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PubMed1995

Perinatal outcomes management: balancing quality with cost.

As flexibility and change become the only constants in health care delivery, providers are seeking improved methods for delivering quality, cost-effective services. Perinatal care is no exception. Length of stay is decreasing for obstetric patients, and the challenges of providing quality care are great. Outcomes management uses outcomes measures to improve clinical and functional results while better utilizing resources. Critical pathways and variances from that pathway are analyzed for opportunities to improve care and quality. Quality indicators are then derived from the variance data. The women's services outcomes manager, a new role, identifies and resolves quality issues.

Cost-Benefit Analysis↗
PubMed1997

Erythrocyte signal transduction pathways and their possible functions.

Human erythrocytes are equipped with a diversity of receptors and effectors that mediate well-characterized signal transduction pathways in nonerythroid cells. Some of these erythrocyte components may be vestiges of signaling pathways critical to the functions of the erythrocyte's precursors but no longer needed in the mature erythrocyte. Other signaling elements, however, are likely involved in enabling the erythrocyte to detect and respond to the needs of other hematopoietic and endothelial cells with which it comes in contact.

Animals↗
PubMed2004

Progress in the development of topiramate for treating alcohol dependence: from a hypothesis to a proof-of-concept study.

Advances in neuroscientific knowledge have evoked interest in developing effective medications for the treatment of alcohol dependence. Pharmacological approaches that involve the use of relatively specific medications at a particular neuronal target to modulate corticomesolimbic dopamine neuronal activity, the critical pathway for expression of the reinforcing effects of abused drugs, have yielded modest efficacy in the treatment of alcohol dependence. A new approach is needed. Because corticomesolimbic dopamine neurons interact with a variety of neurotransmitters that modulate its effects in the nucleus accumbens, it might be possible to more reliably control these dopaminergic effects with a medication that acted contemporaneously on more than one neuromodulator of dopamine function. Additionally, because alcohol use results in neuronal adaptations due to sensitization, the chances of effective therapy might be bolstered by administering a medication that also has utility with mitigating its chronic effects. My proposed conceptual framework suggests that a medication that facilitates inhibitory gamma-aminobutyric acid-A input and antagonizes excitatory glutaminergic afferents to the nucleus accumbens would have pharmacotherapeutic potential in treating the alcohol dependence syndrome because these effects would act contemporaneously to suppress corticomesolimbic dopamine release. Through similar effects, topiramate might also aid chronic drinkers to wean themselves off alcohol and might ameliorate the symptoms of alcohol withdrawal. This commentary highlights the scientific concepts and clinical evidence for the development of topiramate in the treatment of alcohol dependence.

Alcoholism↗
PubMed2006

Complications of nonoperative management of pediatric blunt hepatic injury: Diagnosis, management, and outcomes.

BACKGROUND: Nonoperative management (NOM) of blunt hepatic injury is the standard of care in the hemodynamically stable pediatric patient, but it is not without pitfalls. The purpose of this study is to assess the incidence and types of complications associated with NOM in terms of diagnosis, management, and outcomes. METHODS: A retrospective study of pediatric patients with blunt hepatic injuries admitted from 1991 through 1997 to a Level I pediatric trauma center was conducted. All stable patients were initially managed nonoperatively according to the Isolated Liver Laceration Critical Pathway. Surveillance was performed by physical examination and tracking of hematocrit and liver function test (LFT) results. Follow-up ultrasound (US) or computed tomography (CT) were performed as clinically indicated. RESULTS: In all, 185 patients with nonoperatively managed blunt hepatic injuries were identified during a 7-year period. Over 90% (168/185) were successfully managed nonoperatively without adverse sequelae. Ten patients (5.4%) died: seven as a result of head injury; three as a result of multisystem organ failure; none directly attributable to their hepatic injuries. Complications occurred in seven patients (3.8%) with Grades III or IV right lobe liver lacerations and included biloma (5), hepatic artery pseudoaneurysm with hemobilia (1), and necrotic gallbladder (1). All seven patients (100%) had fever, persistent or worsening right upper quadrant pain, feeding intolerance, and persistently elevated LFTs. Complications were diagnosed by CT or US. Nonoperative treatment of complications was successful in four of the seven patients (57.1%) and consisted of percutaneous drain placement only (1), percutaneous drain placement and endoscopic retrograde cholangiopancreatography (ERCP)-guided stent placement (2) and angioembolization (1). Three patients (42.9%) required laparotomy, one for management of a concomitant pancreatic pseudocyst. CONCLUSION: Complications of NOM of pediatric blunt hepatic injury are rare, but may include biloma, hepatic artery pseudoaneurysm, and necrotic gallbladder. Complications occur only with Grade III or greater injuries and are accompanied by fever, right upper quadrant pain, feeding intolerance, and persistently elevated LFTs. The clinician must maintain a high index of suspicion for the development of complications and have a low threshold for obtaining a CT or US for diagnosis. Interventional radiology techniques, angiography, and ERCP are useful adjuncts to nonoperative management, but some patients may still require laparotomy for management of complications.

Adolescent↗
PubMed2025

Single-cell profiling of trabecular meshwork identifies mitochondrial dysfunction in a glaucoma model that is protected by vitamin B3 treatment.

Since the trabecular meshwork (TM) is central to intraocular pressure (IOP) regulation and glaucoma, a deeper understanding of its genomic landscape is needed. We present a multimodal, single-cell resolution analysis of mouse limbal cells (includes TM). In total, we sequenced 9,394 wild-type TM cell transcriptomes. We discovered three TM cell subtypes with characteristic signature genes validated by immunofluorescence on tissue sections and whole-mounts. The subtypes are robust, being detected in datasets for two diverse mouse strains and in independent data from two institutions. Results show compartmentalized enrichment of critical pathways in specific TM cell subtypes. Distinctive signatures include increased expression of genes responsible for 1) extracellular matrix structure and metabolism (TM1 subtype), 2) secreted ligand signaling to support Schlemm's canal cells (TM2), and 3) contractile and mitochondrial/metabolic activity (TM3). ATAC-sequencing data identified active transcription factors in TM cells, including LMX1B. Mutations in LMX1B cause high IOP and glaucoma. LMX1B is emerging as a key transcription factor for normal mitochondrial function and its expression is much higher in TM3 cells than other limbal cells. To understand the role of LMX1B in TM function and glaucoma, we single-cell sequenced limbal cells from Lmx1b V265D/+ mutant mice (2,491 TM cells). In V265D/+ mice, TM3 cells were uniquely affected by pronounced mitochondrial pathway changes. Mitochondria in TM cells of V265D/+ mice are swollen with a reduced cristae area, further supporting a role for mitochondrial dysfunction in the initiation of IOP elevation in these mice. Importantly, treatment with vitamin B3 (nicotinamide), to enhance mitochondrial function and metabolic resilience, significantly protected Lmx1b mutant mice from IOP elevation.

Journal Article↗
PubMed2005

Recruitment and activation of mRNA decay enzymes by two ARE-mediated decay activation domains in the proteins TTP and BRF-1.

In human cells, a critical pathway in gene regulation subjects mRNAs with AU-rich elements (AREs) to rapid decay by a poorly understood process. AREs have been shown to directly activate deadenylation, decapping, or 3'-to-5' exonucleolytic decay. We demonstrate that enzymes involved in all three of these mRNA decay processes, as well as 5'-to-3' exonucleolytic decay, associate with the protein tristetraprolin (TTP) and its homolog BRF-1, which bind AREs and activate mRNA decay. TTP and BRF-1 each contain two activation domains that can activate mRNA decay after fusion to a heterologous RNA-binding protein, and inhibit ARE-mediated mRNA decay when overexpressed. Both activation domains employ trans-acting factors to trigger mRNA decay, and the N-terminal activation domain functions as a binding platform for mRNA decay enzymes. Our data suggest that the TTP protein family functions as a molecular link between ARE-containing mRNAs and the mRNA decay machinery by recruitment of mRNA decay enzymes, and help explain how deadenylation, decapping, and exonucleolytic decay can all be independently activated on ARE-containing mRNAs. This describes a potentially regulated step in activation of mRNA decay.

Butyrate Response Factor 1↗
PubMed2006

The Notch coactivator, MAML1, functions as a novel coactivator for MEF2C-mediated transcription and is required for normal myogenesis.

The MAML (mastermind-like) proteins are a family of three co-transcriptional regulators that are essential for Notch signaling, a pathway critical for cell fate determination. Though the functions of MAML proteins in normal development remain unresolved, their distinct tissue distributions and differential activities in cooperating with various Notch receptors suggest that they have unique roles. Here we show that mice with a targeted disruption of the Maml1 gene have severe muscular dystrophy. In vitro, Maml1-null embryonic fibroblasts failed to undergo MyoD-induced myogenic differentiation, further suggesting that Maml1 is required for muscle development. Interestingly, overexpression of MAML1 in C2C12 cells dramatically enhanced myotube formation and increased the expression of muscle-specific genes, while RNA interference (RNAi)-mediated MAML1 knockdown abrogated differentiation. Moreover, we determined that MAML1 interacts with MEF2C (myocyte enhancer factor 2C), functioning as its potent co-transcriptional regulator. Surprisingly, however, MAML1's promyogenic effects were completely blocked upon activation of Notch signaling, which was associated with recruitment of MAML1 away from MEF2C to the Notch transcriptional complex. Our study thus reveals novel and nonredundant functions for MAML1: It acts as a coactivator for MEF2C transcription and is essential for proper muscle development. Mechanistically, MAML1 appears to mediate cross-talk between Notch and MEF2 to influence myogenic differentiation.

Animals↗
PubMed2006

A positive feedback loop between the p53 and Lats2 tumor suppressors prevents tetraploidization.

Damage to the mitotic spindle and centrosome dysfunction can lead to cancer. To prevent this, cells trigger a succession of checkpoint responses, where an initial mitotic delay is followed by slippage without cytokinesis, spawning tetraploid G1 cells that undergo a p53-dependent G1/S arrest. We describe the importance of Lats2 (Large Tumor Suppressor 2) in this checkpoint response. Lats2 binds Mdm2, inhibits its E3 ligase activity, and activates p53. Nocodazole, a microtubule poison that provokes centrosome/mitotic apparatus dysfunction, induces Lats2 translocation from centrosomes to the nucleus and p53 accumulation. In turn, p53 rapidly and selectively up-regulates Lats2 expression in G2/M cells, thereby defining a positive feedback loop. Abrogation of Lats2 promotes accumulation of polyploid cells upon exposure to nocodazole, which can be prevented by direct activation of p53. The Lats2-Mdm2-p53 axis thus constitutes a novel checkpoint pathway critical for the maintenance of proper chromosome number.

Animals↗
PubMedDate not supplied

A model of Pavlovian eyelid conditioning based on the synaptic organization of the cerebellum.

We present a model based on the synaptic and cellular organization of the cerebellum to derive a diverse range of phenomena observed in Pavlovian eyelid conditioning. These phenomena are addressed in terms of critical pathways and network properties, as well as the sites and rules for synaptic plasticity. The theory is based on four primary hypotheses: (1) Two cerebellar sites of plasticity are involved in conditioning: (a) bidirectional long-term depression/potentiation at granule cell synapses onto Purkinje cells (gr-->Pkj) in the cerebellar cortex and (b) bidirectional plasticity in the interpositus nucleus that is controlled by inhibitory inputs from Purkinje cells; (2) climbing fiber activity is regulated to an equilibrium level at which the net strength of gr-->Pkj synapses remains constant unless an unexpected unconditioned stimulus (US) is presented or an expected US is omitted; (3) a time-varying representation of the conditioned stimulus (CS) in the cerebellar cortex permits the temporal discrimination required for conditioned response timing; and (4) the ability of a particular segment of the CS to be represented consistently across trials varies as a function of time since CS onset. This variation in across-trials consistency is thought to contribute to the ISI function. The model suggests several empirically testable predictions, some of which have been tested recently.

Animals↗
PubMed1994

A FUSCA gene of Arabidopsis encodes a novel protein essential for plant development.

Arabidopsis fusca mutants display striking purple coloration due to anthocyanin accumulation in their cotyledons. We describe six recessive fusca mutants isolated from Agrobacterium-transformed Arabidopsis families. These mutants first become defective during embryogenesis and exhibit limited seedling development. Double mutant constructs revealed that developmental defects were not simply a consequence of anthocyanin accumulation. fusca seedlings showed altered responses to several environmental and endogenous factors. Allelism tests established that three fusca loci are represented by mutants previously described as defective in light-regulated responses. To study the molecular basis of the fusca phenotype, we cloned the FUS6 gene. FUS6 encodes a novel protein that is hydrophilic, alpha-helical, and contains potential protein kinase C phosphorylation sites. The FUSCA proteins appear to act in a network of signal transduction pathways critical for plant development.

Alleles↗
PubMed2004

Breaking symmetry: a clinical overview of left-right patterning.

It is increasingly recognized that mutations in genes and pathways critical for left-right (L-R) patterning are involved in common isolated congenital malformations such as congenital heart disease, biliary tract anomalies, renal polycystic disease, and malrotation of the intestine, indicating that disorders of L-R development are far more common than a 1 in 10,000 incidence of heterotaxia might suggest. Understanding L-R patterning disorders requires knowledge of molecular biology, embryology, pediatrics, and internal medicine and is relevant to day-to-day clinical genetics practice. We have reviewed data from mammalian (human and mouse) L-R patterning disorders to provide a clinically oriented perspective that might afford the clinician or researcher additional insights into this diagnostically challenging area.

Animals↗
PubMed2005

Transforming growth factor-beta and Smad signalling in kidney diseases.

Extensive studies have demonstrated that transforming growth factor-beta (TGF-beta) plays an important role in the progression of renal diseases. TGF-beta exerts its biological functions mainly through its downstream signalling molecules, Smad2 and Smad3. It is now clear that Smad3 is critical for TGF-beta's pro-fibrotic effect, whereas the functions of Smad2 in fibrosis in response to TGF-beta still need to be determined. Our recent studies have demonstrated that Smad signalling is also a critical pathway for renal fibrosis induced by other pro-fibrotic factors, such as angiotensin II and advanced glycation end products (AGE). These pro-fibrotic factors can activate Smads directly and independently of TGF-beta. They can also cause renal fibrosis via the ERK/p38 MAP kinase-Smad signalling cross-talk pathway. In contrast, blockade of Smad2/3 activation by overexpression of an inhibitory Smad7 prevents collagen matrix production induced by TGF-beta, angiotensin II, high glucose and AGE and attenuates renal fibrosis in various animal models including rat obstructive kidney, remnant kidney and diabetic kidney diseases. Results from these studies indicate that Smad signalling is a key and final common pathway of renal fibrosis. In addition, TGF-beta has anti-inflammatory and immune-regulatory properties. Our most recent studies demonstrated that TGF-beta transgenic mice are protected against renal inflammation in mouse obstructive and diabetic models. Upregulation of renal Smad7, thereby blocking NF.kappaB activation via induction of IkappaBalpha, is a central mechanism by which TGF-beta inhibits renal inflammation. In conclusion, TGF-beta signals through Smad2/3 to mediate renal fibrosis, whereas induction of Smad7 inhibits renal fibrosis and inflammation. Thus, targeting Smad signalling by overexpression of Smad7 may have great therapeutic potential for kidney diseases.

Animals↗
PubMed2000

A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients.

OBJECTIVE: To test the cost effectiveness of Hospital in the Home compared to hospital admission for acute medical conditions. METHOD: Randomised controlled trial at the Prince of Wales Hospital, Sydney, from October 1995 to February, 1997; 100 patients with acute medical conditions admitted through the Emergency Department. RESULTS: The Hospital in the Home (HITH) group costs per separation ($1,764, CI 95% $1,416-$2,111, n = 50) were significantly lower (p < 0.0001, Mann-Whitney U-Wilcoxon Rank Sum) than the control group hospital separation ($3,614, CI 95% $2,881.37-$4,347.27, n = 47) with no significant difference in clinical outcomes, and comparable or better user satisfaction. CONCLUSION: Given the favourable clinical outcomes the HITH model produces at a lower cost, the cost-effectiveness of the care mode is high, and the allocative efficiency favourable. IMPLICATIONS: As a care model and critical pathway, HITH offers hospitals real bed day savings that can either be used to rationalise resource usage for a given level of activity, or increase throughput.

Acute Disease↗
PubMed2004

CSRP2, TIMP-1, and SM22alpha promoter fragments direct hepatic stellate cell-specific transgene expression in vitro, but not in vivo.

BACKGROUND/AIMS: The activation of hepatic stellate cells (HSC) and their transdifferentiation into myofibroblasts (MFB) is the key step for development of liver fibrosis. Over the past several years, significant progress has been made in the understanding of the critical pathways involved incells undergoing activation. Cellular activation in the course of transdifferentiation involves, among other biochemical modifications, functionally relevant changes in the control of gene expression. These include the up-regulation of transcription factors, different extracellular matrix proteins, cell adhesion molecules, smooth muscle specific genes, and proteins involved in matrix remodelling, or cytoskeletal organization. The corresponding regulatory elements of these genes have afforded us the opportunity to express transgenes with antifibrotic potential in a cell type- and/or transdifferentiation-dependent manner. METHODS: In the present study, we have tested several promoters for their ability to mediate cell-specific expression, including those for CSRP2, SM22alpha, and TIMP-1 (CSRP2, gene encoding the LIM domain protein CRP2; SM22alpha, smooth muscle-specific gene encoding a 22-kDa protein; TIMP-1, gene encoding the tissue inhibitor of metalloproteinases-1), which in liver are specifically expressed in HSC or become strongly activated during the acute remodelling into MFB. We constructed adenoviral reporter vectors in which relevant portions of the promoters were fused to the green fluorescent protein. RESULTS AND CONCLUSION: Our experiments demonstrate that each of these promoters is sufficient to achieve strong or partially selective expression in vitro but none is able to direct a specific or inducible expression of transgenes in HSC/MFB in vivo.

Animals↗
PubMed1999

The treatment and prevention of coronary heart disease in Canada: do older patients receive efficacious therapies? The Clinical Quality Improvement Network (CQIN) Investigators.

OBJECTIVES: To review the evidence for clinical efficacy and cost-effectiveness of proven medications in the treatment and prevention of myocardial infarction (MI) in older patients; to summarize Canadian data on treatment patterns and clinical outcomes for younger and older patients with coronary heart disease; to explore the reasons for gaps between best care, based on the evidence of efficacy from trials, and usual care, based on the population effectiveness audits; and to explore potential approaches to closing the care gaps. DESIGN: Review of the recent clinical trial literature on the management of MI, highlighting results in older patients. Review of medication utilization and outcomes data from a series of large, consecutively enrolled patient cohorts with acute MI (N = 7070) in a variety of cardiac care settings (10 centers in five Canadian provinces, including university-based teaching hospitals, community hospitals, cardiologist and family physician out-patient clinics) from 1987 to 1996. RESULTS: There is no qualitative interaction of cardiac therapies: thrombolytics, beta-blockers, acetylsalicylic acid (ASA), and statins are efficacious in all clinically relevant patient subgroups, including older people. However, there are consistent gaps between usual care and best care, particularly among older patients (in whom there is also a concomitantly higher mortality risk). Repeated multivariate analyses confirm older age to be an independent contributor to increased risk. Use of efficacious medications is, in contrast, consistently associated with increased survival. Analysis of temporal trends suggests beneficial changes in practice patterns and outcomes are possible to achieve. However, "best care" has not been rapidly or completely achieved. Review of strategies to close these care gaps suggests that audit and feedback, critical pathways, and multifactorial interventions involving patients and other members of the healthcare team as well as physicians may be the most efficacious strategies for change. CONCLUSIONS: Despite equal or enhanced efficacy, there is consistently less prescription of proven drugs among older cardiac patients. These care patterns may contribute to their enhanced risk. The causes underlying these practice patterns are complex, and their population impact may be undervalued by clinicians and managers. Improvement of these patterns is difficult, but ultimately it would be beneficial for this presently disadvantaged, readily identified, high risk patient population.

Aged↗
PubMed2025

Cr3a, a candidate gene conferring fruit cracking resistance, was fine-mapped in an introgression line of Solanum lycopersicum L.

In the cultivation and production of tomato (Solanum lycopersicum L.), fruit cracking is a prevalent and detrimental issue that significantly impacts the esthetic quality and commercial value of the fruit. The complexity of the trait has resulted in a slow advancement in research aimed at identifying genes that influence tomato fruit cracking and the underlying regulatory mechanisms. In this study, a sub-introgression population for tomato crack-resistant fruit has been constructed from the cross between S. lycopersicum 1052 and Solanum pennellii LA0716, followed by 11 generations of selfing. Utilizing specifically designed InDel markers, the tomato crack-resistant gene, Cr3a, was fine-mapped, cloned, and its functionality was confirmed through transgenic and gene-knockout approaches. The precise localization of Cr3a was delineated to a 30&#x2009;kb genomic region on chromosome 3, corresponding to the gene Sopen03g034650 in S. pennellii and Solyc03g115660.3 in the Heinz1706 variety. An integrated transcriptomic and metabolomic analysis of fruits with and without the Cr3a gene was finally conducted to elucidate the intricate regulatory mechanisms associated with Cr3a. The findings revealed a molecular regulatory network for tomato fruit crack resistance, characterized by 7 key metabolites, 13 pivotal genes, and 4 critical pathways: the phenylpropanoid biosynthesis pathway, the phenylalanine, tyrosine, and tryptophan biosynthesis pathway, the linolenic acid metabolism pathway, and the cysteine and methionine metabolism pathway. In summary, this research provides novel insights into the molecular underpinnings of tomato fruit crack resistance and holds substantial promise for accelerating the molecular breeding of tomatoes with enhanced fruit crack resistance.

Solanum lycopersicum↗
PubMed1983

Mutual coupling between the ocular circadian pacemakers of Bulla gouldiana.

The ocular circadian pacemakers of Bulla gouldiana were found to be mutually coupled, and their interaction could be observed in an isolated nervous system maintained in vitro. Experimentally induced phase separations between the two ocular pacemakers were reduced when the eyes were allowed to interact for 48 hours. The reduction in phase separation did not occur however when the cerebral commissure was severed, indicating that this neural tract is a critical pathway coupling these two circadian clocks.

Animals↗
PubMed2006

Functional imaging of tumor proteolysis.

The roles of proteases in cancer are now known to be much broader than simply degradation of extracellular matrix during tumor invasion and metastasis. Furthermore, proteases from tumor-associated cells (e.g., fibroblasts, inflammatory cells, endothelial cells) as well as tumor cells are recognized to contribute to pathways critical to neoplastic progression. Although elevated expression (transcripts and proteins) of proteases, and in some cases protease inhibitors, has been documented in many tumors, techniques to assess functional roles for proteases require that we measure protease activity and inhibition of that activity rather than levels of proteases, activators, and inhibitors. Novel techniques for functional imaging of protease activity, both in vitro and in vivo, are being developed as are imaging probes that will allow us to determine protease activity and in some cases to discriminate among protease activities. These should be useful clinically as surrogate endpoints for therapies that alter protease activities.

Animals↗