuTCPP. The 67CuTCPP was intravenously injected into the tail vein of Fischer F344 male rats. The kidneys, liver, and spleen localize the greatest amounts of 67CuTCPP. The elimination of 67CuTCPP from the body is described by a normal exponential decay curve with a biological half-life of 108 hours and an effective half-life of 32 hours. We have also examined the biodistribution of 5-(4-carboxyphenyl)-10, 15,20-tris(4-sulfophenyl) porphinato [67Cu] copper (II) anti-Thy 1.2 antibody conjugates in normal and tumor-bearing male AKR/J mice. The liver, kidney, and tumor have the highest uptake of the 67Cu labeled antibody conjugate. In all 67Cu labeled compounds studied, the blood clearance was rapid and the bone concentration of the radiolabeled species was low.

Copper-67 labeled porphyrin localization in inflamed tissue.

A series of experiments compared the uptake of 5,10,15,20 tetrakis(4-carboxyphenyl) porphinato [67Cu] copper (II), 67CuTCPP, by the lymph nodes of inflamed and two sets or control rats. The results demonstrate that 67CuTCPP localizes in greater concentration in inflamed lymph nodes than in noninflamed control lymph nodes. This enhanced uptake of 67CuTCPP by inflamed lymph nodes was 3.6 times greater than was the uptake by control lymph nodes. A time course study demonstrated that the uptake of 67CuTCPP by inflamed lymph nodes reached the maximum level by 24 hours post-injection of 67CuTCPP and remained constant throughout the 96 hours examined. It was also found that the uptake of 67CuTCPP by inflamed lymph nodes was not exclusively dependent upon an increase in the weight of inflamed lymph nodes. These studies show that 67CuTCPP has potential as a lymphoscintigraphy agent.

Preparation and characterization of copper-67 porphyrin-antibody conjugates.

Methods were developed to label antibodies with copper-67, a potentially useful medical radioisotope, using the porphyrin chelating agent N-benzyl-5,10,15,20-tetrakis(4-carboxyphenyl) porphine. The porphyrin was activated for coupling using either (1) 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide HCl and N-hydroxysuccinimide or (2) 1,1'-carbonyldiimidazole. The coupling reactions were optimized as a function of activation time, coupling time, coupling pH, and reagent concentrations to achieve maximum coupling to IgG monomer. Sodium dodecylsulfate polyacrylamide gel electrophoresis was used to determine coupling yields. After purification by gel filtration, the antibody-porphyrin conjugates were labeled with copper-67 in aqueous solution. The coupling protocols were used to label antibodies from several species, demonstrating the general utility of these methods. Characterization of the conjugates indicated that the porphyrin label was attached randomly to the IgG molecule. Antigen binding capacities after conjugation were unaltered or slightly lowered as determined by a competitive ELISA.