ProPACC: Protocol for a Trial of Integrated Specialty Palliative Care for Critically Ill Older Adults.

BACKGROUND: Each year, approximately one million older adults die in American intensive care units (ICUs) or survive with significant functional impairment. Inadequate symptom management, surrogates' psychological distress and inappropriate healthcare use are major concerns. Pioneering work by Dr. J. Randall Curtis paved the way for integrating palliative care (PC) specialists to address these needs, but convincing proof of efficacy has not yet been demonstrated. DESIGN: We will conduct a multicenter patient-randomized efficacy trial of integrated specialty PC (SPC) vs. usual care for 500 high-risk ICU patients over age 60 and their surrogate decision-makers from five hospitals in Pennsylvania. INTERVENTION: The intervention will follow recommended best practices for inpatient PC consultation. Patients will receive care from a multidisciplinary SPC team within 24 hours of enrollment that continues until hospital discharge or death. SPC clinicians will meet with patients, families, and the ICU team every weekday. SPC and ICU clinicians will jointly participate in proactive family meetings according to a predefined schedule. Patients in the control arm will receive routine ICU care. OUTCOMES: Our primary outcome is patient-centeredness of care, measured using the modified Patient Perceived Patient-Centeredness of Care scale. Secondary outcomes include surrogates' psychological symptom burden and health resource utilization. Other outcomes include patient survival, as well as interprofessional collaboration. We will also conduct prespecified subgroup analyses using variables such as PC needs, measured by the Needs of Social Nature, Existential Concerns, Symptoms, and Therapeutic Interaction scale. CONCLUSIONS: This trial will provide robust evidence about the impact of integrating SPC with critical care on patient, family, and health system outcomes.

Degradability of Biodegradable Soil Moisture Sensor Components and Their Effect on Maize (Zea mays L.) Growth.

Inexpensive and no-maintenance biodegradable soil moisture sensors could improve existing knowledge on spatial and temporal variability of available soil water at field-scale. Such sensors can unlock the full potential of variable-rate irrigation (VRI) systems to optimize water applications in irrigated cropping systems. The objectives of this study were to assess (i) the degradation of soil moisture sensor component materials and (ii) the effects of material degradation on maize (Zea Mays L.) growth and development. This study was conducted in a greenhouse at Colorado State University, Colorado, USA, by planting maize seeds in pots filled with three growing media (field soil, silica sand, and Promix commercial potting media). The degradation rate of five candidate sensor materials (three blends of beeswax and soy wax, balsa wood, and PHBV (poly(3-hydroxybutyrate-co-3-hydroxyvalerate))) was assessed by harvesting sensor materials at four maize growth stages (30, 60, 90, and 120 days after transplanting). All materials under consideration showed stability in terms of mass and dimension except PHBV. PHBV was degraded entirely within 30 days in soil and Promix, and within 60 days in sand. Balsa wood did now show any significant reduction in mass and dimensions in all growth media. Similarly, there was no significant mass loss across wax blends (p = 0.05) at any growth stage, with a few exceptions. Among the wax blends, 3:1 (beeswax:soy wax) was the most stable blend in terms of mass and dimension with no surface cracks, making it a suitable encapsulant for soil sensor. All materials under consideration did not have any significant effect on maize growth (dry biomass, green biomass, and height) as compared to control plants. These results indicated that 3:1 beeswax:soy wax blend, PHBV, and balsa wood could be suitable candidates for various components of biodegradable soil moisture sensors.

Measuring couple relationship quality in a rural African population: Validation of a Couple Functionality Assessment Tool in Malawi.

Available data suggest that individual and family well-being are linked to the quality of women's and men's couple relationships, but few tools exist to assess couple relationship functioning in low- and middle-income countries. In response to this gap, Catholic Relief Services has developed a Couple Functionality Assessment Tool (CFAT) to capture valid and reliable data on various domains of relationship quality. This tool is designed to be used by interventions which aim to improve couple and family well-being as a means of measuring the effectiveness of these interventions, particularly related to couple relationship quality. We carried out a validation study of the CFAT among 401 married and cohabiting adults (203 women and 198 men) in rural Chikhwawa District, Malawi. Using psychometric scales, the CFAT addressed six domains of couple relationship quality (intimacy, partner support, sexual satisfaction, gender roles, decision-making, and communication and conflict management), and included questions on intimate partner violence. We used exploratory factor analysis to assess scale performance of each domain and produce a shortened Relationship Quality Index (RQI) composed of items from five relationship quality domains. This article reports the performance of the RQI. Internal reliability and validity of the RQI were found to be good. Regression analyses examined the relationship of the RQI to outcomes important to health and development: intra-household cooperation, positive health behaviors, intimate partner violence, and gender-equitable norms. We found many significant correlations between RQI scores and these couple- and family-level development issues. There is a need to further validate the tool with use in other populations as well as to continue to explore whether the observed linkages between couple functionality and development outcomes are causal relationships.

Analysis of chromatin dynamics during glucocorticoid receptor activation.

Steroid hormone receptors initiate a genetic program tightly regulated by the chromatin environment of the responsive regions. Using the glucocorticoid receptor (GR) as a model factor for transcriptional initiation, we classified chromatin structure through formaldehyde-assisted isolation of regulatory elements (FAIRE). We looked at dynamic changes in FAIRE signals during GR activation specifically at regions of receptor interaction. We found a distribution of GR-responsive regions with diverse responses to activation and chromatin modulation. The majority of GR binding regions demonstrate increases in FAIRE signal in response to ligand. However, the majority GR-responsive regions shared a similar FAIRE signal in the basal chromatin state, suggesting a common chromatin structure for GR recruitment. Supporting this notion, global FAIRE sequencing (seq) data indicated an enrichment of signal surrounding the GR binding site prior to activation. Brg-1 knockdown showed response element-specific effects of ATPase-dependent chromatin remodeling. FAIRE induction was universally decreased by Brg-1 depletion, but to varying degrees in a target specific manner. Taken together, these data suggest classes of nuclear receptor response regions that react to activation through different chromatin regulatory events and identify a chromatin structure that classifies the majority of response elements tested.

Defective erythropoiesis in transgenic mice expressing dominant-negative upstream stimulatory factor.

Transcription factor USF is a ubiquitously expressed member of the helix-loop-helix family of proteins. It binds with high affinity to E-box elements and, through interaction with coactivators, aids in the formation of transcription complexes. Previous work demonstrated that USF regulates genes during erythroid differentiation, including HoxB4 and beta-globin. Here, we show that the erythroid cell-specific expression of a dominant-negative mutant of USF, A-USF, in transgenic mice reduces the expression of all beta-type globin genes and leads to the diminished association of RNA polymerase II with locus control region element HS2 and with the beta-globin gene promoter. We further show that the expression of A-USF reduces the expression of several key erythroid cell-specific transcription factors, including EKLF and Tal-1. We provide evidence demonstrating that USF interacts with known regulatory DNA elements in the EKLF and Tal-1 gene loci in erythroid cells. Furthermore, A-USF-expressing transgenic mice exhibit a defect in the formation of CD71(+) progenitor and Ter-119(+) mature erythroid cells. In summary, the data demonstrate that USF regulates globin gene expression indirectly by enhancing the expression of erythroid transcription factors and directly by mediating the recruitment of transcription complexes to the globin gene locus.

Calpeptin increases the activity of upstream stimulatory factor and induces high level globin gene expression in erythroid cells.

Differentiation of erythroid cells is regulated by cell signaling pathways including those that change the intracellular concentration of calcium. Calcium-dependent proteases have been shown previously to process and regulate the activity of specific transcription factors. We show here that the protein levels of upstream stimulatory factor (USF) increase during differentiation of murine erythroleukemia (MEL) cells. USF was subject to degradation by the Ca(2+)-dependent protease m-calpain in undifferentiated but not in differentiated MEL cells. Treatment of MEL cells with the specific calpain inhibitor calpeptin increased the levels of USF and strongly induced expression of the adult alpha- and beta-globin genes. The induction of globin gene expression was associated with an increase in the association of USF and RNA po ly mer ase II with regulatory elements of the beta-globin gene locus. Calpeptin also induced high level alpha- and beta-globin gene expression in primary CD71-positive erythroid progenitor cells. The combined data suggest that inhibition of calpain activity is required for erythroid differentiation-associated increase in globin gene expression.

Recruitment of coregulator complexes to the beta-globin gene locus by TFII-I and upstream stimulatory factor.

Upstream stimulatory factor and TFII-I are ubiquitously expressed helix-loop-helix transcription factors that interact with E-box sequences and or initiator elements. We previously demonstrated that upstream stimulatory factor is an activator of beta-globin gene expression whereas TFII-I is a repressor. In the present study, we demonstrate that upstream stimulatory factor interacts with the coactivator p300 and that this interaction is restricted to erythroid cells expressing the adult beta-globin gene. Furthermore, we demonstrate that Suz12, a component of the polycomb repressor complex 2, is recruited to the beta-globin gene. Reducing expression of Suz12 significantly activates beta-globin gene expression in an erythroid cell line with an embryonic phenotype. Suz12 also interacts with the adult beta-globin gene during early stages of erythroid differentiation of mouse embryonic stem cells. Our data suggest that TFII-I contributes to the recruitment of the polycomb repressor complex 2 complex to the beta-globin gene. Together, these data demonstrate that the antagonistic activities of upstream stimulatory factor and TFII-I on beta-globin gene expression are mediated at least in part by protein complexes that render the promoter associated chromatin accessible or inaccessible for the transcription complex.

Neuronal responses to passive movement in the globus pallidus internus in primary dystonia.

Abnormal sensory processing has been implicated in the pathophysiology of primary dystonia. In the globus pallidus internus (GPi), the primary output structure of the basal ganglia, many neurons respond to sensory (proprioceptive) stimulation. Here we have characterized GPi neuronal responses to passive movement of the contralateral limbs in 22 patients with primary dystonia undergoing microelectrode recording for placement of deep brain stimulator leads. We plotted coordinates of cells responding to limb movement in a common space. We observed distinct representations of leg and arm movement localized to the dorsal and ventral part of the posterior GPi, respectively. Comparing patients with generalized dystonia versus patients with segmental craniocervical dystonia, there was no difference in the volumes or separations of leg and arm related territories. In contrast to parkinsonism, only a small minority of units were responsive to movement across multiple joints. Abnormally increased directional selectivity was found in units responding to dystonic limbs compared with nondystonic limbs. Some affected GPi neurons therefore appear to have altered proprioceptive tuning for movement direction. There is an apparent preservation of GPi somatotopic organization in dystonia in comparison with prior studies of GPi somatotopic organization in non-human primates and humans with Parkinson's disease.

Antagonistic regulation of beta-globin gene expression by helix-loop-helix proteins USF and TFII-I.

The human beta-globin genes are expressed in a developmental stage-specific manner in erythroid cells. Gene-proximal cis-regulatory DNA elements and interacting proteins restrict the expression of the genes to the embryonic, fetal, or adult stage of erythropoiesis. In addition, the relative order of the genes with respect to the locus control region contributes to the temporal regulation of the genes. We have previously shown that transcription factors TFII-I and USF interact with the beta-globin promoter in erythroid cells. Herein we demonstrate that reducing the activity of USF decreased beta-globin gene expression, while diminishing TFII-I activity increased beta-globin gene expression in erythroid cell lines. Furthermore, a reduction of USF activity resulted in a significant decrease in acetylated H3, RNA polymerase II, and cofactor recruitment to the locus control region and to the adult beta-globin gene. The data suggest that TFII-I and USF regulate chromatin structure accessibility and recruitment of transcription complexes in the beta-globin gene locus and play important roles in restricting beta-globin gene expression to the adult stage of erythropoiesis.

Recruitment of transcription complexes to the beta-globin locus control region and transcription of hypersensitive site 3 prior to erythroid differentiation of murine embryonic stem cells.

Eukaryotic chromosomal DNA is densely packaged in the nucleus and organized into discrete domains of active and inactive chromatin. Gene loci that are activated during the process of cell differentiation undergo changes that result in modifications of specific histone tail residues and in loosening of chromatin structure. The beta-globin genes are expressed exclusively in erythroid cells. High-level expression of these genes is mediated by a locus control region (LCR), a powerful DNA regulatory element composed of several DNase I hypersensitive (HS) sites and located far upstream of the beta-globin genes. Here we show that RNA polymerase II and specific histone modifications that mark transcriptionally active chromatin domains are associated with the LCR core elements HS2 and HS3 in murine embryonic stem cells prior to differentiation along the erythroid lineage. At this stage HS3 is abundantly transcribed. After in vitro differentiation, RNA Polymerase II can also be detected at the embryonic epsilon- and adult beta-globin genes. These results are consistent with the hypothesis that activation of the beta-globin gene locus is initiated by protein complexes recruited to the LCR.

Spontaneous pallidal neuronal activity in human dystonia: comparison with Parkinson's disease and normal macaque.

Dystonia is a movement disorder defined by sustained muscle contractions, causing twisting and repetitive movements and abnormal postures. To understand the abnormalities in pallidal discharge in dystonia, we have analyzed the spontaneous activity of 453 neurons sampled from the internal or external pallidum (GPi or GPe) of 22 patients with dystonia, 140 neurons from 11 patients with Parkinson's disease (PD), and 157 neurons from two normal non-human primates (NHPs; Macacca mulatta). All recordings were performed without systemic sedation. Mean GPi discharge rate in dystonia was 55.3 +/- 1.3 (SE) Hz. This was significantly lower than in the normal NHPs (82.5 +/-2.5 Hz) and lower than in PD patients (95.2 +/- 2.3 Hz). Mean GPe discharge rate in dystonia (54.0 +/- 1.9 Hz) was lower than in the normal NHPs (69.7 +/- 3.3 Hz) and was indistinguishable from that in PD patients (56.6 +/- 3.5 Hz). Mean GPi discharge rate was inversely correlated with dystonia severity. GPi showed increased oscillatory activity in the 2- to 10-Hz range and increased bursting activity in both dystonia and PD as compared with the normal NHPs. Because the abnormalities in discharge patterns were similar in dystonia compared with PD, we suggest that bursting and oscillatory activity superimposed on a high background discharge rate are associated with parkinsonism, whereas similar bursting and oscillations superimposed on a lower discharge rate are associated with dystonia. Our findings are most consistent with a model of dystonia pathophysiology in which the two striatal cell populations contributing to the direct and indirect intrinsic pathways of the basal ganglia both have increased spontaneous activity.

Efficacy of a jellyfish sting inhibitor in preventing jellyfish stings in normal volunteers.

OBJECTIVE: To evaluate the protective effects of a jellyfish sting inhibitor formulated in sunscreen lotion vs conventional sunscreen against Chrysaora fuscescens and Chiropsalmus quadrumanus jellyfish. METHODS: Twenty-four healthy subjects at 2 research sites were randomly assigned to receive the jellyfish sting inhibitor (Nidaria Technology Ltd, Jordan Valley, Israel) to one forearm and conventional sunscreen to the other arm in a blinded fashion. Subjects were stung with jellyfish tentacles on each forearm for up to 60 seconds. Erythema and pain were assessed at 15-minute intervals over a 2-hour period. RESULTS: In the C. fuscescens group, all 12 arms pretreated with conventional sunscreen demonstrated erythema, and all subjects noted subjective discomfort. In contrast, no arm pretreated with the jellyfish sting inhibitor had objective skin changes (P < .01). Two subjects noted minimal discomfort in the arm treated with the sting inhibitor (P < .01). In the C. quadrumanus group, discomfort was reported in 3 of the 12 inhibitor-treated arms compared with 10 of the 12 placebo-treated arms (P < .05). Erythema was noted on 1 arm treated with the inhibitor and 9 arms treated with the placebo (P < .01). CONCLUSIONS: The jellyfish sting inhibitor prevented sting symptoms of C. fuscescens jellyfish in 10 of 12 subjects and diminished the pain of the jellyfish sting in the remaining 2 subjects. The jellyfish sting inhibitor also inhibited the more severe sting of the C. quadrumanus jellyfish in the majority of subjects. The jellyfish sting inhibitor does not eliminate the sting from C. fuscescens or C. quadrumanus jellyfish but significantly reduces the frequency and severity of stings.

Increased Reliability in Detection of Enterotoxigenic Escherichia coli by DNA Colony Hybridization 1.

Previously a DNA hybridization assay was designed to detect the presence of and to enumerate enterotoxigenic foodborne Escherichia coli . The determinative step in the method involves autoradiographic analysis of the DNA from foodborne isolates after hybridization with a 32P-labeled probe specific for an enterotoxin gene. Dark spots appearing on the X-ray film after exposure indicate which colonies carry genes encoding the pathogenic determinant. A problem with this assay is the tendency of some colonies to detach from the nitrocellulose filters during hybridization or washing to remove the unbound probe DNA; this results in a false-negative interpretation in up to 60% of the samples processed at 80°C. By lowering the temperature to 70°C and increasing the incubation time to 3 h during in vacuo baking of filters, detachment (flotation) of colonies is reduced to about 37%. At 65°C only 2% of the colonies came off the filter after in vacuo baking of filters for 24 h. Another problem has been the inadequacy of exposure of X-ray film at -20°C when a -70°C freezer is not available. This problem can be alleviated by exposing the X-ray film in cassette holders "sandwiched" between slabs of dry ice (CO2 ice has a temperature of -78.5°C). These modifications improve the reliability and accuracy of this DNA colony hybridization method.