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Introduction: Intra-abdominal infections are becoming increasingly common and can lead to significant morbidity and mortality. The incidence of these infections due to resistant gram-negative organisms is also increasing. Given this resistance, new antibiotic combinations are being developed, often utilizing older antibiotics and newer β-lactamase inhibitors. Aztreonam/avibactam (ATM-AVI) is one of the combination antibiotics, which combines aztreonam, a monobactam, with avibactam, a broad-spectrum β-lactamase inhibitor for the treatment of complicated intra-abdominal infections in combination with metronidazole., Areas Covered: In this drug evaluation manuscript, we provide an overview of intra-abdominal infections and an overview of currently available antimicrobial agents used to treat these infections. ATM-AVI is introduced, including chemistry, pharmacodynamics, pharmacokinetics and clinical studies of this compound., Expert Opinion: There are limited treatment options for complicated intra-abdominal infections due to resistant gram-negative organisms, especially those with metallo-β-lactamases. One treatment option for these infections is ATM-AVI, which was recently approved in Europe, in addition to metronidazole. These bacteria are difficult to treat, and this new compound is a safe and effective option for empiric treatment in places with a high incidence of infections due to these bacteria, and also treatment for infections when these resistant bacteria are isolated in culture.

Background: The appropriate third-line vasopressor in septic shock patients receiving norepinephrine and vasopressin is unknown. Angiotensin-II (AT-II) offers a unique mechanism of action to traditionally used vasopressors in septic shock., Objective: The objective of this study was to compare the clinical efficacy and safety of third-line AT-II to epinephrine in patients with septic shock., Methods: A single-center, retrospective cohort study of critically ill patients was performed between April 1, 2019 and July 31, 2022. Propensity-matched (2:1) analysis compared adults with septic shock who received third-line AT-II to controls who received epinephrine following norepinephrine and vasopressin. The primary outcome was clinical response 24 hours after third-line vasopressor initiation. Additional efficacy and safety outcomes were investigated., Results: Twenty-three AT-II patients were compared with 46 epinephrine patients. 47.8% of AT-II patients observed a clinical response at hour 24 compared with 28.3% of epinephrine patients ( P = 0.12). In-hospital mortality (65.2% vs 73.9%, P = 0.45), cardiac arrhythmias (26.1% vs 26.1%, P = 0.21), and thromboembolism (4.3% vs 2.2%, P = 0.61) were not observed to be statistically different between groups., Conclusions and Relevance: Administration of AT-II as a third-line vasopressor agent in septic shock patients was not associated with significantly improved clinical response at hour 24 compared with epinephrine. Although underpowered to detect meaningful differences, the clinical observations of this study warrant consideration and further investigation of AT-II as a third-line vasopressor in septic shock., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: KDB discloses being a member of La Jolla Pharmaceutical Company’s speakers bureau at the time this work was completed. KDB is a current employee of Innoviva Specialty Therapeutics. GAG discloses being a member of the speakers bureau for AstraZeneca. All other authors have no relevant disclosures.

Objective: The objective was to determine the mean duration of diagnosis delay for patients with myasthenia gravis from five European countries and explore the impact of >1 year diagnosis delay., Methods: Patients with myasthenia gravis (N = 387) from Europe (France/Germany/Italy/Spain/United Kingdom) and their physicians participated in the Adelphi Real World Myasthenia Gravis Disease Specific Programme™. Diagnosis delay (time from symptom onset to diagnosis) was calculated and characteristics described for patients experiencing >1 year and ≤1 year diagnosis delay. Denominators varied according to outcome as missing data were not imputed., Results: Mean (standard deviation) diagnosis delay was 363.1 (520.9) days, and 27.1% (105 out of 387) of patients experienced diagnosis delay >1 year. Among patients with >1 year and ≤1 year diagnosis delay, respectively, 69.2% (72 out of 104) and 17.4% [45 out of 259] had initially received a different diagnosis (physician-reported); 40.0% (42 out of 105) and 24.1% (68 out of 282) were Myasthenia Gravis Foundation of America class III at the time of the survey (physician-reported); 72.4% (76 out of 105) and 61.3% (173 out of 282) had fatigue (subjective physician reporting from a pre-selected list of symptoms); 30.5% (32 out of 105) and 17.4% (49 out of 282) had anxiety and 21.9% (23 out of 105) and 13.1% (37 out of 282) had depression (both subjective physician reporting from a pre-selected list, Likert-style); and mean (standard deviation) MG-QoL-15r score was 14.4 (5.50) and 12.6 (7.84) (self-reported by N = 43 and N = 74 patients, respectively)., Interpretation: More than a quarter of patients with myasthenia gravis experienced diagnosis delay of >1 year. These patients had a different clinical profile with regards to severity, symptoms, comorbidities and MG-QoL-15r score, compared with patients experiencing ≤1 year diagnosis delay., (© 2024 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background: Adjunctive vasopressin use in septic shock reduces catecholamine requirements and is associated with a lower incidence of new-onset arrhythmias (NOAs). The association of vasopressin timing on NOA development is ill-described. Objective: To determine whether early administration of vasopressin was associated with a lower incidence of NOA in septic shock patients. Methods: A retrospective analysis of intensive care unit (ICU) patients at a large, academic medical center. Septic shock patients who required vasopressin and norepinephrine were eligible for inclusion. Patients were excluded for receipt of other vasoactive agents, history of cardiac arrhythmias, or outside hospital admission. Early vasopressin was defined as receipt within 6 hours of septic shock onset. The primary outcome was incidence of NOA. Results : In total, 436 patients, 220 (50.4%) in the early and 216 (49.6%) in the late vasopressin group, were included. Early vasopressin was not associated with a lower incidence of NOA compared with late vasopressin (9% vs 7%, median absolute difference [95% confidence interval, CI]: -2.1 [-7.2, 3.0], P = 0.41). Early vasopressin patients were observed to have shorter shock duration (2 vs 4 days, median absolute difference [95% CI]: 2 [1, 2], P < 0.001), and ICU length of stay (6 vs 7 days, median absolute difference [95% CI]: 1 [0, 2], P = 0.02). Conclusions and Relevance: Early vasopressin use was not associated with a lower incidence of NOA. Additional studies are needed to elucidate the effect of vasopressin timing on NOA and other clinical outcomes., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K.D.B. discloses being a member of La Jolla Pharmaceutical Company’s speaker’s bureau. M.H.K.’s research efforts are supported by the Barnes-Jewish Hospital Foundation.

Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: KDB discloses being a member of La Jolla Pharmaceutical Company’s speakers bureau. MHK’s research efforts are supported by the Barnes-Jewish Hospital Foundation.

Objectives: A number of trials related to critical care pharmacotherapy were published in 2022. We aimed to summarize the most influential publications related to the pharmacotherapeutic care of critically ill patients in 2022., Data Sources: PubMed/Medical Literature Analysis and Retrieval System Online and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update., Study Selection: Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critically ill patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2022, and December 31, 2022, were included in this article., Data Extraction: Articles from a systematic search and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update were included and stratified into clinical domains based upon consistent themes. Consensus was obtained on the most influential publication within each clinical domain utilizing an a priori defined three-round modified Delphi process with the following considerations: 1) overall contribution to scientific knowledge and 2) novelty to the literature., Data Synthesis: The systematic search and Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update yielded a total of 704 articles, of which 660 were excluded. The remaining 44 articles were stratified into the following clinical domains: emergency/neurology, cardiovascular, gastroenterology/fluids/nutrition, hematology, infectious diseases/immunomodulation, and endocrine/metabolic. The final article selected from each clinical domain was summarized following a three-round modified Delphi process and included three randomized controlled trials and three systematic review/meta-analyses. Article topics summarized included dexmedetomidine versus other sedatives during mechanical ventilation, beta-blocker treatment in the critically ill, restriction of IV fluids in septic shock, venous thromboembolism prophylaxis in critically ill adults, duration of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia, and low-dose methylprednisolone treatment in severe community-acquired pneumonia., Conclusions: This concise review provides a perspective on articles published in 2022 that are relevant to the pharmacotherapeutic care of critically ill patients and their potential impact on clinical practice., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Open-access publishing promotes accessibility to scholarly research at no cost to the reader. The emergence of predatory publishers, which exploit the author-pay model by charging substantial publication fees for publication in journals with questionable publishing processes, is on the rise. Authors are solicited through aggressive marketing tactics, though who is targeted is not well described. The purpose of this study was to identify characteristics associated with critical care pharmacists that make them targets of unsolicited invitations to publish. A prospective, observational study of critical care pharmacists was performed. Participants archived emails received by their professional email that were unsolicited invitations to submit their original work for publication in a journal (unsolicited journals). Variables were evaluated to determine which were associated with unsolicited invitations; these were compared to legitimate journals, defined as all PubMed-indexed journals in which the participants were previously published. Twenty-three pharmacist participants were included, all of whom were residency and/or fellowship trained and practicing in an academic medical center. Participants had a median of 7 years of experience since their post-graduate training, 6 years since their last change in professional email address, and 2 years since their first PubMed-indexed publication. From these participants, 136 unsolicited and 59 legitimate journals were included. The average number of invitations increased 1.04 (95% CI, 1.02-1.05) times for every additional PubMed-indexed publication ( P < .001). Most unsolicited journals were considered predatory. Legitimate and unsolicited journals differed significantly. The number of previous PubMed-indexed publications strongly correlates with the likelihood of critical care pharmacists receiving unsolicited publication invitations, often from predatory journal.

In critically ill patients, the gut microbiota is subjected to various factors including antimicrobial exposure, modified gastrointestinal transit, nutrition support, as well as infection, which may lead to dysbiosis during the intensive care unit and hospital stay. Dysbiosis occupies an increasingly important role in driving morbidity and perhaps mortality in the critically ill or injured. Given that antibiotics lead to dysbiosis, it is relevant to understand the range of non-antibiotic approaches to infection-including those related to multi-drug-resistant organisms-that may leave the microbiome unimpacted. These strategies most prominently include the elimination of unabsorbed antibiotic agents from the digestive tract, pro-/pre-/synbiotics, fecal microbiota transplant, selective digestive and oropharyngeal decontamination, phage therapy, anti-sense oligonucleotides, structurally nanoengineered antimicrobial peptide polymers, and vitamin C-based lipid nanoparticles for adoptive macrophage transfer. Herein, we review the rationale for these therapies, current data regarding their use in critically ill patients, and the therapeutic potential for strategies that are not yet deployed in human medical care.

Introduction: Myasthenia gravis (MG) is a rare, debilitating, chronic disorder caused by the production of pathogenic immunoglobulin G autoantibodies against the neuromuscular junction. A lack of real-world studies in rare diseases reflects a relatively limited understanding of the significant unmet needs and burden of disease for patients. We aimed to provide comprehensive real-world insights into the management and burden of MG from treating physicians in the United States (US)., Methods: Data were collected using the Adelphi Real World MG Disease Specific Programme™, a point-in-time survey of physicians and their patients with MG, in the US between March and July 2020. Physician-reported clinical data, including demographics, comorbidities, symptoms, disease history, treatments, and healthcare resource utilization, were collected., Results: In total, 456 patient record forms were completed by 78 physicians based in the US. At time of survey completion, patient mean age was 54.5 years. Mean time from symptom onset to diagnosis was 9.0 months (n = 357). Ocular symptoms were reported in 71.7% of patients. General fatigue affected 47.1% of patients and over half of those reported the severity as moderate or severe (59.5%, n = 128). Acetylcholinesterase inhibitors and/or steroids were the most frequently prescribed first-line treatment type among patients receiving treatment at time of survey completion and with moderate-to-severe symptoms (77.9%, n = 159/204). High-dose steroids (n = 14) and intravenous immunoglobulin (n = 13) were the most prescribed acute treatments among those receiving an acute treatment at time of survey completion (n = 36), with symptom exacerbations or myasthenic crises being the most common reasons for acute treatment. On average, 2.5 healthcare professionals were involved in patient management and 5.0 consultations were made per patient over the last 12 months., Conclusions: Our findings indicated that, despite treatment, there is a proportion of patients with MG in the US who had a significant need for improved disease management., (© 2022. The Author(s).)

Sickle cell disease (SCD) was once a disease of childhood because of a limited life expectancy. Due to medical advances, it is now common for people with SCD to live into adulthood. Funding and resources for adults with SCD, however, remain limited. Adult patients would benefit from increased access to medical care, mental health care services, and workforce development. The Indiana Sickle Cell Consortium, a group of medical providers and community-based organizations, worked closely with people living with SCD and their family members to create a campaign advocating for state funding for programs for adults with SCD. This campaign culminated with the passage of a bill that provides $250,000 in funding for program development for adults with SCD. The bill also directs the Indiana Department of Health to carry out a needs assessment for people with SCD in Indiana. However, continued efforts are needed to reduce health disparities for people with SCD. The Indiana Sickle Cell Consortium will continue advocacy efforts in future legislative cycles and bring attention to the health inequities that affect people with SCD.

Purpose: Patients presenting with life-threatening bleeding associated with oral anticoagulants (OACs) are challenging with few available treatments. Prothrombin complex concentrate (PCC) is an option for OAC reversal in the setting of life-threatening bleeding with a relatively benign safety profile. Little is known about the risk of developing thromboembolic complications (TEC) in patients receiving PCC who were previously anticoagulated. The aim of this study is to characterize the rate of TEC after receipt of PCC. Methods: All adult patients who received 4-Factor PCC for life-threatening bleeding were retrospectively evaluated over a 2-year time period. Data collected included anticoagulant and indication, bleeding source, PCC dose, INR, and TEC within 14 days of PCC dose, including venous thromboembolism (VTE), acute myocardial infarction, and ischemic stroke. Results: Three hundred thirty-three patients received 383 PCC doses. Of these, 55 (16.5%) patients developed TEC, including VTE, ischemic stroke, and acute myocardial infarction. There was increased rivaroxaban use in patients who developed TEC (25.4% vs 12.2%; P  = .011). Additionally, there were more patients who had anticoagulation for a previous TEC in those who developed a new TEC (38.2% vs 23.4%; P  = .022). Lastly, there was a higher rate of TEC in those who received >1 dose of PCC (21.8% vs 7.9%; P  = .002). Conclusion: PCC administration in the setting of life-threatening bleeding is not benign. Risk of TEC increases in patients who have rivaroxaban reversal, receive a repeat dose of PCC, and have a TEC indication for their anticoagulation and these factors should be further investigated., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Emily J. Owen and Gabrielle A. Gibson are on speakers bureau for Portola Pharmaceuticals, LLC., (© The Author(s) 2020.)

Background: No clear association between standard vasopressin doses and body mass index exists, despite potential pharmacokinetic and pharmacodynamic variability among patients with septic shock. It is unknown if higher doses may alter hemodynamic response., Objective: The purpose of this study was to evaluate the effect of vasopressin dose on hemodynamic response in obese patients with septic shock., Methods: A single-center, retrospective cohort study was conducted in adult, obese patients with septic shock receiving catecholamine vasopressors and vasopressin. Patients were analyzed according to vasopressin dose received: standard dose (≤0.04 U/min) and high dose (>0.04 U/min). The primary outcome was percentage change in norepinephrine equivalent (NEQ) dose., Results: A total of 182 patients were included in the analysis, with 136 in the standard-dose vasopressin group and 46 in the high-dose vasopressin group. There was no difference in percentage change in NEQ dose at 6 hours after standard- or high-dose vasopressin attainment (-28.6% vs -19.1%; P = 0.166). A greater increase in mean arterial pressure (MAP) at 6 hours was observed with receipt of high-dose vasopressin (23.3% vs 15.3%; P = 0.023). Duration of shock and length of stay were significantly longer in patients who received high-dose vasopressin, with no difference in in-hospital mortality., Conclusion and Relevance: This represents the first analysis comparing standard and higher doses of vasopressin in obese patients with septic shock. Receipt of high-dose vasopressin was not associated with a difference in catecholamine requirement or improved outcomes. Further studies are warranted to provide guidance on the use of high-dose vasopressin in septic shock.

Objective: To describe the use of amiodarone in critically ill, septic shock patients experiencing new-onset atrial fibrillation (NOAF) during the acute resuscitative phase of septic shock. Methods: Single-center, retrospective review of adult medical or surgical intensive care unit (ICU) patients with septic shock and NOAF. All patients received amiodarone for NOAF during the acute resuscitative phase of septic shock. The cohort was analyzed via descriptive statistics. Associations between amiodarone exposure and clinical outcomes were analyzed via a Cox proportional-hazards model. An a priori defined sensitivity analysis of hospital survivors was also employed. Main Results: A total of 239 patients were included in the analysis. Patients had a median baseline Charlson Comorbidity Index of 4 (interquartile range [IQR]: 2-6) and were acutely ill with a median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 18 (IQR: 13-22) and an incidence of mechanical ventilation of 85%. In-hospital mortality was 56% with median ICU and hospital length of stay (LOS) of 9 and 15 days, respectively. Included patients received a median of 2760 (IQR: 1110-6415) mg of intravenous (IV) amiodarone during their ICU stay. Receipt of more than or equal to 2700 mg of amiodarone was identified as an independent factor associated with longer ICU LOS (hazard ratio [HR]: 1.30; 95% confidence interval [CI], 1.10-2.28). In a sensitivity analysis of hospital survivors (n = 105), receipt of more than or equal to 2700 mg of amiodarone remained independently associated with longer ICU LOS (HR: 1.64; 95% CI, 1.05-2.58). Conclusions: Exposure to more than or equal to 2700 mg of amiodarone in the setting of NOAF and septic shock is positively correlated with longer ICU LOS. Identifying opportunities to limit amiodarone exposure and address/resolve potential precipitating causes of NOAF in this clinical scenario may reduce the morbidity associated with septic shock., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

The development of a fluorescent probe for a specific metal has required exquisite design, synthesis, and optimization of fluorogenic molecules endowed with chelating moieties with heteroatoms. These probes are generally chelation- or reactivity-based. Catalysis-based fluorescent probes have the potential to be more sensitive; however, catalytic methods with a biocompatible fluorescence turn-on switch are rare. Here, we have exploited ligand-accelerated metal catalysis to repurpose known fluorescent probes for different metals, a new approach in probe development. We used the cleavage of allylic and propargylic ethers as platforms that were previously designed for palladium. After a single experiment that combinatorially examined >800 reactions with two variables (metal and ligand) for each ether, we discovered a platinum- or copper-selective method with the ligand effect of specific phosphines. Both metal-ligand systems were previously unknown and afforded strong signals owing to catalytic turnover. The fluorometric technologies were applied to geological, pharmaceutical, serum, and live cell samples and were used to discover that platinum accumulates in lysosomes in cisplatin-resistant cells in a manner that appears to be independent of copper distribution. The use of ligand-accelerated catalysis may present a new blueprint for engineering metal selectivity in probe development., Competing Interests: The authors declare no competing financial interest.

Decreased cerebral blood flow (CBF) after cardiac arrest (CA) contributes to secondary ischemic injury in infants and children. We previously reported cortical hypoperfusion with tissue hypoxia early in a pediatric rat model of asphyxial CA. In order to identify specific alterations as potential therapeutic targets to improve cortical hypoperfusion post-CA, we characterize the CBF alterations at the cortical microvascular level in vivo using multiphoton microscopy. We hypothesize that microvascular constriction and disturbances of capillary red blood cell (RBC) flow contribute to cortical hypoperfusion post-CA. After resuscitation from 9 min asphyxial CA, transient dilation of capillaries and venules at 5 min was followed by pial arteriolar constriction at 30 and 60 min (19.6 ± 1.3, 19.3 ± 1.2 µm at 30, 60 min vs. 22.0 ± 1.2 µm at baseline, p < 0.05). At the capillary level, microcirculatory disturbances were highly heterogeneous, with RBC stasis observed in 25.4% of capillaries at 30 min post-CA. Overall, the capillary plasma mean transit time was increased post-CA by 139.7 ± 51.5%, p < 0.05. In conclusion, pial arteriolar constriction, the no-reflow phenomenon and increased plasma transit time were observed post-CA. Our results detail the microvascular disturbances in a pediatric asphyxial CA model and provide a powerful platform for assessing specific vascular-targeted therapies.

Background: The glymphatic system is a proposed pathway for clearance of proteins and macromolecules from brain, and disrupted glymphatic flux is implicated in neurological disease. We capitalized on colorimetric, fluorescent, and protein-binding properties of Evans blue to evaluate glymphatic flux., New Method: Twenty-five μL of 1% Evans blue-labeled albumin (EBA) in artificial cerebrospinal fluid (aCSF) was injected into the intracisternal space of anesthetized postnatal day 17 rats. Serum was collected at various time points after injection (n = 37) and EBA was measured spectrophotometrically. In separate rats (n = 3), a cranial window was placed over the parietal cortex and EBA transit was evaluated using in vivo multiphoton microscopy. Separate rats (n = 6) were processed for immunohistochemistry to examine localization of EBA. In some rats, intracranial pressure (ICP) was increased via intracisternal injection of aCSF., Results: EBA was detected in serum as early as 30 min, was maximal at 4 h, and was undetectable at 72 h after intracisternal injection. Using intra-vital microscopy and immunohistochemistry EBA could be tracked from CSF to perivascular locations. Consistent with removal via glymphatic flux, increasing ICP to 40 mmHg accelerated transit of EBA from CSF to blood., Comparison With Existing Methods: Transit of EBA from CSF to serum could be quantified spectrophotometrically without radioactive labeling. Glymphatic flux could also be qualitatively evaluated using EBA fluorescence., Conclusion: We present a novel technique for simultaneous quantitative and qualitative evaluation of glymphatic flux in rats., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Biologic tissues are generally opaque due to optical properties that result in scattering and absorption of light. Preparation of tissues for optical microscopy often involves sectioning to a thickness of 50-100 µm, the practical limits of light penetration and recovery. A researcher who wishes to image a whole tissue must acquire potentially hundreds of individual sections before rendering them into a three-dimensional volume. Clearing removes strongly light-scattering and light-absorbing components of a tissue and equalizes the refractive index of the imaging medium to that of the tissue. After clearing, the maximum depth of imaging is often defined by the microscope optics rather than the tissue. Such visibility enables the interrogation of whole tissues and even animals without the need to section. Researchers can study a biological process in the context of its three-dimensional environment, identify rare events in large volumes of tissues, and trace cells and cell-cell interactions over large distances. This article describes four popular clearing protocols that are relevant to a wide variety of scenarios across biologic disciplines: CUBIC, CLARITY, 3DISCO, and SeeDB. © 2018 by John Wiley & Sons, Inc., (© 2018 John Wiley & Sons, Inc.)

Background: Hydractinia symbiolongicarpus, a colonial cnidarian, is a tractable model system for many cnidarian-specific and general biological questions. Until recently, tests of gene function in Hydractinia have relied on laborious forward genetic approaches, randomly integrated transgenes, or transient knockdown of mRNAs., Results: Here, we report the use of CRISPR/Cas9 genome editing to generate targeted genomic insertions in H. symbiolonigcarpus. We used CRISPR/Cas9 to promote homologous recombination of two fluorescent reporters, eGFP and tdTomato, into the Eukaryotic elongation factor 1 alpha (Eef1a) locus. We demonstrate that the transgenes are expressed ubiquitously and are stable over two generations of breeding. We further demonstrate that CRISPR/Cas9 genome editing can be used to mark endogenous proteins with FLAG or StrepII-FLAG affinity tags to enable in vivo and ex vivo protein studies., Conclusions: This is the first account of CRISPR/Cas9 mediated knockins in Hydractinia and the first example of the germline transmission of a CRISPR/Cas9 inserted transgene in a cnidarian. The ability to precisely insert exogenous DNA into the Hydractinia genome will enable sophisticated genetic studies and further development of functional genomics tools in this understudied cnidarian model.

This study aimed to quantify biometric modifications of the anterior segment (AS) during accommodation and to compare them against changes in both accommodative demand and response. Thirty adults, aged 18-25 years were rendered functionally emmetropic with contact lenses. AS optical coherence tomography (AS-OCT) images were captured along the 180° meridian (Visante, Zeiss Meditec, Jena, Germany) under stimulated accommodative demands (0-4 D). Images were analysed and lens thickness (LT) was measured, applying a refractive index correction of 1.00. Accommodative responses were also measured sequentially through a Badal optical system fitted to an autorefractor (Shin Nippon NVision-K 5001, Rexxam, Japan). Data were compared with Dubbelman schematic eye calculations. Significant changes occurred in LT, anterior chamber depth (ACD), lens centroid (i.e., ACD + LT/2), and AS length (ASL = ACD + LT) with accommodation (all p < 0.01). There was no significant change in CT with accommodation ( p = 0.81). Measured CT, ACD, and lens centroid values were similar to Dubbelman modelled parameters, however AS-OCT overestimated LT and ASL. As expected, the accommodative response was less than the demand. Interestingly, up until approximately 1.5 D of response (2.0 D demand), the anterior crystalline lens surface appears to be the primary correlate. Beyond this point, the posterior lens surface moves posteriorly resulting in an over-all sigmoidal trajectory. he posterior crystalline lens surface demonstrates a sigmoidal response with increasing accommodative effort.

Critically ill patients with severe infections often have altered pharmacokinetic and pharmacodynamic variables that lead to challenging treatment decisions. These altered variables can often lead to inadequate dosing and poor treatment outcomes. The pharmacokinetic parameters include absorption, distribution, metabolism, and excretion. Pharmacodynamics is the relationship between drug serum concentrations and pharmacologic and toxicologic properties of the medication. In addition to these altered parameters, these critically ill patients frequently are receiving organ support in the forms of continuous renal replacement therapy or extra-corporeal membrane oxygenation. Altered pharmacodynamics can lead to decreased end-organ perfusion, which can ultimately lead to treatment failure or exposure-related toxicity. The most common antimicrobials utilized in the intensive care unit are classified by the pharmacodynamic principles of time-dependent, concentration-dependent, and concentration dependent with time-dependence. Thus, the aim of this review is to outline pharmacokinetic and pharmacodynamic changes of critically ill patients with severe infections and provide strategies for optimal antibiotic agent dosing in these patients.

Current-voltage characteristics of oxide-based resistive switching memories often show a pronounced asymmetry with respect to the voltage polarity in the high resistive state (HRS), where the HRS after the RESET is more conducting than the one before the SET. Here, we report that most of this HRS asymmetry is a volatile effect as the HRS obtained from a read operation differs from the one taken from the switching cycle at identical polarity and voltages. Transitions between the relaxed and the volatile excited states can be achieved via voltage sweeps, which are named subloops. The excited states are stable over time as long as a voltage is applied to the device and have a higher conductance than the stable relaxed state. Experimental data on the time and voltage dependence of the excitation and decay are presented for Ta/TaO x /Pt and Ta/ZrO x /Pt devices. The effect is not limited to one oxide or electrode material but is observed with different magnitudes (up to 10× current change) in several oxide systems. These observations describe an additional state variable of the memristive system that is controlled in a highly polarity dependent manner.

Whole-brain imaging is becoming a fundamental means of experimental insight; however, achieving subcellular resolution imagery in a reasonable time window has not been possible. We describe the first application of multicolor ribbon scanning confocal methods to collect high-resolution volume images of chemically cleared brains. We demonstrate that ribbon scanning collects images over ten times faster than conventional high speed confocal systems but with equivalent spectral and spatial resolution. Further, using this technology, we reconstruct large volumes of mouse brain infected with encephalitic alphaviruses and demonstrate that regions of the brain with abundant viral replication were inaccessible to vascular perfusion. This reveals that the destruction or collapse of large regions of brain micro vasculature may contribute to the severe disease caused by Venezuelan equine encephalitis virus. Visualization of this fundamental impact of infection would not be possible without sampling at subcellular resolution within large brain volumes.

Hepatocellular carcinoma (HCC) patients with reduced natural killer (NK)-cell numbers and function have been shown to have a poor disease outcome. Mechanisms underlying NK-cell deficiency and dysfunction in HCC patients remain largely unresolved. α-Fetoprotein (AFP) is an oncofetal antigen produced by HCC. Previous studies demonstrated that tumor-derived AFP (tAFP) can indirectly impair NK-cell activity by suppressing dendritic cell function. However, a direct tAFP effect on NK cells remains unexplored. The purpose of this study was to examine the ability of cord blood-derived AFP (nAFP) and that of tAFP to directly modulate human NK-cell activity and longevity in vitro Short-term exposure to tAFP and, especially, nAFP proteins induced a unique proinflammatory, IL2-hyperresponsive phenotype in NK cells as measured by IL1β, IL6, and TNF secretion, CD69 upregulation, and enhanced tumor cell killing. In contrast, extended coculture with tAFP, but not nAFP, negatively affected long-term NK-cell viability. NK-cell activation was directly mediated by the AFP protein itself, whereas their viability was affected by hydrophilic components within the low molecular mass cargo that copurified with tAFP. Identification of the distinct impact of circulating tAFP on NK-cell function and viability may be crucial to developing a strategy to ameliorate HCC patient NK-cell functional deficits. Cancer Immunol Res; 5(6); 493-502. ©2017 AACR ., (©2017 American Association for Cancer Research.)

The Neotropical genus Macreupelmus Ashmead (Eupelmidae: Eupelminae) is revised based on females, males being unknown for the genus. The genus is redescribed, its phylogenetic relationships within Eupelminae discussed, and the species keyed, described and illustrated through macrophotography. Nine species are recognized-Macreupelmus auranticrus n. sp., M. aurantispina n. sp., M. brasiliensis Ashmead 1896, M. crassicornis (Cameron 1884), M. dromedarius (Cameron 1884), M. erwini n. sp., M. granulosus n. sp., M. laticlavius n. sp., and M. nigrispina n. sp. Excluded from the genus are Macreupelmus baccharidis Kieffer 1910 (transferred to Brasema Cameron as B. baccharidis (Kieffer) n. comb.), Macreupelmus bekilyi Risbec 1952 (transferred to Reikosiella (Hirticauda Bouček) as Reikosiella (Hirticauda) bekilyi (Risbec) n. comb.), and Macreupelmus pulchriceps Cameron 1905 (transferred to Eupelmus Dalman as E. (Eupelmus) pulchriceps (Cameron) n. comb.). The latter name is recognized as the senior synonym of Cerambycobius cushmani Crawford 1908 n. syn., Cerambycobius townsendi Crawford 1912 n. syn., and Eupelmus cyaniceps amicus Girault 1916 n. syn. Lectotypes are designated for M. brasiliensis, M. dromedarius and E. pulchriceps.

The immune response against transplanted allografts is one of the most potent reactions mounted by the immune system. The acute rejection response has been attributed to donor dendritic cells (DCs), which migrate to recipient lymphoid tissues and directly activate alloreactive T cells against donor MHC molecules. Here, using a murine heart transplant model, we determined that only a small number of donor DCs reach lymphoid tissues and investigated how this limited population of donor DCs efficiently initiates the alloreactive T cell response that causes acute rejection. In our mouse model, efficient passage of donor MHC molecules to recipient conventional DCs (cDCs) was dependent on the transfer of extracellular vesicles (EVs) from donor DCs that migrated from the graft to lymphoid tissues. These EVs shared characteristics with exosomes and were internalized or remained attached to the recipient cDCs. Recipient cDCs that acquired exosomes became activated and triggered full activation of alloreactive T cells. Depletion of recipient cDCs after cardiac transplantation drastically decreased presentation of donor MHC molecules to directly alloreactive T cells and delayed graft rejection in mice. These findings support a key role for transfer of donor EVs in the generation of allograft-targeting immune responses and suggest that interrupting this process has potential to dampen the immune response to allografts.

Lysine acetylation is tightly coupled to the nutritional status of the cell, as the availability of its cofactor, acetyl-CoA, fluctuates with changing metabolic conditions. Recent studies have demonstrated that acetyl-CoA levels act as an indicator of cellular nourishment, and increased abundance of this metabolite can block the induction of cellular recycling programmes. In the present study we investigated the cross-talk between mitochondrial metabolic pathways, acetylation and autophagy, using chemical inducers of mitochondrial acetyl-CoA production. Treatment of cells with α-lipoic acid (αLA), a cofactor of the pyruvate dehydrogenase complex, led to the unexpected hyperacetylation of α-tubulin in the cytosol. This acetylation was blocked by pharmacological inhibition of mitochondrial citrate export (a source for mitochondria-derived acetyl-CoA in the cytosol), was dependent on the α-tubulin acetyltransferase (αTAT) and was coupled to a loss in function of the cytosolic histone deacetylase, HDAC6. We further demonstrate that αLA slows the flux of substrates through autophagy-related pathways, and severely limits the ability of cells to remove depolarized mitochondria through PTEN-associated kinase 1 (PINK1)-mediated mitophagy., (© 2016 The Author(s). published by Portland Press Limited on behalf of the Biochemical Society.)

Purpose: The performance of an updated insulin infusion protocol was evaluated at a large, academic medical center., Methods: A retrospective medical record review was performed after a one-month run-in period for all patients at a large, academic, tertiary care medical center in whom the insulin infusion per protocol was administered from January 1 through February 28, 2014. Data were evaluated to determine the median blood glucose (BG) level, time to achieve BG in the target range, number of BG checks per patient per day, time elapsed between each BG check, and the frequency of hypoglycemia (BG concentration of ≤70 mg/dL)., Results: A total of 170 patients were included. The median preinfusion BG was 244 mg/dL (interquartile range [IQR], 204-304 mg/dL), which decreased to a median of 168 mg/dL (IQR, 147.5-199.5 mg/dL) when the protocol was utilized. However, 70 patients (41%) had a median BG concentration of ≥180 mg/dL, and 25 patients' (15%) BG value remained above 180 mg/dL. The median time to achieve the goal BG value was 4.2 hours (95% confidence interval, 3.2-5.1 hours). BG checks were performed a median of every 2.1 hours (IQR, 1.4-2.3 hours). Hypoglycemia was rare, occurring in only 2 (1.2%) patients., Conclusion: The median BG with an updated insulin infusion protocol approached the upper limit of the target BG range, and 41% of patients had a median BG above the goal range. Protocol specifications for the frequency of BG monitoring were not commonly followed, but the frequency of hypoglycemia was extremely low., (Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Oozetetes lucidus sp. nov. (Hymenoptera: Eupelmidae) is described from Colombia, South America, and through macrophotography compared with all described species in the bucheri species-group of Oozetetes De Santis. An illustrated key modified from Gibson (2004) is provided to distinguish females of the six described species of this group.

One hundred-four extant species of Eupelmus Dalman (Hymenoptera: Eupelmidae: Eupelminae) are recognized from the Palaearctic region, of which 76 species of E. (Eupelmus) are recognized following a revision of the Palaearctic fauna of the subgenus. The following 25 species are described as new: E. (Eupelmus) adustus Gibson & Fusu n. sp., E. (Eupelmus) angustifrons Gibson & Fusu n. sp., E. (Eupelmus) bicolor Gibson & Fusu n. sp., E. (Eupelmus) brachypterus Fusu & Gibson n. sp., E. (Eupelmus) brachystylus Gibson & Fusu n. sp., E. (Eupelmus) brachyurus Fusu & Gibson n. sp., E. (Eupelmus) fasciatus Gibson & Fusu n. sp., E. (Eupelmus) gelechiphagus Gibson & Fusu n. sp., E. (Eupelmus) hayei Gibson & Fusu n. sp., E. (Eupelmus) infimbriatus Gibson & Fusu n. sp., E. (Eupelmus) iris Fusu & Gibson n. sp., E. (Eupelmus) kamijoi Gibson & Fusu n. sp., E. (Eupelmus) lanceolatus Gibson & Fusu n. sp., E. (Eupelmus) luteipes Fusu & Gibson n. sp., E. (Eupelmus) magdalenae Fusu & Gibson n. sp., E. (Eupelmus) mehrnejadi Gibson & Fusu n. sp., E. (Eupelmus) melanostylus Gibson & Fusu n. sp., E. (Eupelmus) punctatifrons Fusu & Gibson n. sp., E. (Eupelmus) setosus Fusu & Gibson n. sp., E. (Eupelmus) tanystylus Gibson & Fusu n. sp., E. (Eupelmus) tetrazostus Gibson & Fusu n. sp., E. (Eupelmus) vanharteni Fusu & Gibson n. sp., E. (Eupelmus) weilli Fusu & Gibson n. sp., E. (Eupelmus) xenium Fusu & Gibson n. sp., and E. (Eupelmus) zebra Fusu & Gibson n. sp. Of previously described species of Eupelmus, 17 are newly assigned to E. (Eupelmus), 10 to E. (Episolindelia Girault), and 8 to E. (Macroneura Walker). Formally transferred to E. (Macroneura) from Macroneura are E. (M.) algiricus (Kalina 1981), E. (M.) coleophorae (Kalina 1981), E. (M.) impennis (Nikol'skaya 1952), E. (M.) longicornis (Kalina 1981), E. (M.) pleuratus (Kalina 1981) and E. (M.) sugonyaevi (Kalina 1981) n. combs. Eupelmus (Eupelmus) kalinai Gibson & Fusu n. name is given to replace E. (Eupelmus) algiricus Kalina 1988, a secondary homonym of E. (M.) algiricus (Kalina 1981). New synonyms proposed are Eupelmus scolyti Liao 1987 n. syn. under E. (Eupelmus) formosae Ashmead 1904, and Eupelmus nigricauda Nikol'skaya 1952 n. syn. under E. (Eupelmus) microzonus Förster 1860. Eupelmus gueneei Giraud 1870 and Eupelmus xambeui Giard 1900 are transferred to Arachnophaga (Parasolindenia Brues) as A. (P.) gueneei (Giraud) and A. (P.) xambeui (Giard) n. combs., and Eupelmus kim Nikol'skaya 1952 is transferred to Brasema Cameron as B. kim (Nikol'skaya) n. comb. Eupelmus puparum Newport 1840 is transferred to Pteromalus Swederus (Pteromalidae) as P. puparum (Newport) n. comb., a secondary homonym of P. puparum (Linnaeus 1758), and Ceraphron brachynterae Schwägrichen 1835 is removed from Eupelmus and Eupelmidae, and the name treated as incertae sedis. Lectotypes are designated for Eupelmus azureus Ratzeburg 1844, Pteromalus cordairii Ratzeburg 1844, Eupelmus hostilis Förster 1860, and Eupelmus splendens Giraud 1872. Neotypes are designated for Pteromalus audouinii Ratzeburg 1844 and Eupelmus bedeguaris Ratzeburg 1852. Newly recorded from the Palaearctic are E. (Eupelmus) orthopterae (Risbec 1951) and E. (Eupelmus) peculiaris Narendran (2011). Excluded from the Palaearctic are E. (Eupelmus) afer Silvestri 1914 (Afrotropical) and E. (Eupelmus) longicorpus (Girault 1915) (Australasian), the former being compared to E. confusus Al khatib 2015 and the latter to E. iranicus Kalina 1988 and E. kalinai. Seven informal species groups are recognized for the purpose of species comparisons, the fulgens-, fulvipes-, iranicus-, orientalis-, splendens-, stramineipes-, and urozonus-groups. The latter group is restricted to E. urozonus Dalman and five other species that were differentiated initially using molecular evidence. Females of all 76 species of E. (Eupelmus) recognized from the Palaearctic are keyed, described and illustrated. Males are recognized for 44 of the species, and keyed and illustrated, though not all males of the fulvipes- and urozonus-groups are distinguished from each other.

Paranastatus Masi, 1917 (Eupelmidae, Eupelminae) was originally described based on two species from Seychelles: Paranastatus egregius and Paranastatus violaceus. Eady (1956) subsequently described Paranastatus nigriscutellatus and Paranastatus verticalis from Fiji. Here, four new species of Paranastatus are described: Paranastatus bellus Scallion, sp. n. and Paranastatus pilosus Scallion, sp. n. from Indonesia, and Paranastatus halko Scallion, sp. n. and Paranastatus parkeri Scallion, sp. n. from Fiji. A key to all Paranastatus species based on females is included and lectotypes are designated for Paranastatus egregius and Paranastatus violaceus. Finally, previously unobserved colour variation from newly collected material of Paranastatus verticalis, distribution patterns of species, and possibilities for future research are discussed.

The increasing prevalence of multidrug-resistant (MDR) nosocomial infections accounts for increased morbidity and mortality of such infections. Infections with MDR Gram-negative isolates are frequently treated with colistin. Based on recent pharmacokinetic studies, current colistin dosing regimens may result in a prolonged time to therapeutic concentrations, leading to suboptimal and delayed effective treatment. In addition, studies have demonstrated an association between an increased colistin dose and improved clinical outcomes. However, the specific dose at which these outcomes are observed is unknown and warrants further investigation. This retrospective study utilized classification and regression tree (CART) analysis to determine the dose of colistin most predictive of global cure at day 7 of therapy. Patients were assigned to high- and low-dose cohorts based on the CART-established breakpoint. The secondary outcomes included microbiologic outcomes, clinical cure, global cure, lengths of intensive care unit (ICU) and hospital stays, and 7- and 28-day mortalities. Additionally, safety outcomes focused on the incidence of nephrotoxicity associated with high-dose colistin therapy. The CART-established breakpoint for high-dose colistin was determined to be >4.4 mg/kg of body weight/day, based on ideal body weight. This study evaluated 127 patients; 45 (35%) received high-dose colistin, and 82 (65%) received low-dose colistin. High-dose colistin was associated with day 7 global cure (40% versus 19.5%; P = 0.013) in bivariate and multivariate analyses (odds ratio [OR] = 3.40; 95% confidence interval [CI], 1.37 to 8.45; P = 0.008). High-dose colistin therapy was also associated with day 7 clinical cure, microbiologic success, and mortality but not with the development of acute kidney injury. We concluded that high-dose colistin (>4.4 mg/kg/day) is independently associated with day 7 global cure., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Background: At the Hospital of the University of Pennsylvania (Philadelphia), it is standard practice to perform medication reconciliation at patient discharge. Although pharmacists historically were available to assist resident physicians in the discharge medication reconciliation process, the process was never standardized. An internal review showed a 60%-70% rate of pharmacist review of discharge medication lists, potentially enabling medication errors to go unnoticed during transitions of care. In response, a medical resident- and pharmacist-led collaboration was designed, and a pre-post-intervention study was conducted to assess its effectiveness., Methods: A new work flow was established in which house staff notified pharmacists when a preliminary discharge medication list was ready for reconciliation and provided access for pharmacists to correct medication errors in the electronic discharge document with physician approval. Length of stay, average time of day of patient discharge, and readmission data were compared in the pre- and post-intervention periods., Results: There were 981 discharges in the preintervention period and 1,207 in the postintervention period. The rate of pharmacist reconciliation increased from 64.0% to 82.4% after the intervention (p<.0001). The average number of errors identified and corrected by pharmacists decreased from 0.979 to 0.862 per discharge (p<.0001). There was no significant change in readmission rates or time of discharge after the intervention., Conclusions: Redesigning the discharge medication reconciliation process in a teaching hospital to include a review of medical resident discharge medication lists by pharmacists provided more opportunities for discharge medication error identification and correction.

The presence and distribution of two species of Notanisus Walker (Hymenoptera: Pteromalidae) in North America is reported. Notanisus sexramosus (Erdős), originally described from Hungary and previously reported from Maryland, USA, is recorded also from Massachusetts and Pennsylvania based on a male and macropterous and brachypterous females. Males of Notanisus are shown to have two types of flagellar structure, ramose and pedicellate, and diagnostic features are given for the previously unknown males of N. clavatus Bouček to differentiate these from those of N. sexramosus and N. versicolor Walker. Five other species are newly described, Notanisus kansensis n. sp. based on a female from Nebraska, USA, and four species from Sub-Saharan Africa and the Arabian Peninsula--Notanisus brevipetiolus n. sp. based on two females from Uganda and Zambia, Notanisus longipetiolus n. sp. based on a female from Zimbabwe and a female and two males from Mozambique, Notanisus vanharteni n. sp. based on a female and several males from United Arab Emirates, and Notanisus yemenensis n. sp. based on a female and male from Yemen. The latter five species are included with the Palaearctic species N. oulmesiensis (Delucchi) and N. gracilis (Yang) in the oulmesiensis species group, defined by the presence of reduced stigmal and postmarginal veins in both sexes. The seven oulmesiensis-group species are differentiated in a key and all treated species are illustrated through macrophotography. Monophyly and relationships of Notanisus within Cleonymini are discussed, including features that indicate it could be paraphyletic relative to Callocleonymus Masi.