It is unclear whether serial measures of body weight are valid indicators of nutritional status in older patients recovering from illness. Objectives. Investigate the relative influence of nutrient ...intake and changes in peripheral edema on weight change.
A prospective cohort study of 404 older men (mean age = 78.7±7.5 years) admitted to a transitional care unit of a Department of Veterans Affairs nursing home. Body weight and several indicators of lower extremity edema were measured at both unit admission and discharge. Complete nutrient intake assessments were performed daily.
Over a median length of stay of 23 days (interquartile range: 15-41 days), 216 (53%) participants gained or lost more than or equal to 2.5% of their body weight. Two hundred eighty-two (70%) participants had recognizable lower extremity pitting edema at admission and/or discharge. The amount of weight change was strongly and positively correlated with multiple indicators of both nutrient intake and the change in the amount of peripheral edema. By multivariable analysis, the strongest predictor of weight change was maximal calf circumference change (partial R (2) = .35, p < .0001), followed by average daily energy intake (partial R (2) = .14, p < .0001), and the interaction of energy intake by time (partial R (2) = .02, p < .0001).
Many older patients either gain or lose a significant amount of weight after admission to a transitional care unit. Because of the apparent high prevalence of co-occurring changes in total body water, the weight changes do not necessarily represent changes in nutritional status. Although repeat calf circumference measurements may provide some indication as to how much of the weight change is due to changes in body water, there is currently no viable alternative to monitoring the nutrient intake of older recuperative care patients in order to ensure that their nutrient needs are being met.
Whereas science teachers often express initial enthusiasm about the student‐centered, reform‐oriented instructional strategies they encounter in professional development (PD), they rarely adopt them ...in practice. One possible obstacle is a mismatch between these strategies and teachers' beliefs about what is possible and desirable in their particular teaching contexts. In the current study, we investigated changes in teachers' beliefs about practices within a PD context, and consider beliefs about practice as one component within teachers' overall professional role identity. Using the Dynamic Systems Model of Role Identity (DSMRI) as our theoretical framework, we analyzed pre‐PD, mid‐PD, and post‐PD interviews, daily written reflections, and responses to exploration and commitment prompts of four high school science teacher participants in an 8‐day, reform‐oriented summer institute. Teachers' experiences, changes in the content, structure and process of various components of their professional role identities, and their eventual endorsement or resistance to new practices, were framed by the dynamic interplay between their current science teacher role identity and other role identities. When discussing possibilities for action in subsequent teaching practices, alignment, and tensions within and between these role identities promoted or impeded changes in behavioral intentions. The findings highlight the importance of considering prior and current role identities when designing and evaluating PD contexts, and the complex and contextual nature of identity change among teachers.
Exercise stress testing is a validated diagnostic test for coronary artery disease in symptomatic patients, and is used in the evaluation of patients with known cardiac disease. Testing of ...asymptomatic patients is generally not indicated. It may be performed in select deconditioned adults before starting a vigorous exercise program, but no studies have compared outcomes from preexercise testing vs. encouraging light exercise with gradual increases in exertion. Preoperative exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery or who have active cardiac symptoms before undergoing nonemergent noncardiac surgery. Exercise stress testing without imaging is the preferred initial choice for risk stratification in most women. Sensitivity and specificity increase with the use of adjunctive imaging such as echocardiography or myocardial perfusion imaging with single-photon emission computed tomography. Exercise stress testing is rarely an appropriate option to evaluate persons with known coronary artery disease who have no new symptoms less than two years after percutaneous intervention or less than five years after coronary artery bypass grafting. The Duke treadmill score has excellent prognostic value for exercise stress testing. Imaging is not necessary if patients are able to achieve more than 10 metabolic equivalents on exercise stress testing. Exercise stress testing is not indicated before noncardiac surgeries in patients who can achieve 4 metabolic equivalents without symptoms.
The retention of weight gained during pregnancy may contribute to obesity. Lactation should promote weight loss, but weight loss is highly variable among lactating women. The risks associated with ...the restriction of energy intake during lactation have not been adequately evaluated. The purpose of this study was to determine whether weight loss by women during lactation affects the growth of their infants.
We randomly assigned 40 breast-feeding women who were overweight (defined as a body-mass index the weight in kilograms divided by the square of the height in meters of 25 to 30) at 4 weeks post partum either to restrict their energy intake by 500 kcal per day and to exercise for 45 minutes per day for 4 days per week (the diet-and-exercise group) or to maintain their usual dietary intake and not exercise more than once per week for 10 weeks (the control group). We measured the weight and fat mass of the women and the weight and length of the infants before, during, and at the end of the study period.
The mean (+/-SD) energy intake decreased by 544+/-471 kcal per day in the diet-and-exercise group. As compared with the control group, the women in the diet-and-exercise group lost more weight (4.8+/-1.7 kg vs. 0.8+/-2.3 kg, P<0.001) and fat mass (4.0+/-2.0 kg vs. 0.3+/-1.8 kg, P<0.001). The gains in weight and length of the infants whose mothers were in the diet-and-exercise group (1925+/-500 g and 7.8+/-2.0 cm, respectively) were not significantly different from those of the infants whose mothers were in the control group (1861+/-576 g and 7.3+/-1.7 cm).
Weight loss of approximately 0.5 kg per week between 4 and 14 weeks post partum in overweight women who are exclusively breast-feeding does not affect the growth of their infants.
To demonstrate protein modulation of metal‐cofactor reactivity through noncovalent interactions, pH‐dependent sulfoxidation and 2,2′‐azino‐bis(3‐ethylbenzthiazoline‐6‐sulphonic acid) (ABTS) oxidation ...reactivity of a designed myoglobin (Mb) containing non‐native Mn–salen complex (1) was investigated using H2O2 as the oxidant. Incorporation of 1 inside the Mb resulted in an increase in the turnover numbers through exclusion of water from the metal complex and prevention of Mn–salen dimer formation. Interestingly, the presence of protein in itself is not enough to confer the increase activity as mutation of the distal His64 in Mb to Phe to remove hydrogen‐bonding interactions resulted in no increase in the turnover numbers, while mutation His64 to Arg, another residue with ability to hydrogen‐bond interactions, resulted in an increase in reactivity. These results strongly suggest that the distal ligand His64, through its hydrogen‐bonding interaction, plays important roles in enhancing and fine‐tuning reactivity of the Mn–salen complex. Nonlinear least‐squares fitting of rate versus pH plots demonstrates that 1⋅Mb(H64X) (X=H, R and F) and the control Mn–salen 1 exhibit pKa values varying from pH 6.4 to 8.3, and that the lower pKa of the distal ligand in 1⋅Mb(H64X), the higher the reactivity it achieves. Moreover, in addition to the pKa at high pH, 1⋅Mb displays another pKa at low pH, with pKa of 5.0±0.08. A comparison of the effect of different pH on sulfoxidation and ABTS oxidation indicates that, while the intermediate produced at low pH conditions could only perform sulfoxidation, the intermediate at high pH could oxidize both sulfoxides and ABTS. Such a fine‐control of reactivity through hydrogen‐bonding interactions by the distal ligand to bind, orient and activate H2O2 is very important for designing artificial enzymes with dramatic different and tunable reactivity from catalysts without protein scaffolds.
Biosynthetic model: To demonstrate the protein modulation of metal‐cofactor reactivity through noncovalent interactions, pH‐dependent sulfoxidation and 2,2′‐azino‐bis(3‐ethylbenzthiazoline‐6‐sulphonic acid) oxidation reactivity of a designed myoglobin (Mb) containing non‐native Mn–salen complex (1) was investigated by using H2O2 as the oxidant.
Psoriasis is an inflammatory skin and systemic disorder that affects 3.2% of the U.S. population, including 1% of children. It is an immune-mediated process triggered by an interplay of genetic, ...environmental, physical (e.g., skin trauma), and infectious factors. Associated comorbidities include cardiovascular disease, obesity, metabolic syndrome, diabetes mellitus, and inflammatory bowel disease. Psoriasis presents in various forms, including plaque, guttate, erythrodermic, pustular, inverse, nail, and psoriatic arthritis. The most common form is plaque psoriasis, which affects 90% of adults with psoriasis. Psoriasis is diagnosed clinically based on the presence of characteristic erythematous, scaly skin plaques in typical locations, with associated history and systemic symptoms. Treatment strategies are similar for most forms of psoriasis and based on body surface area involved. Topical corticosteroids, vitamin D analogues, and tazarotene are used to treat mild to moderate disease. Systemic treatment with nonbiologic and biologic agents and ultraviolet B phototherapy are used for moderate to severe disease, with the exception of apremilast, a systemic agent approved for mild psoriasis. Disease management is improved with maintaining ideal body weight, avoiding tobacco products, limiting alcohol, and practicing stress reduction techniques. The Psoriasis Area and Severity Index is a tool to assess severity and monitor treatment effectiveness over time. Special consideration is needed for treatment of children and patients who are pregnant, breastfeeding, or trying to conceive.
Type 1 copper proteins have a conserved ligand set of one cysteine and two histidines, with many proteins, such as azurin, also containing an axial methionine. While the cysteine and methionine in ...azurin have been replaced with their respective isostructural analogues of unnatural amino acids to reveal their roles in tuning electronic structures and functional properties, such as reduction potentials (E°′), the histidine ligands have not been probed in this way. We herein report the substitution of His117 in azurin with three unnatural isostructural analogues, 5-nitrohistidine(Ntr), thiazolylalanine(SHis) and 1-methylhistidine(MeH) by expressed protein ligation. While UV–vis absorption and electron paramagnetic resonance spectroscopies confirm that isostructural replacement results in minimal structural change in the Cu(II) state, the E°′ of these variants increases with increasing pKa of the δ nitrogens of the imidazole. This counter-intuitive relationship between E°′ of the protein and pKa of the sidechain group suggests additional factors may play a role in tuning E°′.
Replacing His117 in azurin with three isostructural analogues, 5-nitrohistidine(Ntr), thiazolylalanine(SHis) and 1-methylhistidine(MeH) resulted in linear tuning of reduction potentials of the type 1 Cu2+/Cu+ couple. Display omitted
•The histidine ligand in azurin is probed with its unnatural amino acid analogs.•Minimal structural perturbation was observed by spectroscopic studies.•Redox potentials of the variants increase with increasing pKa's of the histidine analogs.•The correlation between redox potentials and pKa's of the histidines is counter-intuitive.•This finding suggests additional factors may play a role in tuning the redox potentials.
Traditionally, system leaders, service line managers, researchers, and program evaluators hire specifically dedicated implementation staff to ensure that a healthcare quality improvement effort can ..."go to scale." However, little is known about the impact of hiring dedicated staff and whether funded positions, amid a host of other delivered implementation strategies, are the main difference among sites with and without funding used to execute the program, on implementation effectiveness and cost outcomes.
In this mixed methods program evaluation, we will determine the impact of funding staff positions to implement, sustain, and spread a program, Advance Care Planning (ACP) via Group Visits (ACP-GV), nationally across the entire United States Department of Veterans Affairs (VA) healthcare system. In ACP-GV, veterans, their families, and trained clinical staff with expertise in ACP meet in a group setting to engage in discussions about ACP and the benefits to veterans and their trusted others of having an advance directive (AD) in place. To determine the impact of the ACP-GV National Program, we will use a propensity score-matched control design to compare ACP-GV and non-ACP-GV sites on the proportion of ACP discussions in VHA facilities. To account for variation in funding status, we will document and compare funded and unfunded sites on the effectiveness of implementation strategies (individual and combinations) used by sites in the National Program on ACP discussion and AD completion rates across the VHA. In order to determine the fiscal impact of the National Program and to help inform future dissemination across VHA, we will use a budget impact analysis. Finally, we will purposively select, recruit, and interview key stakeholders, who are clinicians and clinical managers in the VHA who offer ACP discussions to veterans, to identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread.
As an observational evaluation, this protocol will contribute to our understanding of implementation science and practice by examining the natural variation in implementation and spread of ACP-GV with or without funded staff positions.
The cupredoxin fold is an important motif in numerous proteins that are central to several critical cellular processes ranging from aerobic and anaerobic respiration to catalysis and iron ...homeostasis. Three types of copper sites have been found to date within cupredoxin folds: blue type 1 (T1) copper, red type 2 (T2) copper, and purple CuA. Although as much as 90% sequence difference has been observed among some members of this superfamily of proteins that span several kingdoms, sequence alignment and phylogenic trees strongly suggest an evolutionary link and common ancestry. However, experimental evidence for such a link has been lacking. We report herein the observation of pH-dependent transformation between blue T1 copper, red T2 copper, and the native purple CuA centers of nitrous oxide reductase (N₂OR) from Paracoccus denitrificans. The blue and red copper centers form initially before they are transformed into purple CuA center. This transformation process is pH-dependent, with lower pH resulting in fewer trapped T1 and T2 coppers and faster transition to purple CuA. These observations suggest that the purple CuA site contains the essential elements of T1 and T2 copper centers and that the CuA center is preferentially formed at low pH. Therefore, this work provides an underlying link between the various cupredoxin copper sites and possible experimental evidence in vitro for the evolutionary relationship between the cupredoxin proteins. The findings also lend physiological relevance to cupredoxin site biosynthesis.
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