An Evaluation of STFM's National Addiction Curriculum.

BACKGROUND AND OBJECTIVES: Family physicians are well positioned to treat patients with substance use disorders (SUDs), expand access to care, destigmatize addiction, and provide a biopsychosocial treatment approach. There is a great need to train residents and faculty to competency in SUD treatment. Through the Society of Teachers of Family Medicine (STFM) Addiction Collaborative, we created and evaluated the first national family medicine (FM) addiction curriculum using evidence-based content and teaching principles. METHODS: After launching the curriculum with 25 FM residency programs, we collected formative feedback through monthly faculty development sessions and summative feedback through 8 focus groups with 33 faculty members and 21 residents. We used qualitative thematic analysis to assess the value of the curriculum. RESULTS: The curriculum enriched resident and faculty knowledge across all SUD topics. It changed their attitudes in viewing addiction as a chronic disease within the scope of FM practice, increased confidence, and decreased stigma. It nurtured behavior change, enhancing communication and assessment skills and encouraging collaboration across disciplines. Participants valued the flipped-classroom approach, videos, cases, role plays, ready-made teacher's guides, and one-page summaries. Having protected time to complete the modules and temporally coupling the modules with the live, faculty-led sessions enhanced learning. CONCLUSION: The curriculum provides a comprehensive, ready-made, evidenced-based platform for training residents and faculty in SUDs. It can be implemented by faculty with all levels of prior expertise, cotaught by physicians and behavioral health providers, tailored to each program's didactic schedule, and modified based on the local culture and resource availability.

The Impact of Local Education and Resource Distribution on Maternal Health Behaviors.

INTRODUCTION: Community forum participants voted for an education and resource distribution program (using a baby box) to help reduce local infant mortality. Although multiple sites have implemented similar programs, there is limited peer-reviewed literature about outcomes. METHODS: A retrospective pre- and immediate post-survey design with an intervention (video and written education and resource distribution) in between was utilized with a follow-up survey. The primary research objectives were whether viewing educational videos led to change in self-reported likelihood of select maternal behaviors. Other objectives were whether demographic characteristics were associated with self-reported likelihood of behaviors, and to assess the actual self-reported postpartum behavior. RESULTS: Participants reported a change in likelihood in: asking a WIC counselor for help (p < 0.001); talking with a provider about substance use (p = 0.014), postpartum depression (p < 0.001) and birth control (p = 0.025); and using the baby box as a sleeping space (p < 0.01). After watching the educational videos, college-educated participants were significantly more likely than participants with high school education or less to report likelihood to breastfeed (p = 0.039). Over half of the participants (59.2%) in the follow-up survey reported breastfeeding most to all of the time, compared to 91.5% who reported they were more likely to breastfeed in the post-education survey. The proportion of participants at the follow-up survey who reported bed-sharing most or all of the time (5.7%) was lower than those participants who had said they were likely or very likely to bed-share in the post-education survey (11.3%). Although nearly all participants (98.6%) in the post-education survey reported that they were likely to use the baby box, at the postpartum follow-up, 39.1% reported actual use of the baby box. CONCLUSIONS FOR PRACTICE: The program positively impacted self-reported likelihood of several health behaviors. A community-driven approach to maternal education and resource distribution may be beneficial in other cities.

The structure of human Nocturnin reveals a conserved ribonuclease domain that represses target transcript translation and abundance in cells.

The circadian protein Nocturnin (NOCT) belongs to the exonuclease, endonuclease and phosphatase superfamily and is most similar to the CCR4-class of deadenylases that degrade the poly-adenosine tails of mRNAs. NOCT-deficient mice are resistant to high-fat diet induced weight gain, and exhibit dysregulation of bone formation. However, the mechanisms by which NOCT regulates these processes remain to be determined. Here, we describe a pair of high-resolution crystal structures of the human NOCT catalytic domain. The active site of NOCT is highly conserved with other exoribonucleases, and when directed to a transcript in cells, NOCT can reduce translation and abundance of that mRNA in a manner dependent on key active site residues. In contrast to the related deadenylase CNOT6L, purified recombinant NOCT lacks in vitro ribonuclease activity, suggesting that unidentified factors are necessary for enzymatic activity. We also find the ability of NOCT to repress reporter mRNAs in cells depends upon the 3' end of the mRNA, as reporters terminating with a 3' MALAT1 structure cannot be repressed by NOCT. Together, these data demonstrate that NOCT is an exoribonuclease that can degrade mRNAs to inhibit protein expression, suggesting a molecular mechanism for its regulatory role in lipid metabolism and bone development.

Multi-Stakeholder Informed Guidelines for Direct Admission of Children to Hospital.

OBJECTIVES: To develop pediatric direct admission guidelines and prioritize outcomes to evaluate the safety and effectiveness of hospital admission processes. STUDY DESIGN: We conducted deliberative discussions at 1 children's hospital and 2 community hospitals, engaging parents of hospitalized children and inpatient, outpatient, and emergency department physicians and nurses to identify shared and dissenting perspectives regarding direct admission processes and outcomes. Discussions were audio-recorded, professionally transcribed, and analyzed using a general inductive approach. We then convened a national panel to prioritize guideline components and outcome measures using a RAND/UCLA Modified Delphi approach. RESULTS: Forty-eight stakeholders participated in 6 deliberative discussions. Emergent themes related to effective multistakeholder communication, resources needed for high quality direct admissions, written direct admission guidelines, including criteria to identify children appropriate for and inappropriate for direct admission, and families' needs. Building on these themes, Delphi panelists endorsed 71 guideline components as both appropriate and necessary at children's hospitals and community hospitals and 13 outcomes to evaluate hospital admission systems. Guideline components include (1) pre-admission communication, (2) written guidelines, (3) hospital resources to optimize direct admission processes, (4) special considerations for pediatric populations that may be at particular risk of nosocomial infection and/or stress in emergency departments, (5) communication with families referred for direct admission, and (6) quality reviews to evaluate admission systems. CONCLUSIONS: These direct admission guidelines can be adapted by hospitals and health systems to inform hospital admission policies and protocols. Multistakeholder engagement in evaluation of hospital admission processes may improve transitions of care and health system integration.

Paediatric hospital admission processes and outcomes: a qualitative study of parents' experiences and priorities.

BACKGROUND: Hospital admission, like hospital discharge, represents a transition of care associated with changes in setting, healthcare providers and clinical management. While considerable efforts have focused on improving the quality and safety of hospital-to-home transitions, there has been little focus on transitions into hospital. OBJECTIVES: Among children hospitalised with ambulatory care sensitive conditions, we aimed to characterise families' experiences as they transitioned from outpatient to inpatient care, identify hospital admission processes and outcomes most important to families and determine how parental perspectives differed between children admitted directly and through emergency departments (ED). METHODS: We conducted semistructured interviews with parents of hospitalised children at four structurally diverse hospitals. We inquired about preadmission healthcare encounters, how hospital admission decisions were made and parents' preferences regarding hospital admission processes and outcomes. Interviews were transcribed verbatim and analysed using a general inductive approach. RESULTS: We conducted 48 interviews. Participants were predominantly mothers (74%); 45% had children with chronic illnesses and 52% were admitted directly. Children had a median of two (IQR 1-3) healthcare encounters in the week preceding hospital admission, with 44% seeking care in multiple settings. Patterns of healthcare utilisation were influenced by (1) disease acuity and healthcare access; (2) past experiences; and (3) varied perspectives about primary care and ED roles as hospital gatekeepers. Participants' hospital admission priorities included: (1) effective clinical care; (2) efficient admission processes; (3) safety and security; (4) timeliness; and (5) patient and family-centred processes of care. CONCLUSIONS: Families received preadmission care in several settings and described varying degrees of care coordination during their admission processes. This research can guide improvements in hospitals' admission systems, necessary to achieve health system integration and continuity of care.

Importance and Feasibility of Transitional Care for Children With Medical Complexity: Results of a Multistakeholder Delphi Process.

BACKGROUND: Children with medical complexity (CMC) account for disproportionate hospital utilization and adverse outcomes after discharge, and several gaps exist regarding the quality of hospital to home transitional care for this population. We conducted an expert elicitation process to identify important and feasible hospital to home transitional care interventions for CMC from the perspectives of parents and health care professionals. METHODS: We conducted a 2-round electronic Delphi process to identify important and feasible transitional care interventions. Panelists included parents of CMC and multidisciplinary health care professionals. In the first round, panelists rated the importance and feasibility of 39 transitional care interventions on a 9-point Likert scale; agreement between panelists was defined according to RAND/UCLA Appropriateness Methods. The second round of data collection evaluated 16 interventions that panelists did not agree on in the first round and 8 new or revised interventions, accompanied by quantitative and qualitative data summaries. RESULTS: A total of 29 parents of CMC and 37 health care professionals participated in the Delphi process (response rate 75%). Both stakeholder panels endorsed most interventions as important; health care professionals were less likely to rate several interventions as feasible compared with the parent panel. Over 2 rounds of data collection, the 2 stakeholder panels endorsed 25 interventions as important as well as feasible. These interventions related to family engagement during the hospitalization, care coordination and social support assessment, predischarge education, and written materials. CONCLUSIONS: Parents and health care professionals considered several transitional care interventions important as well as feasible. This research might inform hospitals' transitional care programs and policies.

Molecular basis for substrate recognition by lysine methyltransferases and demethylases.

Lysine methylation has emerged as a prominent covalent modification in histones and non-histone proteins. This modification has been implicated in numerous genomic processes, including heterochromatinization, cell cycle progression, DNA damage response, DNA replication, genome stability, and epigenetic gene regulation that underpins developmental programs defining cell identity and fate. The site and degree of lysine methylation is dynamically modulated through the enzymatic activities of protein lysine methyltransferases (KMTs) and protein lysine demethylases (KDMs). These enzymes display distinct substrate specificities that in part define their biological functions. This review explores recent progress in elucidating the molecular basis of these specificities, highlighting structural and functional studies of the methyltransferases SUV4-20H1 (KMT5B), SUV4-20H2 (KMT5C), and ATXR5, and the demethylases UTX (KDM6A), JMJD3 (KDM6B), and JMJD2D (KDM4D). We conclude by examining these findings in the context of related KMTs and KDMs and by exploring unresolved questions regarding the specificities and functions of these enzymes.

Manipulating unconventional CH-based hydrogen bonding in a methyltransferase via noncanonical amino acid mutagenesis.

Recent studies have demonstrated that the active sites of S-adenosylmethionine (AdoMet)-dependent methyltransferases form strong carbon-oxygen (CH···O) hydrogen bonds with the substrate's sulfonium group that are important in AdoMet binding and catalysis. To probe these interactions, we substituted the noncanonical amino acid p-aminophenylalanine (pAF) for the active site tyrosine in the lysine methyltransferase SET7/9, which forms multiple CH···O hydrogen bonds to AdoMet and is invariant in SET domain enzymes. Using quantum chemistry calculations to predict the mutation's effects, coupled with biochemical and structural studies, we observed that pAF forms a strong CH···N hydrogen bond to AdoMet that is offset by an energetically unfavorable amine group rotamer within the SET7/9 active site that hinders AdoMet binding and activity. Together, these results illustrate that the invariant tyrosine in SET domain methyltransferases functions as an essential hydrogen bonding hub and cannot be readily substituted by residues bearing other hydrogen bond acceptors.

Crystal structure and functional analysis of JMJD5 indicate an alternate specificity and function.

JMJD5 is a Jumonji C (JmjC) protein that has been implicated in breast cancer tumorigenesis, circadian rhythm regulation, embryological development, and osteoclastogenesis. Recently, JMJD5 (also called KDM8) has been reported to demethylate dimethylated Lys-36 in histone H3 (H3K36me2), regulating genes that control cell cycle progression. Here, we report high-resolution crystal structures of the human JMJD5 catalytic domain in complex with the substrate 2-oxoglutarate (2-OG) and the inhibitor N-oxalylglycine (NOG). The structures reveal a ß-barrel fold that is conserved in the JmjC family and a long shallow cleft that opens into the enzyme's active site. A comparison with other JmjC enzymes illustrates that JMJD5 shares sequence and structural homology with the asparaginyl and histidinyl hydroxylase FIH-1 (factor inhibiting hypoxia-inducible factor 1 [HIF-1]), the lysyl hydroxylase JMJD6, and the RNA hydroxylase TYW5 but displays limited homology to JmjC lysine demethylases (KDMs). Contrary to previous findings, biochemical assays indicate that JMJD5 does not display demethylase activity toward methylated H3K36 nor toward the other methyllysines in the N-terminal tails of histones H3 and H4. Together, these results imply that JMJD5 participates in roles independent of histone demethylation and may function as a protein hydroxylase given its structural homology with FIH-1 and JMJD6.

Substrate and product specificities of SET domain methyltransferases.

SET domain lysine methyltransferases (KMTs) catalyze the site- and state-specific methylation of lysine residues in histone and non-histone substrates. These modifications play fundamental roles in transcriptional regulation, heterochromatin formation, X chromosome inactivation and DNA damage response, and have been implicated in the epigenetic regulation of cell identity and fate. The substrate and product specificities of SET domain KMTs are pivotal to eliciting these effects due to the distinct functions associated with site and state-specific protein lysine methylation. Here, we review advances in understanding the molecular basis of these specificities gained through structural and biochemical studies of the human methyltransferases Mixed Lineage Leukemia 1 (MLL1, also known as KMT2A) and SET7/9 (KMT7). We conclude by exploring the broader implications of these findings on the biological functions of protein lysine methylation by SET domain KMTs.

SET7/9 catalytic mutants reveal the role of active site water molecules in lysine multiple methylation.

SET domain lysine methyltransferases (KMTs) methylate specific lysine residues in histone and non-histone substrates. These enzymes also display product specificity by catalyzing distinct degrees of methylation of the lysine ε-amino group. To elucidate the molecular mechanism underlying this specificity, we have characterized the Y245A and Y305F mutants of the human KMT SET7/9 (also known as KMT7) that alter its product specificity from a monomethyltransferase to a di- and a trimethyltransferase, respectively. Crystal structures of these mutants in complex with peptides bearing unmodified, mono-, di-, and trimethylated lysines illustrate the roles of active site water molecules in aligning the lysine ε-amino group for methyl transfer with S-adenosylmethionine. Displacement or dissociation of these solvent molecules enlarges the diameter of the active site, accommodating the increasing size of the methylated ε-amino group during successive methyl transfer reactions. Together, these results furnish new insights into the roles of active site water molecules in modulating lysine multiple methylation by SET domain KMTs and provide the first molecular snapshots of the mono-, di-, and trimethyl transfer reactions catalyzed by these enzymes.

ATP synthase b subunit dimerization domain: a right-handed coiled coil with offset helices.

The dimerization domain of Escherichia coli ATP synthase b subunit forms an atypical parallel two-stranded coiled coil. Sequence analysis reveals an 11-residue abcdefghijk repeat characteristic of right-handed coiled coils, but no other naturally occurring parallel dimeric structure of this class has been identified. The arrangement of the helices was studied by their propensity to form interhelix disulfide linkages and analysis of the stability and shape of disulfide-linked dimers. Disulfides formed preferentially between cysteine residues in an a position of one helix and either of the adjacent h positions of the partner. Such heterodimers were far more stable to thermal denaturation than homodimers and, on the basis of gel-filtration chromatography studies, were similar in shape to both non-covalent dimers and dimers linked through flexible Gly(1-3)Cys C-terminal extensions. The results indicate a right-handed coiled-coil structure with intrinsic asymmetry, the two helices being offset rather than in register. A function for the right-handed coiled coil in rotational catalysis is proposed.

Can fine-needle aspiration biopsy of thyroid nodule help in determining the extent of surgery in follicular and Hurthle cell neoplasm at a community teaching institution?

Fine-needle aspiration biopsy (FNAB) was used to evaluate cold thyroid nodules in 179 patients treated between 1990 and 1998. The purpose of this study was to see whether FNAB findings of follicular or Hurthle cells could help in planning the extent of thyroid surgery. Group I patients (47) had findings suggestive of follicular or Hurthle cell neoplasm. Group II patients (132) had inconclusive results. In group I FNAB was 100 per cent correct in diagnosing follicular or Hurthle cell neoplasm with a high percentage of malignant findings (malignancy 85 per cent and benign adenoma 15 per cent). In Group II malignancy was found in 16 per cent and benign pathology in 84 per cent. Women were more likely to have malignancy than men. The average age was over 50 years in patients with either malignant or benign nodules. In addition there was no significant difference in average size of benign or malignant nodules (2.9 vs 2.6 cm respectively). When an FNAB finding was suggestive of neoplasm malignancy was found in 85 per cent. On the other hand when an FNAB was inconclusive malignancy was present in 16 per cent. Thus we conclude that using FNAB finding can guide surgical resection and recommend performing total or subtotal thyroidectomy when FNAB is suggestive of neoplasm and lobectomy when FNAB is inconclusive.

The "second stalk" of Escherichia coli ATP synthase: structure of the isolated dimerization domain.

The b subunit of E. coli F(0)F(1)-ATPase links the peripheral F(1) subunits to the membrane-integral F(0) portion and functions as a "stator", preventing rotation of F(1). The b subunit is present as a dimer in ATP synthase, and residues 62-122 are required to mediate dimerization. To understand how the b subunit dimer is formed, we have studied the structure of the isolated dimerization domain, b(62-122). Analytical ultracentrifugation and solution small-angle X-ray scattering (SAXS) indicate that the b(62-122) dimer is extremely elongated, with a frictional ratio of 1.60, a maximal dimension of 95 A, and a radius of gyration of 27 A, values that are consistent with an alpha-helical coiled-coil structure. The crystal structure of b(62-122) has been solved and refined to 1.55 A. The protein crystallized as an isolated, monomeric alpha helix with a length of 90 A. Combining the crystal structure of monomeric b(62-122) with SAXS data from the dimer in solution, we have constructed a model for the b(62-122) dimer in which the two helices form a coiled coil with a right-handed superhelical twist. Analysis of b sequences from E. coli and other prokaryotes indicates conservation of an undecad repeat, which is characteristic of a right-handed coiled coil and consistent with our structural model. Mutation of residue Arg-83, which interrupts the undecad pattern, to alanine markedly stabilized the dimer, as expected for the proposed two-stranded, right-handed coiled-coil structure.