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The medication in an electronic prescribing system (EPS) does not always match the patient's actual medication. This prospective study analyzes the discrepancies (any inconsistency) between medication prescribed using an EPS and the medication revised by the clinical pharmacist upon admission to the observation area of the emergency department (ED). Adult patients with multimorbidity and/or polypharmacy were included. The pharmacist used multiple sources to obtain the revised medication list, including patient/carer interviews. A total of 1654 discrepancies were identified among 1131 patients. Of these patients, 64.5% had ≥1 discrepancy. The most common types of discrepancy were differences in posology (43.6%), commission (34.7%), and omission (20.9%). Analgesics (11.1%), psycholeptics (10.0%), and diuretics (8.9%) were the most affected. Furthermore, 52.5% of discrepancies affected medication that was high-alert for patients with chronic illnesses and 42.0% of medication involved withdrawal syndromes. Discrepancies increased with the number of drugs (ρ = 0.44, p < 0.01) and there was a difference between non-polypharmacy patients, polypharmacy ones and those with extreme polypharmacy (p < 0.01). Those aged over 75 years had a higher number of prescribed medications and discrepancies occurred more frequently compared with younger patients. The number of discrepancies was larger in women than in men. The EPS medication record requires verification from additional sources, including patient and/or carer interviews.

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The PD-1/PD-L1 protein-protein interaction (PPI) controls an adaptive immune resistance mechanism exerted by tumor cells to evade immune responses. The large-molecule nature of current commercial monoclonal antibodies against this PPI hampers their effectiveness by limiting tumor penetration and inducing severe immune-related side effects. Synthetic small-molecule inhibitors may overcome such limitations and have demonstrated promising clinical translation, but their design is challenging. Microbial natural products (NPs) are a source of small molecules with vast chemical diversity that have proved anti-tumoral activities, but which immunotherapeutic properties as PD-1/PD-L1 inhibitors had remained uncharacterized so far. Here, we have developed the first cell-based PD-1/PD-L1 blockade reporter assay to screen NPs libraries. In this study, 6000 microbial extracts of maximum biosynthetic diversity were screened. A secondary metabolite called alpha-cyclopiazonic acid (α-CPA) of a bioactive fungal extract was confirmed as a new PD-1/PD-L1 inhibitor with low micromolar range in the cellular assay and in an additional cell-free competitive assay. Thermal denaturation experiments with PD-1 confirmed that the mechanism of inhibition is based on its stabilization upon binding to α-CPA. The identification of α-CPA as a novel PD-1 stabilizer proves the unprecedented resolution of this methodology at capturing specific PD-1/PD-L1 PPI inhibitors from chemically diverse NP libraries.

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BACKGROUND: While multidimensional and interdisciplinary assessment of older adult patients improves their short-term outcomes after evaluation in the emergency department (ED), this assessment is time-consuming and ill-suited for the busy environment. Thus, identifying patients who will benefit from this strategy is challenging. Therefore, this study aimed to identify older adult patients suitable for a different ED approach as well as independent variables associated with poor short-term clinical outcomes. METHODS: We included all patients ≥65 years attending 52 EDs in Spain over 7 days. Sociodemographic, comorbidity, and baseline functional status data were collected. The outcomes were 30-day mortality, re-presentation, hospital readmission, and the composite of all outcomes. RESULTS: During the study among 96,014 patients evaluated in the ED, we included 23,338 patients ≥65 years-mean age, 78.4±8.1 years; 12,626 (54.1%) women. During follow-up, 5,776 patients (24.75%) had poor outcomes after evaluation in the ED: 1,140 (4.88%) died, 4,640 (20.51) returned to the ED, and 1,739 (7.69%) were readmitted 30 days after discharge following the index visit. A model including male sex, age ≥75 years, arrival by ambulance, Charlson Comorbidity Index ≥3, and functional impairment had a C-index of 0.81 (95% confidence interval, 0.80-0.82) for 30-day mortality. CONCLUSION: Male sex, age ≥75 years, arrival by ambulance, functional impairment, or severe comorbidity are features of patients who could benefit from approaches in the ED different from the common triage to improve the poor short-term outcomes of this population.

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Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10-4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01-4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

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Discrete-event simulation (DES) is a stochastic modeling approach widely used to address dynamic and complex systems, such as healthcare. In this review, academic databases were systematically searched to identify 231 papers focused on DES modeling in healthcare. These studies were sorted by year, approach, healthcare setting, outcome, provenance, and software use. Among the surveys, conceptual/theoretical studies, reviews, and case studies, it was found that almost two-thirds of the theoretical articles discuss models that include DES along with other analytical techniques, such as optimization and lean/six sigma, and one-third of the applications were carried out in more than one healthcare setting, with emergency departments being the most popular. Moreover, half of the applications seek to improve time- and efficiency-related metrics, and one-third of all papers use hybrid models. Finally, the most popular DES software is Arena and Simul8. Overall, there is an increasing trend towards using DES in healthcare to address issues at an operational level, yet less than 10% of DES applications present actual implementations following the modeling stage. Thus, future research should focus on the implementation of the models to assess their impact on healthcare processes, patients, and, possibly, their clinical value. Other areas are DES studies that emphasize their methodological formulation, as well as the development of frameworks for hybrid models.

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Streptomyces are well-known producers of a range of different secondary metabolites, including antibiotics and other bioactive compounds. Recently, it has been demonstrated that "silent" biosynthetic gene clusters (BGCs) can be activated by heterologously expressing transcriptional regulators from other BGCs. Here, we have activated a silent BGC in Streptomyces sp. CA-256286 by overexpression of a set of SARP family transcriptional regulators. The structure of the produced compound was elucidated by NMR and found to be an N-acetyl cysteine adduct of the pyranonaphtoquinone polyketide 3'-O-α-d-forosaminyl-(+)-griseusin A. Employing a combination of multi-omics and metabolic engineering techniques, we identified the responsible BGC. These methods include genome mining, proteomics and transcriptomics analyses, in combination with CRISPR induced gene inactivations and expression of the BGC in a heterologous host strain. This work demonstrates an easy-to-implement workflow of how silent BGCs can be activated, followed by the identification and characterization of the produced compound, the responsible BGC, and hints of its biosynthetic pathway.

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This work reports the use of two monomers with two tertiary amines and four methacrylic (TTME) or acrylic (TTAC) terminal groups as co-initiators in the formulation of experimental resin adhesive systems. Both monomers were characterized by FT-IR and 1H NMR spectroscopies. The control adhesive was formulated with BisGMA, TEGDMA, HEMA, and the binary system CQ-EDAB as a photo-initiator system. For the experimental adhesives, the EDAB was completely replaced for the TTME or the TTAC monomers. The adhesives formulated with TTME or TTAC monomers achieved double bond conversion values close to 75%. Regarding the polymerization rate, materials formulated with TTME or TTAC achieved lower values than the material formulated with EDAB, giving them high shelf-life stability. The degree of conversion after shelf simulation was only reduced for the EDAB material. Ultimate tensile strength, translucency parameter, and micro-tensile bond strength to dentin were similar for control and experimental adhesive resins. Due to their characteristics, TTME and TTAC monomers are potentially useful in the formulation of photopolymerizable resins for dental use with high shelf-life stability.

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BACKGROUND: Crimean-Congo haemorrhagic fever (CCHF) is a widespread tick-borne viral disease caused by the Crimean-Congo haemorrhagic fever virus (CCHFV). CCHFV has been implicated in severe viral haemorrhagic fever outbreaks. During the summer of 2016, the first two cases with genotype III (Africa 3) were reported in Spain. The first objective of our study was to determine the presence of CCHFV among patients with febrile illness during the spring and summer periods in 2017 and 2018. Finally, we perform a phylogenetic analysis to determine the genotype of the virus. METHODOLOGY: We prospectively evaluated patients aged 18 years and older who came to the emergency department at the Salamanca's University Hospital (HUS) with fever. Specific IgM and IgG antibodies against CCHFV by ELISA and one immunofluorescence assay against two different proteins (nucleoprotein and glycoprotein C) was done. Moreover, molecular detection by Real Time PCR was performed in all collected samples. A phylogenetic analysis was carried out to genetically characterize CCHFV detected in this study. PRINCIPAL FINDINGS: A total of 133 patients were selected. The mean age was 67.63 years and 60.9% were male. One-third of the patients presented an acute undifferentiated febrile illness. Three patients had anti-CCHFV IgG antibodies, suggesting a previous infection. One patient had anti-CCHFV IgM antibodies and a confirmatory RT-PCR. Phylogenetic analysis indicated that the virus corresponds to the European genotype V. This patient came to the emergency department at HUS in August 2018 presenting an acute febrile syndrome with thrombopenia and liver impairment. CONCLUSIONS: We describe a new circulation of European genotype V CCHFV in Spain. Moreover, this study suggests that CCHFV is an identifiable cause of febrile illness of unknown origin in Spain. Thus, CCHF could be suspected in patients with fever, liver damage, and/or haemorrhagic disorders, particularly in people with risk activities who present in the spring or summer.

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BACKGROUND: We present a performance per watt analysis of CUDAlign 4.0, a parallel strategy to obtain the optimal pairwise alignment of huge DNA sequences in multi-GPU platforms using the exact Smith-Waterman method. RESULTS: Our study includes acceleration factors, performance, scalability, power efficiency and energy costs. We also quantify the influence of the contents of the compared sequences, identify potential scenarios for energy savings on speculative executions, and calculate performance and energy usage differences among distinct GPU generations and models. For a sequence alignment on chromosome-wide scale (around 2 Petacells), we are able to reduce execution times from 9.5 h on a Kepler GPU to just 2.5 h on a Pascal counterpart, with energy costs cut by 60%. CONCLUSIONS: We find GPUs to be an order of magnitude ahead in performance per watt compared to Xeon Phis. Finally, versus typical low-power devices like FPGAs, GPUs keep similar GFLOPS/w ratios in 2017 on a five times faster execution.

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In this paper we report the synthesis of a new polyacrylate named poly(1,1'-BP4MA) which is a derivate from 4-biphenylmethanol monomer. Poly(1,1'-BP4MA) was obtained by solution and bulk polymerization techniques to yield polymers with high molecular weight and high solubility. The study of the optical properties showed that poly(1,1'-BP4MA) is a fluorescent material with emission in the UV-green region and it has similar quantum yield to tryptophan.

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The present paper describes a case of hemobilia in a woman with a cystic artery pseudoaneurysm. The pseudoaneurysm could be seen with ultrasound, Doppler sonography and CT angiography. In our case, Doppler sonography was the most useful technique for diagnosis, revealing the turbulent forward and backwards flow within the gallbladder, representing the focally dilated artery. This was later confirmed by CT angiography. A recent bleeding site was found on the cholecystectomy specimen.

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BACKGROUND: Socioeconomic status (SES) is an important determinant of health and potential modifier of the effects of environmental contaminants. There has been a lack of comprehensive indices for measuring overall SES in Canada. Here, a more comprehensive SES index is developed aiming to support future studies exploring health outcomes related to environmental pollution in Canada. METHODS: SES variables (n = 22, Census Canada 2006) were selected based on: cultural identities, housing characteristics, variables identified in Canadian environmental injustice studies and a previous deprivation index (Pampalon index). Principal component analysis with a single varimax rotation (factor loadings ≥ │60│) was performed on SES variables for 52974 census dissemination areas (DA). The final index was created by averaging the factor scores per DA according to the three components retained. The index was validated by examining its association with preterm birth (gestational age < 37 weeks), term low birth weight (LBW, <2500 g), small for gestational age (SGA, <10 percentile of birth weight for gestational age) and PM2.5 (particulate matter ≤ 2.5 µm) exposures in Edmonton, Alberta (1999-2008). RESULTS: Index values exhibited a relatively normal distribution (median = 0.11, mean = 0.0, SD = 0.58) across Canada. Values in Alberta tended to be higher than in Newfoundland and Labrador, Northwest Territories and Nunavut (Pearson chi-square p < 0.001 across provinces). Lower quintiles of our index and the Pampalon's index confirmed know associations with a higher prevalence of LBW, SGA, preterm birth and PM2.5 exposure. Results with our index exhibited greater statistical significance and a more consistent gradient of PM2.5 levels and prevalence of pregnancy outcomes. CONCLUSIONS: Our index reflects more dimensions of SES than an earlier index and it performed superiorly in capturing gradients in prevalence of pregnancy outcomes. It can be used for future research involving environmental pollution and health in Canada.

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Se presentó una paciente femenina escolar de seis años de edad raza mestiza, con antecedentes de salud, sin antecedentes familiares a destacar; embarazo y parto normales, a término, sin patología perinatal, correctamente alimentada, bien inmunizada; buen crecimiento y desarrollo. Controlada por el pediatra, que acudió a su médico de familia por presentar síntomas catarrales (tos pertinaz y fiebre) recibió medicación con fenitoina y al segundo día de tratamiento comienza con manifestaciones cutáneas de ampollas que se destechan y dejan observar zonas eritematosas y húmedas que se extendieron a casi la totalidad de la superficie corporal. El síndrome de Stevens-Johnson es una dermatosis potencialmente fatal caracterizada por una extensanecrosis epidérmica y de mucosas que se acompaña de ataque al estado general. Este síndrome y la necrólisis epidérmica tóxica son reacciones de hipersensibilidad que se consideran formas polares clínico-patológicas de una misma enfermedad. Ambas son reacciones adversas cutáneas severas relacionadas con varios medicamentos. Estas enfermedades tienen impacto significante en la salud pública debido a su alta morbilidad y mortalidad. El porcentaje de superficie cutánea afectada es pronóstico y clasifica a esta dermatosis en tres grupos: síndrome Stevens Johnson (cuando afecta menos de 10 % de superficie corporal) superposición síndrome Stevens Johnson - necrólisis epidérmica tóxica (del 10 al 30 %) y necrólisis epidérmica tóxica (despegamiento cutáneo mayor al 30 %).

Six years old, mixed race school girl patient, with a health record, no family history to note, was presented. Born from a normal pregnancy and a delivery at term. Properly fed, well immunized. Good growth and development. The patient had come to her family physician because of cold symptoms with persistent cough and fever; she received a medication with phenytoin among other drugs. On the second day of treatment the patient developed cutaneous manifestations of blisters that exposed, when opened, erythematous and humid areas that extended to almost the entire body surface. The Stevens - Johnson syndrome is a potentially fatal skin disease characterized by extensive epidermal and mucosal necrosis that is accompanied by malaise. Stevens Johnson Syndrome and toxic epidermal necrolysis are hypersensitivity reactions that are considered clinic and pathologic entity of the same polar forms. Both Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe cutaneous adverse reactions associated with some medications (RACS). These conditions have significant impact on public health because of its high morbidity and mortality. The percentage of affected skin surface classifies this disease into three groups and could define the prognosis: -SSJ, when it affects less than 10% body surface - Overlapping SSJ-NET of 10-30% - NET, greater than 30% skin detachment.

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Se presentó una paciente femenina escolar de seis años de edad raza mestiza, con antecedentes de salud, sin antecedentes familiares a destacar; embarazo y parto normales, a término, sin patología perinatal, correctamente alimentada, bien inmunizada; buen crecimiento y desarrollo. Controlada por el pediatra, que acudió a su médico de familia por presentar síntomas catarrales (tos pertinaz y fiebre) recibió medicación con fenitoina y al segundo día de tratamiento comienza con manifestaciones cutáneas de ampollas que se destechan y dejan observar zonas eritematosas y húmedas que se extendieron a casi la totalidad de la superficie corporal. El síndrome de Stevens-Johnson es una dermatosis potencialmente fatal caracterizada por una extensanecrosis epidérmica y de mucosas que se acompaña de ataque al estado general. Este síndrome y la necrólisis epidérmica tóxica son reacciones de hipersensibilidad que se consideran formas polares clínico-patológicas de una misma enfermedad. Ambas son reacciones adversas cutáneas severas relacionadas con varios medicamentos. Estas enfermedades tienen impacto significante en la salud pública debido a su alta morbilidad y mortalidad. El porcentaje de superficie cutánea afectada es pronóstico y clasifica a esta dermatosis en tres grupos: síndrome Stevens Johnson (cuando afecta menos de 10 por ciento de superficie corporal) superposición síndrome Stevens Johnson - necrólisis epidérmica tóxica (del 10 al 30 por ciento) y necrólisis epidérmica tóxica (despegamiento cutáneo mayor al 30 por ciento)(AU)

Six years old, mixed race school girl patient, with a health record, no family history to note, was presented. Born from a normal pregnancy and a delivery at term. Properly fed, well immunized. Good growth and development. The patient had come to her family physician because of cold symptoms with persistent cough and fever; she received a medication with phenytoin among other drugs. On the second day of treatment the patient developed cutaneous manifestations of blisters that exposed, when opened, erythematous and humid areas that extended to almost the entire body surface. The Stevens - Johnson syndrome is a potentially fatal skin disease characterized by extensive epidermal and mucosal necrosis that is accompanied by malaise. Stevens Johnson Syndrome and toxic epidermal necrolysis are hypersensitivity reactions that are considered clinic and pathologic entity of the same polar forms. Both Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe cutaneous adverse reactions associated with some medications (RACS). These conditions have significant impact on public health because of its high morbidity and mortality(AU)

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Spatial variation in particulate matter-related health and toxicological outcomes is partly due to its composition. We studied spatial variability in particle composition and induced cellular responses in Mexico City to complement an ongoing epidemiologic study. We measured elements, endotoxins, and polycyclic aromatic hydrocarbons in two particle size fractions collected in five sites. We compared the in vitro proinflammatory response of J774A.1 and THP-1 cells after exposure to particles, measuring subsequent TNFα and IL-6 secretion. Particle composition varied by site and size. Particle constituents were subjected to principal component analysis, identifying three components: C(1) (Si, Sr, Mg, Ca, Al, Fe, Mn, endotoxin), C(2) (polycyclic aromatic hydrocarbons), and C(3) (Zn, S, Sb, Ni, Cu, Pb). Induced TNFα levels were higher and more heterogeneous than IL-6 levels. Cytokines produced by both cell lines only correlated with C(1) , suggesting that constituents associated with soil induced the inflammatory response and explain observed spatial differences.

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Particulate matter may promote cardiovascular disease, possibly as a consequence of its oxidative potential. Studies using susceptible animals indicate that particulate matter aggravates atherosclerosis by increasing lipid/macrophage content in plaques. Macrophage lipid uptake requires oxidized low-density lipoprotein and scavenger receptors; same receptors are involved in particulate matter uptake. We studied in vitro particulate matter potential to oxidize low-density lipoproteins and subsequent cell uptake through scavenger receptors. Particulate matter-induced low-density lipoproteins oxidation was evaluated by the thiobarbituric acid assay. Binding/internalization was tested in wild type and scavenger receptor-transfected Chinese hamster ovary cells, and in RAW264.7 cells using fluorescently labeled low-density lipoproteins. Dose-dependent binding/internalization only occurred in scavenger receptor-transfected Chinese hamster ovary cells and RAW264.7 cells. Competition binding/internalization using particles showed that particulate matter induced decreased binding (∼50%) and internalization (∼70%) of particle-oxidized low-density lipoproteins and native low-density lipoproteins. Results indicate that particulate matter was capable of oxidizing low-density lipoproteins, favoring macrophage internalization, and also altered scavenger and low-density lipoproteins receptor function.

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A fiber optic interferometric sensor with an intrinsic transducer along a length of the fiber is presented for ultrasound measurements of the acoustic emission from partial discharges inside oil-filled power apparatus. The sensor is designed for high sensitivity measurements in a harsh electromagnetic field environment, with wide temperature changes and immersion in oil. It allows enough sensitivity for the application, for which the acoustic pressure is in the range of units of Pa at a frequency of 150 kHz. In addition, the accessibility to the sensing region is guaranteed by immune fiber-optic cables and the optical phase sensor output. The sensor design is a compact and rugged coil of fiber. In addition to a complete calibration, the in-situ results show that two types of partial discharges are measured through their acoustic emissions with the sensor immersed in oil.