Computerized clinical decision support (CDS) faces challenges to interoperability and scalability. Centralized, web-based solutions offer a mechanism to share the cost of CDS development, ...maintenance, and implementation across practices. Data standards have emerged to facilitate interoperability and rapid integration of such third-party CDS. This case report describes the challenges to implementation and scalability of an integrated, web-based CDS intervention for EMergency department-initiated BuprenorphinE for opioid use Disorder which will soon be evaluated in a trial across 20 sites in five healthcare systems. Due to limitations of current standards, security concerns, and the need for resource-intensive local customization, barriers persist related to centralized CDS at this scale. These challenges demonstrate the need and importance for future standards to support two-way messaging (read and write) between electronic health records and web applications, thus allowing for more robust sharing across health systems and decreasing redundant, resource-intensive CDS development at individual sites.
In high glucose protein kinase C-ζ activation is required for mesangial cell generation of reactive oxygen species.
We postulated that in mesangial cells exposed to high glucose, protein kinase C-ζ ...(PKC-ζ) is necessary for the generation of reactive oxygen species (ROS) by nicotinamide adenine dinucleotide phosphate (NADPH) oxidase and that the requirement of PKC-ζ for filamentous (F)-actin disassembly may involve ROS. To identify signaling mechanisms relevant to PKC-ζ activation and ROS generation, including phosphoinositide 3 kinase (PI3 kinase), we examined mesangial cell stimulation with platelet-derived growth factor (PDGF).
In primary rat mesangial cells cultured in 5.6mmol/L or 30mmol/L D-glucose, PKC-ζ expression was identified with immunoblotting and activity was analyzed in cell membrane immunoprecipitates and by confocal immunofluorescence imaging. ROS generation was measured by dichlorofluorescein fluorescence using confocal microscopy and was inhibited by transfection of antisense against NADPH subunits p22phox or p47phox or with Tempol. F-actin disassembly was observed by dual-channel confocal fluorescence imaging. PI3 kinase activity was detected by immunoblotting of phosphorylated Akt.
In high glucose, generation of NADPH oxidase-dependent ROS was dependent on PKC-ζ. Conversely, sustained PKC-ζ activity was dependent on ROS generation, suggesting a positive feedback. PKC-ζ-dependent F-actin disassembly in high glucose required ROS generation. PDGF stimulated NADPH oxidase generation of ROS through a PKC-ζ mechanism that was independent of Akt phosphorylation and remained unchanged in high glucose.
In high glucose, mesangial cell PKC-ζ is required for ROS generation from NADPH oxidase similar to PDGF stimulation of PKC-ζ-dependent ROS generation through a pathway independent of PI3 kinase. F-actin disassembly in high glucose also requires ROS. A positive feedback loop occurs between ROS and the activation of PKC-ζ in high glucose.
Increased flux through the hexosamine biosynthesis pathway (HBP) has been shown to stimulate the expression of a number of genes. We previously demonstrated in glomerular mesangial and endothelial ...cells that both high glucose concentrations and glucosamine activated the plasminogen activator inhibitor-1 (PAI-1) gene promoter through the transcription factor, Sp1; and that the glutamine:fructose-6-phosphate amidotransferase inhibitor, 6-diazo-5-oxonorleucine, inhibited the effect of high glucose, but not that of glucosamine. Here, we examined the role of protein kinase C (PKC) isoforms in the regulation of the PAI-1 promoter and Sp1 transcriptional activity by the HBP. In transient transfections, exposure to 2 mm glucosamine or 20 mmglucose for 4 days increased the activities of a PAI-1 promoter-luciferase reporter gene as well as the Sp1 transcriptional activation domain fused to the GAL4 DNA-binding domain cotransfected with a GAL4 promoter-luciferase reporter. Cotransfected dominant negative PKC-βI and -δ completely blocked the induction of PAI-1 promoter transcription by both sugars, whereas only dominant negative PKC-βI interfered with Sp1-GAL4 activation. Both glucosamine and high glucose stimulated the in vitro kinase activity of immunoprecipitated PKC-βI and -δ. Furthermore, 6-diazo-5-oxonorleucine suppressed high glucose-induced PKC kinase activity and Sp1-GAL4 transcriptional activation. These findings demonstrate a requirement for the PKC-βI and -δ signal transduction pathways in HBP-induced transcription.
Vena cava filters represent an alternative treatment option for patients with contraindications to anticoagulation, or they might serve as adjunctive treatment for continued emboli despite ...anticoagulation. The fracture of a filter strut with subsequent end-organ embolization is a rarely reported but potentially life-threatening occurrence.
We sought to determine the prevalence of fracture and embolization of the Bard Recovery (first generation) and the Bard G2 (second generation) vena cava filters. A retrospective, single-center, cross-sectional study was conducted by evaluating all patients who received either a Bard Recovery or Bard G2 filter from April 2004 until January 2009. A total of 189 patients had undergone implantation: 1 pregnant woman and 35 patients who died were excluded from our study. In addition, 10 patients who had the filter removed were also excluded. Ultimately, 80 patients participated in the trial. Subjects underwent fluoroscopy to assess the filter's integrity. Embolized struts were localized by fluoroscopy. Echocardiography and cardiac computed tomography were performed in patients with fragment embolization to the heart.
Thirteen of 80 patients had at least 1 strut fracture (16%). At least 1 strut in 7 of the 28 Bard Recovery filters fractured and embolized (25%). In 5 of these 7 cases, patients had at least 1 fragment embolize to the heart (71%). Three patients experienced life-threatening symptoms of ventricular tachycardia and/or tamponade, including 1 patient who experienced sudden death at home. Six of 52 Bard G2 filters fractured (12%). In 2 of these 6 cases, the patients had asymptomatic end-organ fragment embolization.
The Bard Recovery and Bard G2 filters had high prevalences of fracture and embolization, with potentially life-threatening sequelae.
High glucose (HG) is the underlying factor contributing to long term complications of diabetes mellitus. The molecular mechanisms transforming the glomerular mesangial cell phenotype to cause ...nephropathy including diacylglycerol-sensitive protein kinase C (PKC) are still being defined. Reactive oxygen species (ROS) have been postulated as a unifying mechanism for HG-induced complications. We hypothesized that in HG an interaction between ROS generation, from NADPH oxidase, and PKC suppresses mesangial Ca2+ signaling in response to endothelin-1 (ET-1). In primary rat mesangial cells, growth-arrested (48 h) in 5.6 mm (NG) or 30 mm (HG) glucose, the total cell peak Ca2+ i response to ET-1 (50 nm) was 630 ± 102 nm in NG and was reduced to 159 ± 15 nm in HG, measured by confocal imaging. Inhibition of PKC with phorbol ester down-regulation in HG normalized the ET-1-stimulated Ca2+ i response to 541 ± 74 nm. Conversely, an inhibitory peptide specific for PKC-ζ did not alter Ca2+ signaling in HG. Furthermore, overexpression of conventional PKC-β or novel PKC-δ in NG diminished the Ca2+ i response to ET-1, reflecting the condition observed in HG. Likewise, catalase or p47 phox antisense oligonucleotide normalized the Ca2+ i response to ET-1 in HG to 521 ± 58 nm and 514 ± 48 nm, respectively. Pretreatment with carbonyl cyanide m-chlorophenylhydrazone or rotenone did not restore Ca2+ signaling in HG. Detection of increased intracellular ROS in HG by dichlorofluorescein was inhibited by catalase, diphenyleneiodonium, or p47 phox antisense oligonucleotide. HG increased p47 phox mRNA by 1.7 ± 0.1-fold as measured by reverse transcriptase-PCR. In NG, H2O2 increased membrane-enriched PKC-β and -δ, suggesting activation of these isozymes. HG-enhanced immunoreactivity of PKC-δ visualized by confocal imaging was attenuated by diphenyleneiodium chloride. Thus, mesangial cell Ca2+ i signaling in response to ET-1 in HG is attenuated through an interaction mechanism between NADPH oxidase ROS production and diacylglycerol-sensitive PKC.
The purpose of this study was to evaluate the adequacy of the International Classification of Nursing Practice (1) (ICPN) Version 1.0 as a representational model for nursing assessment documentation.
...To identify representational requirements of nursing assessments, the authors mapped key concepts and semantic relations extracted from standardized and local nursing admission assessment documentation forms/templates and inpatient admission assessment records to the ICNP. Next, they expanded the list of ICNP semantic relations with those obtained from the admission assessment forms/templates. The expanded ICNP semantic relations were then validated against the semantic relations identified from an additional set of admission assessment records and a set of 300 randomly selected North American Nursing Diagnosis Association defining characteristic phrases. The concept coverage of the ICNP was evaluated by mapping the concepts extracted from these sources to the ICNP concepts. The UMLS Methathesaurus was then used to map concepts without exact matches to other American Nursing Association (ANA) recognized terminologies.
The authors found that along with the 30 existing ICNP semantic relations, an additional 17 are required for the ICNP to function as a representational model for nursing assessment documentation. Eight hundred and five unique assessment concepts were extracted from all sources. Forty-three percent of these unique assessment concepts had exact matches in the ICNP. An additional 20% had matches in the ICNP classified as narrower, broader, or "other." Of the concepts without exact matches in the ICNP, 81% had exact matches found in other ANA recognized terminologies.
The broad concept coverage and the logic-based structure of the ICNP make it a flexible and robust standard. The ICNP provides a framework from which to capture and reuse atomic level data to facilitate evidence-based practice.
Increased flux through the hexosamine biosynthetic pathway is associated with altered gene expression. To investigate the underlying mechanisms, we treated glomerular mesangial cells with glucosamine ...and studied the regulation of the plasminogen activator inhibitor (PAI)-1 gene. Incubating mesangial cells with 2 mmol/l glucosamine for 4 days resulted in a 3.1+/-0.4-fold increase in PAI-1 mRNA levels (P < 0.01) and a 33+/-9-fold increase in the activity of a transiently transfected PAI-1 promoter-luciferase reporter gene (P < 0.01). Cotransfection of an expression vector for a dominant-negative type II TGF-beta receptor with the PAI-1 promoter-reporter gene did not interfere with this effect of glucosamine. However, mutation of 2 putative Sp1 sites in the PAI-1 promoter, at -76 to -71 and -44 to -39, markedly reduced induction of PAI-1 luciferase activity by glucosamine, from 8.9+/-1.9-fold to 1.7+/-0.5-fold (P < 0.01). An electrophoretic mobility shift assay demonstrated that glucosamine increased Sp1 DNA binding by 31+/-11% (P < 0.05), implying that the effects of glucosamine were explained, in part, by changes in Sp1 DNA binding. High glucose (20 mmol/l) also activated the transiently transfected PAI-1 promoter (2.5+/-0.4-fold). This effect was diminished by mutation of both the PAI-1 promoter Sp1 sites (1.2+/-0.3-fold, P < 0.05). In addition, 6-diazo-5-oxo-L-norleucine, a glutamine:fructose-6-phosphate-amidotransferase inhibitor, blocked the induction by high glucose (4.7+/-0.8- to 0.9+/-0.1-fold, P < 0.01). These results indicate that stimulation of the PAI-1 promoter by both high glucose and glucosamine involves Sp1 and that the hexosamine pathway may be involved in the regulation of gene expression by high glucose in glomerular mesangial cells.
Objectives. In 1996, the U.S. Congress passed legislation making female genital mutilation/cutting (FGM/C) illegal in the United States. CDC published the first estimates of the number of women and ...girls at risk for FGM/C in 1997. Since 2012, various constituencies have again raised concerns about the practice in the United States. We updated an earlier estimate of the number of women and girls in the United States who were at risk for FGM/C or its consequences. Methods. We estimated the number of women and girls who were at risk for undergoing FGM/C or its consequences in 2012 by applying country-specific prevalence of FGM/C to the estimated number of women and girls living in the United States who were born in that country or who lived with a parent born in that country. Results. Approximately 513,000 women and girls in the United States were at risk for FGM/C or its consequences in 2012, which was more than three times higher than the earlier estimate, based on 1990 data. The increase in the number of women and girls younger than 18 years of age at risk for FGM/C was more than four times that of previous estimates. Conclusion. The estimated increase was wholly a result of rapid growth in the number of immigrants from FGM/C-practicing countries living in the United States and not from increases in FGM/C prevalence in those countries. Scientifically valid information regarding whether women or their daughters have actually undergone FGM/C and related information that can contribute to efforts to prevent the practice in the United States and provide needed health services to women who have undergone FGM/C are needed.
Hyperglycemia augments flux through the hexosamine biosynthetic pathway and subsequent O-linkage of single β-N-acetyl-d-glucosamine moieties to serine and threonine residues on cytoplasmic and ...nuclear proteins (O-GlcNAcylation). Perturbations in this posttranslational modification have been proposed to promote glomerular matrix accumulation in diabetic nephropathy, but clear evidence and mechanism are lacking. We tested the hypothesis that O-GlcNAcylation enhances profibrotic signaling in rat mesangial cells. An adenovirus expressing shRNA directed against O-GlcNAc transferase (OGT) markedly reduced basal and high-glucose-stimulated O-GlcNAcylation. Interestingly, O-GlcNAc depletion prevented high-glucose-induced p38 mitogen-activated protein kinase (MAPK) and c-Jun NH(2)-terminal kinase phosphorylation. Downstream of p38, O-GlcNAc controlled the expression of plasminogen activator inhibitor-1, fibronectin, and transforming growth factor-β, important factors in matrix accumulation in diabetic nephropathy. Treating mesangial cells with thiamet-G, a highly selective inhibitor of O-GlcNAc-specific hexosaminidase (O-GlcNAcase), increased O-GlcNAcylation and p38 phosphorylation. The high-glucose-stimulated kinase activity of apoptosis signal-regulating kinase 1 (ASK1), an upstream MAPK kinase kinase for p38 that is negatively regulated by Akt, was inhibited by OGT shRNA. Akt Thr(308) and Ser(473) phosphorylation were enhanced following OGT shRNA expression in high-glucose-exposed mesangial cells, but high-glucose-induced p38 phosphorylation was not attenuated by OGT shRNA in cells pretreated with the phosphatidylinositol 3-kinase inhibitor LY-294002. OGT shRNA also reduced high-glucose-stimulated reactive oxygen species (ROS) formation. In contrast, diminished O-GlcNAcylation caused elevated ERK phosphorylation and PKCδ membrane translocation. Thus, O-GlcNAcylation is coupled to profibrotic p38 MAPK signaling by high glucose in part through Akt and possibly through ROS.
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