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Background: The use of personal protective equipment (PPE) is a critical intervention in preventing the spread of transmission-based infections in healthcare settings. However, contamination of the skin and clothing of healthcare personnel (HCP) frequently occurs during the doffing of PPE. In fact, nearly 40% of HCP make errors while doffing their PPE, causing them to contaminate themselves. PPE monitors are staff that help to promote their colleagues’ safety by guiding them through the PPE donning and doffing processes. With the advent of the COVID-19 pandemic in early 2020, the UNC Medical Center chose to incorporate PPE monitors as part of its comprehensive COVID-19 prevention strategy, using them in inpatient areas (including COVID-19 containment units and all other units with known or suspected SARS-CoV-2–positive patients), procedural areas, and outpatient clinics. Methods: Infection prevention and nursing developed a PPE monitoring team using redeployed staff from outpatient clinics and inpatient areas temporarily closed because of the pandemic. Employee training took place online and included fundamentals of disease transmission, hand hygiene basics, COVID-19 policies and signage, and videos on proper donning and doffing, including coaching tips. The monitors’ first shifts were supervised by experienced monitors to continue in-place training. Employees had competency sheets signed off by a supervisor. Results: The Medical Center’s nursing house supervisors took over management and deployment of the PPE monitoring team, and infection prevention staff continued to train new members. Eventually, as closed clinics and areas reopened and these PPE monitors returned to their regular positions, areas used their own staff to perform the role of PPE monitor. In the fall of 2020, a facility-wide survey was sent to all inpatient staff to assess their perceptions of the Medical Center’s efforts to protect them from acquiring COVID-19. It included a question asking how much staff agreed or disagreed that PPE monitors “play an important role in keeping our staff who care for COVID-19 patients safe.” Of the 626 staff who answered this question, 67.6% agreed or strongly agreed that PPE monitors played an important role in keeping staff safe. Thus far, there has been no direct transmission or clusters of COVID-19 involving HCP in COVID-19 containment units with PPE monitors. Conclusions: PPE monitors are an important part of a comprehensive COVID-19 prevention strategy. In early 2021, the UNC Medical Center posted and hired paid PPE monitor positions to continue this critical work in a sustainable way.Funding: NoDisclosures: None

OBJECTIVEBurn patients are particularly vulnerable to infection, and an estimated half of all burn deaths are due to infections. This study explored risk factors for healthcare-associated infections (HAIs) in adult burn patients.DESIGNRetrospective cohort study.SETTINGTertiary-care burn center.PATIENTSAdults (≥18 years old) admitted with burn injury for at least 2 days between 2004 and 2013.METHODSHAIs were determined in real-time by infection preventionists using Centers for Disease Control and Prevention criteria. Multivariable Cox proportional hazards regression was used to estimate the direct effect of each risk factor on time to HAI, with inverse probability of censor weights to address potentially informative censoring. Effect measure modification by burn size was also assessed.RESULTSOverall, 4,426 patients met inclusion criteria, and 349 (7.9%) patients had at least 1 HAI within 60 days of admission. Compared to 6 times as likely to acquire an HAI (HR, 6.38; 95% CI, 3.64–11.17); and patients with >20% TBSA were >10 times as likely to acquire an HAI (HR, 10.33; 95% CI, 5.74–18.60). Patients with inhalational injury were 1.5 times as likely to acquire an HAI (HR, 1.61; 95% CI, 1.17–2.22). The effect of inhalational injury (P=.09) appeared to be larger among patients with ≤20% TBSA.CONCLUSIONSLarger burns and inhalational injury were associated with increased incidence of HAIs. Future research should use these risk factors to identify potential interventions.Infect Control Hosp Epidemiol 2017;38:1441–1448

Health care-associated infections in burn patients, from ventilator-associated pneumonia to skin and soft tissue infections, can substantially compromise outcomes, because these complications are associated with longer lengths of stay, increased morbidity and mortality, and greater direct medical costs. Health care-associated infections are largely preventable, through surveillance, education, appropriate hand hygiene, and culture change, especially for device-related infections. Systems-based practice, which allows individuals and clinical microsystems to navigate and improve the macro health care system, may be one of the most powerful skill sets to effect change, permitting a shift in culture toward patient safety and quality improvement.

Background Fecal indicator bacteria used to assess illness risks in recreational waters (e.g., Escherichia coli, Enterococci) cannot discriminate among pollution sources. To address this limitation, human-associated Bacteroides markers have been proposed, but the risk of illness associated with the presence of these markers in recreational waters is unclear. Our objective was to estimate associations between human-associated Bacteroides markers in water and self-reported illness among swimmers at 6 U.S. beaches spanning 2003–2007. Methods We used data from a prospectively-enrolled cohort of 12,060 swimmers surveyed about beach activities and water exposure on the day of their beach visit. Ten to twelve days later, participants reported gastroinestinal, diarrheal, and respiratory illnesses experienced since the visit. Daily water samples were analyzed for the presence of human-associated Bacteroides genetic markers: HF183, BsteriF1, BuniF2, HumM2. We used model-based standardization to estimate risk differences (RD) and 95% confidence intervals (CI). We assessed whether the presence of Bacteroides markers were modifiers of the association between general Enterococcus and illness among swimmers using interaction contrast. Results Overall we observed inconsistent associations between the presence of Bacteroides markers and illness. There was a pattern of increased risks of gastrointestinal (RD = 1.9%; 95% CI: 0.1%, 3.7%), diarrheal (RD = 1.3%; 95% CI: -0.2%, 2.7%), and respiratory illnesses (RD = 1.1%; 95% CI: -0.2%, 2.5%) associated with BsteriF1. There was no evidence that Bacteroides markers acted as modifiers of Enterococcus and illness. Patterns were similar when stratified by water matrix. Conclusions Quantitative measures of fecal pollution using Bacteroides, rather than presence-absence indicators, may be necessary to accurately assess human risk specific to the presence of human fecal pollution. Electronic supplementary material The online version of this article (10.1186/s12940-017-0308-3) contains supplementary material, which is available to authorized users.

Cisplatin and other metal-based drugs often display side effects and tumor resistance after prolonged use. Because rhenium-based anticancer complexes are often less toxic, a novel series of organorhenium complexes were synthesized of the types: XRe(CO)(3)Z (X = α-diimines and Z = p-toluenesulfonate, 1-naphthalenesulfonate, 2-naphthalenesulfonate, picolinate, nicotinate, aspirinate, naproxenate, flufenamate, ibuprofenate, mefenamate, tolfenamate, N-acetyl-tryptophanate), and their biological properties were examined. Specifically, in hormone-dependent MCF-7 and hormone-independent triple-negative MDA-MB-231 breast cancer cells, the p-toluenesulfonato, 1-naphthalenesulfonato, 2-naphthalenesulfonato, picolinato, nicotinato, acetylsalicylato, flufenamato, ibuprofenato, mefenamato, and N-acetyl-tryptophanato complexes were found to be far more potent than conventional drug cisplatin. DNA-binding studies were performed in each case via UV–Vis titrations, cyclic voltammetry, gel electrophoresis, and viscosity, which suggest DNA partial intercalation interaction, and the structure–activity relationship studies suggest that the anticancer activities increase with the increasing lipophilicities of the compounds, roughly consistent with their DNA-binding activities.

During the past decade, the incidence and severity of Clostridium difficile infection (CDI) have significantly increased, leading to a rise in CDI-associated hospitalizations, health care costs, and mortality. Although treatment options exist for CDI, recurrence is frequent following treatment. Furthermore, patients with at least one CDI recurrence are at an increased risk of developing additional recurrences. A novel approach to the prevention of recurrent CDI is the use of monoclonal antibodies directed against the toxins responsible for CDI as an adjunct to antibiotic treatment. Bezlotoxumab, a human monoclonal antibody that binds and neutralizes C. difficile toxin B, is the first therapeutic agent to receive United States Food and Drug Administration approval for the prevention of CDI recurrence. Clinical studies have demonstrated superior efficacy of bezlotoxumab in adults receiving antibiotic therapy for CDI compared with antibiotic therapy alone for the prevention of CDI recurrence. Bezlotoxumab was well tolerated in clinical trials, with the most common adverse effects being nausea, vomiting, fatigue, pyrexia, headache, and diarrhea. The demonstrated efficacy, safety, and characteristics of bezlotoxumab present an advance in prevention of CDI recurrence.

Purpose Payment for healthcare services in the USA has shifted from fee for service to compensation based on value and quality. The indicators used for payments are a variety of clinical measures, including administration of vaccines to patients. The purpose of this paper is to describe the implementation of programs in health systems to improve vaccination rates and patient outcomes. Design/methodology/approach A search of the literature was conducted to find examples of vaccine programs in US health systems, and also to identify policies to improve immunization rates. Findings Successful programs for improving vaccination rates require advocacy and support of leadership, a systematic and multidisciplinary approach, and an evaluation of local resources and capacity. Numerous examples exist of medical, nursing, and pharmacy led programs that improve vaccination rates. The department in charge has relied on the support of other groups to ensure the success. Social implications Mandatory vaccination of healthcare personnel (HCP) in the health system has been a growing trend in the USA. Although there has been some resistance to mandatory vaccinations for HCP, the standards and requirements have resulted in improved rates in health systems, which ultimately improve efficiency and protects patients. Originality/value This review describes considerations for implementing a successful vaccination program in a health system and provides examples of specific strategies. An overview of mandatory vaccinations for HCP is also described.

Purpose The purpose of this paper is to describe the history of pharmacist involvement as vaccine providers in the USA and discuss examples of growing interests in other parts of the world. Design/methodology/approach Literature searches were performed in PubMed as well as pharmacy-related journals. Findings Pharmacists have been involved with the storage and management of vaccines for more than a century. Based on the unmet needs in meeting national goals for vaccination rates among adults in the USA, efforts led to training and recognizing pharmacists as vaccine providers which is now within the scope of practice for a pharmacist in all US states and territories. Pharmacists complete a comprehensive training program in vaccine sciences, regulatory considerations, as well as demonstration of skills in administering vaccines. Over 300,000 pharmacists have been trained in vaccine delivery and this represents the majority of the pharmacist workforce in the USA. There are examples of the beneficial impact of pharmacist involvement as vaccine providers in community pharmacy settings. Research limitations/implications This review is based on a thorough review of the literature but was not conducted in a systematic fashion. Originality/value This review provides a historical perspective and evidence of the benefit of pharmacists as vaccine providers.

This article reviews a single burn center experience with life-threatening skin disorders, over a 10-year period. It explores the incidence of health care-associated infections and the impact on length of stay, hospital charges, and mortality.

This article reviews a single burn center experience with porcine xenografts to treat pediatric scald injuries, over a 10-year period. The authors compare xenografting to autografting, as well as wound care only, and provide outcome data on length of stay, incidence of health care-associated infections, and need for reconstructive surgery.

Background We evaluated the extent to which hospital characteristics, infection control practices, and compliance with prevention bundles impacted multidrug-resistant organism (MDRO) infections in Thai hospitals. Methods From 1 January 2014 to 30 November 2014, we surveyed all Thai hospitals with an intensive care unit and ≥250 beds. Infection control practices for methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant Acinetobacter baumannii (MDR-AB) were assessed. Linear regression was used to examine associations between hospital characteristics and prevention bundle compliance and changes in MDRO infection rates. Results A total of 212 of 245 (86.5%) eligible hospitals responded. Most hospitals regularly used several fundamental infection control practices for MRSA and MDR-AB (ie, contact precautions, private room/cohorting, hand hygiene, environmental cleaning, and antibiotic stewardship); advanced infection control practices (ie, active surveillance, chlorhexidine bathing, decolonization for MRSA, and hydrogen peroxide vaporizer for MDR-AB) were used less commonly. Facilities with ≥75% compliance with the MRSA prevention bundle experienced a 17.4% reduction in MRSA rates (P = .03). Although the presence of environmental cleaning services (41.3% reduction, P = .01) and a microbiology laboratory (82.8% reduction, P = .02) were among characteristics associated with decreases in MDR-AB rates, greater compliance with the MDR-AB prevention bundle did not lead to reductions in MDR-AB rates. Conclusions Although fundamental MRSA and MDR-AB control practices are used regularly in most Thai hospitals, compliance with more comprehensive bundled prevention approaches is suboptimal. Improving compliance with bundled infection prevention approaches and promoting the integration of certain hospital factors into infection control efforts may help reduce MDRO infections in Thai hospitals.

Biochemical and structural studies demonstrate that S100A1 is involved in a Ca2+-dependent interaction with the type 2α and type 2β regulatory subunits of protein kinase A (PKA) (RIIα and RIIβ) to activate holo-PKA. The interaction was specific for S100A1 because other calcium-binding proteins (i.e., S100B and calmodulin) had no effect. Likewise, a role for S100A1 in PKA-dependent signaling was established because the PKA-dependent subcellular redistribution of HDAC4 was abolished in cells derived from S100A1 knockout mice. Thus, the Ca2+-dependent interaction between S100A1 and the type 2 regulatory subunits represents a novel mechanism that provides a link between Ca2+ and PKA signaling, which is important for the regulation of gene expression in skeletal muscle via HDAC4 cytosolic–nuclear trafficking.

To examine the uptake of prenatal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) immunization among pregnant women in the United States.Using MarketScan data, we conducted a historical cohort study among pregnant women with employer-based commercial insurance in the United States who delivered between January 1, 2010, and December 31, 2014. We examined temporal trends of uptake, predictors of uptake, and timing of Tdap immunization.Among 1,222,384 eligible pregnancies in 1,147,711 women, receipt of prenatal Tdap immunization increased from 0.0% of women who delivered in January 2010 to 9.8% who delivered in October 2012 (the date of the recommendation by the Advisory Committee on Immunization Practices for Tdap during every pregnancy) to 44.4% who delivered in December 2014. Among women who received Tdap during pregnancy, the majority were immunized between 27 weeks and 36 6/7 weeks of gestation per the Advisory Committee on Immunization Practices recommendation. In multivariable analyses among women who delivered between November 2012 and December 2014, rates of prenatal Tdap immunization were lower for women younger than 25 years of age (eg, 20-24 compared with 30-34 years rate ratio [RR] 0.83, 95% confidence interval [CI] 0.85-0.88), with other children (eg, three compared with zero children: RR 0.86, 95% CI 0.84-0.88), residing in the South compared with the Midwest (RR 0.81, 95% CI 0.80-0.82), or with emergency department visits in early pregnancy (RR 0.93, 95% CI 0.92-0.95). The proportion of pregnant women who received prenatal Tdap increased with increasing gestational age at birth.By the end of 2014, fewer than half of pregnant women in the United States were receiving prenatal Tdap immunization. Implementation and dissemination strategies are needed to increase Tdap coverage among pregnant women, especially those who are young, have other children, or reside in the South.

S100A1 is a member of the S100 family of Ca2+-binding proteins and regulates several cellular processes, including those involved in Ca2+signaling and cardiac and skeletal muscle function. In Alzheimer's disease, brain S100A1 is overexpressed and gives rise to disease pathologies, making it a potential therapeutic target. The 2.25 Å resolution crystal structure of Ca2+-S100A1 is solved here and is compared with the structures of other S100 proteins, most notably S100B, which is a highly homologous S100-family member that is implicated in the progression of malignant melanoma. The observed structural differences in S100A1versusS100B provide insights regarding target protein-binding specificity and for targeting these two S100 proteins in human diseases using structure-based drug-design approaches.

The heterogeneous ribonucleoprotein A18 (hnRNP A18) is upregulated in hypoxic regions of various solid tumors and promotes tumor growthviathe coordination of mRNA transcripts associated with pro-survival genes. Thus, hnRNP A18 represents an important therapeutic target in tumor cells. Presented here is the first X-ray crystal structure to be reported for the RNA-recognition motif of hnRNP A18. By comparing this structure with those of homologous RNA-binding proteins (i.e.hnRNP A1), three residues on one face of an antiparallel β-sheet (Arg48, Phe50 and Phe52) and one residue in an unstructured loop (Arg41) were identified as likely to be involved in protein–nucleic acid interactions. This structure helps to serve as a foundation for biophysical studies of this RNA-binding protein and structure-based drug-design efforts for targeting hnRNP A18 in cancer, such as malignant melanoma, where hnRNP A18 levels are elevated and contribute to disease progression.

Background: Well-designed infection prevention programs include basic elements aimed at reducing the risk of transmission of infectious agents in healthcare settings. Although most acute-care facilities have robust infection prevention programs, data are sporadic and often lacking in other healthcare settings. Infection control assessment tools were developed by the CDC to assist health departments in assessing infection prevention preparedness across a wide spectrum of health care including acute care, long-term care, outpatient care, and hemodialysis. Methods: The North Carolina Division of Public Health collaborated with the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) to conduct a targeted number of on-site assessments for each healthcare setting. Three experienced infection preventionists recruited facilities, conducted on-site assessments, provided detailed assessment findings, and developed educational resources. Results: The goal of 250 assessments was exceeded, with 277 on-site assessments completed across 75% of North Carolina counties (Table 1). Compliance with key observations varied by domain and type of care setting (Table 2). Conclusions: Comprehensive on-site assessments of infection prevention programs are an effective way to identify gaps or breaches in infection prevention practices. Gaps identified in acute care primarily related to competency validation: however, gaps presenting a threat to patient safety (ie, reuse of single dose vials, noncompliance with sterilization and/or high-level disinfection processes) were identified in other care settings. Infection control assessment and response findings underscore the need for ongoing assessment, education, and collaboration among all healthcare settings.Funding: NoneDisclosures: None

Background: Antibiotic time outs (ABTOs), formal reassessments of all new antimicrobial regimens by the care team, can optimize antimicrobial regimens, reducing antimicrobial overuse and potentially improving outcomes. Implementation of ABTOs is a substantial challenge. We used quality improvement methods to implement robust, meaningful, team-driven ABTOs in general medicine ward services. Methods: We identified and engaged stakeholders to serve as champions for the quality improvement initiative. On October 1, 2018, 2 internal medicine teaching services (services A and B), began conducting ABTOs on all patients admitted to their services receiving systemic antimicrobials for at least 36 hours. Eligible patients were usually identified by the team pharmacist. ABTOs were completed within 72 hours of antibiotic initiation and were documented in the electronic medical record (EMR) by providers using a template. The process was modified as necessary in response to feedback from frontline clinicians using plan-do-study-act (PDSA) methods. We subsequently spread the project to 2 additional internal medicine services (services C and D); 2 family medicine teams (services E and F); and 1 general pediatric service (service G). The project is ongoing. We collected data for the following metrics: (1) proportion of ABTO-eligible patients with an ABTO; (2) proportion of ABTOs conducted within the recommended time frame; (3) documented plan changes as a result of ABTO (eg, change IV antibiotics to PO); (4) proportion of documented plan changes actually completed within 24 hours. Results: Within 12 weeks, services A and B were successfully completing time outs in >80% of their patients. This target was consistently reached by services C, D, E, F, and G almost immediately following launch on those services. As of June 29, 2019, >80% of eligible patients across all participating services have had a time out conducted for 16 consecutive weeks. ABTOs have resulted in a change in management in 35% of cases, including IV-to-PO change in 19% of cases and discontinuation in 5%. Overall, 77% of time outs occurred during the 36–72-hour window. Ultimately, 95% of documented plan changes were completed within 24 hours. Conclusions: ABTOs are effective but implementation is challenging. We achieved high compliance with ABTOs without using electronic reminders. Our results suggest that ABTOs were impactful in the non–critical-care general medicine setting. Next steps include (1) development of EMR-based tools to facilitate identifying eligible patients and ABTO documentation; (2) continued spread through our health care system; and (3) analysis of ABTO impact using ABTO-unexposed patients as a control group.Funding: NoneDisclosures: None

Background: The contaminated healthcare environment, including operating rooms (ORs), can serve as an important role in transmission of healthcare-associated pathogens. Studies are very limited regarding the level of contamination of ORs during the surgery of a patient on contact precautions and the risk to the next surgery patient after standard room cleaning and disinfection. Objective: Here, we investigated the microbial burden on the OR environment when patients on contact precautions receive surgery, and we assessed the impact of cleaning and disinfection on the contamination of OR environmental sites. Methods: This investigation was conducted in the ORs of an academic facility during an 8-month period. It involved 10 patients on contact precautions for multidrug-resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA; n = 7); carbapenem-resistant Enterobacteriaceae (CRE) plus MRSA (n = 2); and vancomycin-resistant Enterococcus (VRE) plus MRSA (n = 1), who underwent surgery. Environmental sampling was performed at the following time points: (1) immediately before the surgical patient’s arrival in the OR, (2) after surgery but before the OR cleaning and disinfection, and (3) after the OR cleaning and disinfection. In total, 1,520 environmental samples collected from 15 OR sites for 10 surgical patients at 3 time points were analyzed. Relatedness among environmental MRSA isolates was determined by pulsed-field gel electrophoresis. Results: Overall, the mean CFUs of aerobes per Rodac plate (CFU/25 cm2) were 10.1 before patient arrival, 14.7 before cleaning and disinfection, and 6.3 after cleaning and disinfection (P < .0001, after cleaning and disinfection vs before cleaning and disinfection). Moreover, 7 environmental sites (46.7%) after cleaning and disinfection, including bed, arm rest, pyxis counter, floor (near, door side), floor (far, by door), steel counter (small, near bed), and small computer desk, had significantly lower mean counts of aerobes than before patient arrival or before cleaning and disinfection (Fig. 1). The mean CFUs of MRSA per Rodac plate (CFU/25 cm2) were 0.04 before patient arrival, 0.66 before cleaning and disinfection, and 0.08 after cleaning and disinfection (P = .0006, after cleaning and disinfection vs before cleaning and disinfection). Of environmental sites where MRSA was identified, 87.2% were on floors (41 of 47) and 19.1% were after cleaning and disinfection (9 of 47, 8 from floors and 1 from pyxis touchscreen). The A2/B2 MRSA strain was identified on different environmental sites (eg, floor, computer desk, counter) in various rooms (eg, OR2, OR10, and OR16), even after cleaning and disinfection (Fig. 2). Conclusions: Our study has demonstrated that the OR environment was contaminated with aerobic bacteria and MRSA after surgery and that MRSA persisted in the environment even after cleaning and disinfection. Enhanced environmental cleaning in the perioperative environment used for patients on isolation is necessary to prevent transmission of healthcare-associated pathogens in ORs.Funding: NoneDisclosures: Drs. Rutala and Weber are consultants to PDI (Professional Disposable International)

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly common in the United States and have the potential to spread widely across healthcare networks. Only a fraction of patients with CRE carriage (ie, infection or colonization) are identified by clinical cultures. Interventions to reduce CRE transmission can be explored with agent-based models (ABMs) comprised of unique agents (eg, patients) represented by a synthetic population or model-generated representation of the population. We used electronic health record data to determine CRE carriage risk, and we discuss how these results can inform CRE transmission parameters for hospitalized agents in a regional healthcare network ABM. Methods: We reviewed the laboratory data of patients admitted during July 1, 2016−June 30, 2017, to any of 7 short-term acute-care hospitals of a regional healthcare network in North Carolina (N = 118,022 admissions) to find clinically detected cases of CRE carriage. A case was defined as the first occurrence of Enterobacter spp, Escherichia coli, or Klebsiella spp resistant to any carbapenem isolated from a clinical specimen in an admitted patient. We used Poisson regression to estimate clinically detected CRE carriage risk according to variables common to data from both the electronic health records and the ABM synthetic population, including patient demographics, systemic antibiotic administration, intensive care unit stay, comorbidities, length of stay, and admitting hospital size. Results: We identified 58 (0.05%) cases of CRE carriage among all admissions. Among these cases, 30 (52%) were ≥65 years of age and 37 (64%) were female. During their admission, 47 cases (81%) were administered systemic antibiotics and 18 cases (31%) had an intensive care unit stay. Patients administered systemic antibiotics and those with an intensive care unit stay had CRE carriage risk 6.5 times (95% CI, 3.4–12.5) and 4.9 times (95% CI, 2.8–8.5) higher, respectively, than patients without these exposures (Fig. 1). Patients ≥50 years of age and those with a higher Elixhauser comorbidity index score and with longer length of stay also had increased CRE carriage risk. Conclusions: Among admissions in our dataset, CRE carriage risk was associated with systemic antibiotic exposure, intensive care unit stay, higher Elixhauser comorbidity index score, and longer length of stay. We will use these risk estimates in the ABM to inform agents’ CRE carriage status upon hospital admission and the CRE transmission parameters for short-term acute-care hospitals. We will explore CRE transmission interventions in the parameterized regional healthcare network ABM and assess the impact of CRE carriage underestimation.Funding: This work was supported by Centers for Disease Control and Prevention (CDC) Cooperative Agreement number U01CK000527. The conclusions, findings, and opinions expressed do not necessarily reflect the official position of CDC.Disclosures: None

Type 2 transglutaminase (TG2) is an important cancer stem cell survival protein that exists in open and closed conformations. The major intracellular form is the closed conformation that functions as a GTP-binding GTPase and is required for cancer stem cell survival. However, at a finite rate, TG2 transitions to an open conformation that exposes the transamidase catalytic site involved in protein-protein crosslinking. The activities are mutually exclusive, as the closed conformation has GTP binding/GTPase activity, and the open conformation transamidase activity. We recently showed that GTP binding, but not transamidase activity, is required for TG2-dependent cancer stem cell invasion, migration and tumour formation. However, we were surprised that transamidase site-specific inhibitors reduce cancer stem cell survival. We now show that compounds NC9, VA4 and VA5, which react exclusively at the TG2 transamidase site, inhibit both transamidase and GTP-binding activities. Transamidase activity is inhibited by direct inhibitor binding at the transamidase site, and GTP binding is blocked because inhibitor interaction at the transamidase site locks the protein in the extended/open conformation to disorganize/inactivate the GTP binding/GTPase site. These findings suggest that transamidase site-specific inhibitors can inhibit GTP binding/signalling by driving a conformation change that disorganizes the TG2 GTP binding to reduce TG2-dependent signalling, and that drugs designed to target this site may be potent anti-cancer agents.

Background Infections are an important cause of morbidity and mortality after burn injuries. Here, we describe the time line of infections and pathogens after burns. Methods A retrospective study was performed in a large tertiary care burn center from 2004-2013. Analyses were performed on health care–associated infections (HAIs) meeting Centers for Disease Control and Prevention criteria and on all positive cultures. Incidence rates per 1,000 days were calculated for specific HAI categories and pathogens and across hospitalization time (week 1, weeks 2-3, and week ≥4). Results Among 5,524 patients, the median burn size was 4% of total body surface area (interquartile range, 2%-10%). Of the patients, 7% developed an HAI, of whom 33% had >1 HAI episode. Gram-positive bacteria were isolated earlier, and gram-negative bacteria were isolated later during hospitalization. Of 1,788 bacterial isolates, 44% met criteria for multidrug resistance, and 23% met criteria for extensive drug resistance. Bacteria tended to become increasingly resistant to antibiotics as time from admission increased. Conclusions We observed differences in infection type, pathogen, and antibiotic-resistant bacterium risk across time of hospitalization. These results may guide infection prevention in various stages of the postburn admission.

We measured the disinfection of MRSA and Clostridium difficile spores using an ultraviolet C (UV-C) device, and we correlated those results to measurements and computer simulations of UV-C surface intensity. The results demonstrate both large differences in UV light intensity across various surfaces and how this leads to significant differences in disinfection.

Clonal Mycobacterium mucogenicum isolates (determined by molecular typing) were recovered from 19 bronchoscopic specimens from 15 patients. None of these patients had evidence of mycobacterial infection. Laboratory culture materials and bronchoscopes were negative for Mycobacteria. This pseudo-outbreak was caused by contaminated ice used to provide bronchoscopic lavage. Control was achieved by transitioning to sterile ice.

TargetingClostridium difficileinfection (CDI) is challenging because treatment options are limited, and high recurrence rates are common. One reason for this is that hypervirulent CDI often has a binary toxin termed theC. difficiletoxin (CDT), in addition to the enterotoxins TsdA and TsdB. CDT has an enzymatic component, termed CDTa, and a pore-forming or delivery subunit termed CDTb. CDTb was characterized here using a combination of single particle cryoEM, X-ray crystallography, NMR, and other biophysical methods. In the absence of CDTa, two novel di-heptamer structures foractivated CDTb (aCDTb; 1.0 MDa) were solved at atomic resolution including a symmetric (SymCDTb; 3.14 Å) and an asymmetric form (AsymCDTb; 2.84 Å). Roles played by two receptor-binding domains of aCDTb were of particular interest since RBD1 lacks sequence homology to any other known toxin, and the RBD2 domain is completely absent in other well-studied heptameric toxins (i.e. anthrax). ForAsymCDTb, a novel Ca2+binding site was discovered in RBD1 that is important for its stability, and RBD2 was found to be critical for host cell toxicity and the novel di-heptamer fold for both forms of aCDTb. Together, these studies represent a starting point for structure-based drug-discovery strategies to targeting CDT in the most severe strains of CDI.SIGNIFICANCE STATEMENTThere is a high burden fromC. difficileinfection (CDI) throughout the world, and the Center for Disease Control (CDC) reports more than 500,000 cases annually in the United States, resulting in an estimated 15,000 deaths. In addition to the large clostridial toxins, TcdA/TcdB, a thirdC. difficilebinary toxin (CDT) is associated with the most serious outbreaks of drug resistant CDI in the 21stcentury. Here, structural biology and biophysical approaches were used to characterize the cell binding component of CDT, termed CDTb, at atomic resolution. Surprisingly, two novel structures were solved from a single sample that help to explain the molecular underpinnings ofC. difficiletoxicity. These structures will also be important for targeting this human pathogen via structure-based therapeutic design methods.

Objective:To update current estimates of non–device-associated pneumonia (ND pneumonia) rates and their frequency relative to ventilator associated pneumonia (VAP), and identify risk factors for ND pneumonia.Design:Cohort study.Setting:Academic teaching hospital.Patients:All adult hospitalizations between 2013 and 2017 were included. Pneumonia (device associated and non–device associated) were captured through comprehensive, hospital-wide active surveillance using CDC definitions and methodology.Results:From 2013 to 2017, there were 163,386 hospitalizations (97,485 unique patients) and 771 pneumonia cases (520 ND pneumonia and 191 VAP). The rate of ND pneumonia remained stable, with 4.15 and 4.54 ND pneumonia cases per 10,000 hospitalization days in 2013 and 2017 respectively (P= .65). In 2017, 74% of pneumonia cases were ND pneumonia. Male sex and increasing age we both associated with increased risk of ND pneumonia. Additionally, patients with chronic bronchitis or emphysema (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.40–3.06), congestive heart failure (HR, 1.48; 95% CI, 1.07–2.05), or paralysis (HR, 1.72; 95% CI, 1.09–2.73) were also at increased risk, as were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18–2.00) or in the ICU (HR, 1.49; 95% CI, 1.06–2.09). We did not detect a change in ND pneumonia risk with use of chlorhexidine mouthwash, total parenteral nutrition, all medications of interest, and prior ventilation.Conclusion:The incidence rate of ND pneumonia did not change from 2013 to 2017, and 3 of 4 nosocomial pneumonia cases were non–device associated. Hospital infection prevention programs should consider expanding the scope of surveillance to include non-ventilated patients. Future research should continue to look for modifiable risk factors and should assess potential prevention strategies.

A novel disinfectant studied using an EPA protocol demonstrated sustained antimicrobial activity (ie, 3–5 log10 reduction) in 5 minutes after 24 hours for Staphylococcus aureus, vancomycin-resistant Enterococcus, Candida auris, carbapenem-resistant Escherichia coli and antibiotic-susceptible E. coli, and Enterobacter spp. Only ∼2 log10 reduction occurred with carbapenem-resistant Enterobacter spp and K. pneumoniae, and antibiotic-susceptible K. pneumoniae.

HIV type I (HIV-1) reverse transcriptase (RT) catalyzes the conversion of viral RNA into DNA, initiating the chain of events leading to integration of proviral DNA into the host genome. RT is expressed as a single polypeptide chain within the Gag-Pol polyprotein, and either prior to or following excision by HIV-1 protease forms a 66 kDa chain (p66) homodimer precursor. Further proteolytic attack by HIV-1 protease cleaves the ribonuclease H (RNase H) domain of a single subunit to yield the mature p66/p51 heterodimer. Here, we probe the spatial domain organization within the p66 homodimer using pulsed Q-band double electron-electron resonance (DEER) EPR spectroscopy to measure a large number of intra- and intersubunit distances between spin labels attached to surface-engineered cysteines. The DEER-derived distances are fully consistent with the structural subunit asymmetry found in the mature p66/p51 heterodimer in which catalytic activity resides in the p66 subunit, while the p51 subunit purely serves as a structural scaffold. Furthermore, the p66 homodimer precursor undergoes a conformational change involving the thumb, palm, and finger domains in one of the subunits (corresponding to the p66 subunit in the mature p66/p51 heterodimer) from a closed to a partially open state upon addition of a nonnucleoside inhibitor. The relative orientation of the domains was modeled by simulated annealing driven by the DEER-derived distances. Finally, the RNase H domain that is cleaved to generate p51 in the mature p66/p51 heterodimer is present in 2 major conformers. One conformer is fully solvent accessible thereby accounting for the observation that only a single subunit of the p66 homodimer precursor is susceptible to HIV-1 protease.

Second harmonic generation (SHG) is an emergent biophysical method that sensitively measures real-time conformational change of biomolecules in the presence of biological ligands and small molecules. This study describes the successful implementation of SHG as a primary screening platform to identify fragment ligands to oncogenic Kirsten rat sarcoma (KRas). KRas is the most frequently mutated driver of pancreatic, colon, and lung cancers; however, there are few well-characterized small molecule ligands due to a lack of deep binding pockets. Using SHG, we identified a fragment binder to KRas(G12D) and used (1)H (15)N transverse relaxation optimized spectroscopy (TROSY) heteronuclear single-quantum coherence (HSQC) NMR to characterize its binding site as a pocket adjacent to the switch 2 region. The unique sensitivity of SHG furthered our study by revealing distinct conformations induced by our hit fragment compared with 4,6-dichloro-2-methyl-3-aminoethyl-indole (DCAI), a Ras ligand previously described to bind the same pocket. This study highlights SHG as a high-throughput screening platform that reveals structural insights in addition to ligand binding.

Rationale & Objective Studies of patients on maintenance dialysis therapy suggest that standard-dose influenza vaccine (SDV) may not prevent influenza-related outcomes. Little is known about the comparative effectiveness of SDV versus high-dose influenza vaccine (HDV) in this population. Study Design Cohort study using data from the US Renal Data System. Setting & Participants 507,552 adults undergoing in-center maintenance hemodialysis between the 2010 to 2011 and 2014 to 2015 influenza seasons. Exposures SDV and HDV. Outcomes All-cause mortality, hospitalization due to influenza or pneumonia, and influenza-like illness during the influenza season. Analytic Approach Patients were eligible for inclusion in multiple yearly cohorts; thus, our unit of analysis was the influenza patient-season. To examine the relationship between vaccine dose and effectiveness outcomes, we estimated risk differences and risk ratios using propensity score weighting of Kaplan-Meier functions, accounting for a wide range of patient- and facility-level characteristics. For nonmortality outcomes, we used competing-risk methods to account for the high mortality rate in the dialysis population. Results Within 225,215 influenza patient-seasons among adults 65 years and older, 97.4% received SDV and 2.6% received HDV. We observed similar risk estimates for HDV and SDV recipients for mortality (risk difference, −0.08%; 95% CI, −0.85% to 0.80%), hospitalization due to influenza or pneumonia (risk difference, 0.15%; 95% CI, −0.69% to 0.93%), and influenza-like illness (risk difference, 0.00%; 95% CI, −1.50% to 1.08%). Our findings were similar among adults younger than 65 years, as well as within other subgroups defined by influenza season, age group, dialysis vintage, month of influenza vaccination, and vaccine valence. Limitations Residual confounding and outcome misclassification. Conclusions The HDV does not appear to provide additional protection beyond the SDV against all-cause mortality or influenza-related outcomes for adults undergoing hemodialysis. The additional cost and side effects associated with HDV should be considered when offering this vaccine. Future studies of HDV and other influenza vaccine strategies are warranted.

A 37-year-old immunosuppressed female presented with pain and swelling in her left lower extremity associated with a chronic nonhealing ulceration of her left lateral shin. The patient had a complex medical history most noted for systemic lupus erythematous (SLE), for which she was being treated

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (eg, gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection. As many of these items are temperature sensitive, low-temperature chemical methods must be used rather than steam sterilization. Strict adherence to current guidelines is required as more outbreaks have been linked to inadequately cleaned or disinfected endoscopes and other semicritical items than any other reusable medical devices.

The contaminated surface environment in the rooms of hospitalized patients is an important risk factor for the colonization and infection of patients with multidrug-resistant pathogens. Improved terminal cleaning and disinfection have been demonstrated to reduce the incidence of health care–associated infections. In the United States, hospitals generally perform daily cleaning and disinfection of patient rooms. However, cleaning and disinfection are limited by the presence of the patient in room (eg, current ultraviolet devices and hydrogen peroxide systems cannot be used) and the fact that after disinfection pathogenic bacteria rapidly recolonize surfaces and medical devices/equipment. For this reason, there has been great interest in developing methods of continuous room disinfection and/or “self-disinfecting” surfaces. This study will review the research on self-disinfecting surfaces (eg, copper-coated surfaces and persistent chemical disinfectants) and potential new room disinfection methods (eg, “blue light” and diluted hydrogen peroxide systems).

Millions of gastrointestinal endoscopes are performed each year in the United States. Gastrointestinal endoscopes become highly contaminated during use (ie, internal channels contain 7-10-log10 enteric microorganisms). Currently, endoscopes (eg, bronchoscopes and gastrointestinal endoscopes) are classified as semicritical items because they contact intact mucous membranes and most commonly undergo cleaning followed by high-level disinfection, which may result in as little as a 6-log10 reduction of microorganisms. Therefore, and not surprisingly, in recent years there have been multiple reports that have documented that endoscopes, especially duodenoscopes, frequently remain contaminated with bacterial pathogens after proper cleaning and disinfection. Multiple outbreaks of multidrug-resistant organisms from contaminated duodenoscopes have resulted in substantial death and morbidity. Because duodenoscopes commonly contact nonintact mucous membranes and sterile tissue, such endoscopes should be considered critical items. We propose that to ensure patient safety, we follow the Spaulding scheme and move from high-level disinfection to sterilization of reusable endoscopes or use an alternative diagnostic/therapeutic method (eg, disposable sterile endoscopes).

Serving a critical role in neurotransmission, human acetylcholinesterase (hAChE) is the target of organophosphate nerve agents. Hence, there is an active interest in studying the mechanism of inhibition and recovery of enzymatic activity, which could lead to better countermeasures against nerve agents. As hAChE is found in different oligomeric assemblies, certain approaches to studying it have been problematic. Herein, we examine the biochemical and structural impact of monomerizing hAChE by using two mutations: L380R/F535K. The activities of monomeric hAChE L380R/F535K and dimeric hAChE were determined to be comparable utilizing a modified Ellman's assay. To investigate the influence of subunit–subunit interactions on the structure of hAChE, a 2.1 Å X‐ray crystallographic structure was determined. Apart from minor shifts along the dimer interface, the overall structure of the hAChE L380R/F535K mutant is similar to that of dimeric hAChE. To probe whether the plasticity of the active site was overtly impacted by monomerizing hAChE, the kinetic constants of (PR/S) − VX (ethyl({2‐[bis(propan‐2‐yl)amino]ethyl}sulfanyl)(methyl)phosphinate) inhibition and subsequent rescue of hAChE L380R/F535K activity with HI‐6 (1‐(2′‐hydroxyiminomethyl‐1′‐pyridinium)‐3‐(4′‐carbamoyl‐1‐pyridinium)) were determined and found to be comparable to those of dimeric hAChE. Thus, hAChE L380R/F535K could be used as a substitute for dimeric hAChE when experimentally probing the ability of the hAChE active site to accommodate future nerve agent threats or judge the ability of new therapeutics to access the active site., PDB Code(s): 6O69

S100B is a small, dimeric, calcium-binding protein that is implicated in various diseases, most significantly cancer; therefore, there is interest in identifying S100B inhibitors that may have therapeutic value (Bresnick et al. Nat Rev Cancer 15:96–109, 2015; Chong et al. Curr Med Chem 23:1571–1596). Two fiuorescence polarization competition assays (FPCA) are described here for S100B and S100A1 that are amenable to high-throughput screening (HTS) campaigns and can be used to determine the binding affinity (K(i)) of the inhibitors. One FPCA is used to identify and characterize inhibitors of S100B with the aim of finding new therapeutics, and the other was developed as a counter-screen to avoid inhibitors of S100A1 due to its role in regulating skeletal and cardiac muscle function. Also outlined are methods for expressing and purifying S100B and S100A1 in quantities needed for performing large HTS campaigns.

OBJECTIVES To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group. DESIGN Two-year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group). SETTING A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate. PARTICIPANTS Nursing staff and medical care providers in the participating NHs. INTERVENTION Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit. MEASUREMENTS Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) infections. RESULTS Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69-0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65-0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92-0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2-year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653. CONCLUSIONS Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46-54, 2019.

Febrile-range hyperthermia worsens and hypothermia mitigates lung injury, and temperature dependence of lung injury is blunted by inhibitors of p38 mitogen-activated protein kinase (MAPK). Of the two predominant p38 isoforms, p38α is proinflammatory and p38β is cytoprotective. Here, we analyzed the temperature dependence of p38 MAPK activation, substrate interaction, and tertiary structure. Incubating HeLa cells at 39.5 °C stimulated modest p38 activation, but did not alter tumor necrosis factor-α (TNFα)-induced p38 activation. In in vitro kinase assays containing activated p38α and MAPK-activated kinase-2 (MK2), MK2 phosphorylation was 14.5-fold greater at 39.5 °C than at 33 °C. By comparison, we observed only 3.1- and 1.9-fold differences for activating transcription factor-2 (ATF2) and signal transducer and activator of transcription-1α (STAT1α) and a 7.7-fold difference for p38β phosphorylation of MK2. The temperature dependence of p38α:substrate binding affinity, as measured by surface plasmon resonance, paralleled substrate phosphorylation. Hydrogen–deuterium exchange MS (HDX-MS) of p38α performed at 33, 37, and 39.5 °C indicated temperature-dependent conformational changes in an α helix near the common docking and glutamate:aspartate substrate-binding domains at the known binding site for MK2. In contrast, HDX-MS analysis of p38β did not detect significant temperature-dependent conformational changes in this region. We observed no conformational changes in the catalytic domain of either isoform and no corresponding temperature dependence in the C-terminal p38α-interacting region of MK2. Because MK2 participates in the pathogenesis of lung injury, the observed changes in the structure and function of proinflammatory p38α may contribute to the temperature dependence of acute lung injury.

To the Editor—Implementation of an antimicrobial stewardship program (ASP) in an acute-care setting requires several important components: hospital administration support, an appropriate ASP team (eg, infectious disease physician(s) and pharmacist(s)), ASP program goals and carefully planned interventions, a structured reporting system, adequate hospital infrastructure, and mechanisms for education. 1 Examination of these components can provide a useful gap analysis for acute-care hospitals in various resource settings to fulfill the hospital ASP goals. To evaluate the feasibility of gap analysis based on previous ASP consensus in Asia,1 we performed a survey of hospital components and analyzed the gaps to help inform the implementation of ASP in central Thailand.

A key component to protecting healthcare personnel (HCP) and their patients is HCP immunity to vaccine preventable diseases. The Centers for Disease Control and Prevention (CDC) and many professional organizations recommend that all HCPs have demonstrated immunity to mumps, measles, rubella, varicella, influenza, and pertussis. CDC recommends and the US Occupational Safety and Health Administration (OSHA) requires that HCP with potential exposure to blood or infectious body fluids be offered hepatitis B vaccine. Immunity can be provided by appropriate immunizations (mumps, measles, rubella [MMR]; varicella; influenza, pertussis [Tdap]) or depending on the disease by one or more of the following: a positive serology, physician diagnosed disease (laboratory confirmation may be required), or birth before 1957 (MMR). Persons providing vaccines to HCP should adhere to recommendations from the Advisory Committee on Immunization Practices (ACIP) and the manufacturer’s package insert. Several vaccines can be used for postexposure prophylaxis of susceptible HCP including MMR vaccine following unprotected airborne exposure to measles exposure; varicella vaccine following unprotected airborne or contact exposure to chicken pox; hepatitis B following exposure (percutaneous, mucosal, nonintact skin) to blood or an infectious body fluid of a HBsAg-positive patient; hepatitis A (unprotected exposure to stool of infectious patient); and rabies (exposure to infectious saliva). Several vaccines can also be used for outbreak control including MMR, Tdap, meningococcal ACWY and meningococcal B, and hepatitis A. All healthcare facilities should have an organized method for assessing immunity of HCP to vaccine preventable diseases and providing appropriate immunization of susceptible HCP.

The taro plant, Colocasia esculenta, contains bioactive proteins with potential as cancer therapeutics. Several groups have reported anti-cancer activity in vitro and in vivo of taro-derived extracts (TEs). We reported that TE inhibits metastasis in a syngeneic murine model of Triple-Negative Breast Cancer (TNBC). Purpose: We sought to confirm our earlier studies in additional models and to identify novel mechanisms by which efficacy is achieved. Methods: We employed a panel of murine and human breast and ovarian cancer cell lines to determine the effect of TE on tumor cell viability, migration, and the ability to support cancer stem cells. Two syngeneic models of TNBC were employed to confirm our earlier report that TE potently inhibits metastasis. Cancer stem cell assays were employed to determine the ability of TE to inhibit tumorsphere-forming ability and to inhibit aldehyde dehydrogenase activity. To determine if host immunity contributes to the mechanism of metastasis inhibition, efficacy was assessed in immune-compromised mice. Results: We demonstrate that viability of some, but not all cell lines is inhibited by TE. Likewise, tumor cell migration is inhibited by TE. Using 2 immune competent, syngeneic models of TNBC, we confirm our earlier findings that tumor metastasis is potently inhibited by TE. We also demonstrate, for the first time, that TE directly inhibits breast cancer stem cells. Administration of TE to mice elicits expansion of several spleen cell populations but it was not known if host immune cells contribute to the mechanism by which TE inhibits tumor cell dissemination. In novel findings, we now show that the ability of TE to inhibit metastasis relies on immune T-cell-dependent, but not B cell or Natural Killer (NK)-cell-dependent mechanisms. Thus, both tumor cell-autonomous and host immune factors contribute to the mechanisms underlying TE efficacy. Our long-term goal is to evaluate TE efficacy in clinical trials. Most of our past studies as well as many of the results reported in this report were carried out using an isolation protocol described earlier (TE). In preparation for a near future clinical trial, we have now developed a strategy to isolate an enriched taro fraction, TE-method 2, (TE-M2) as well as a more purified subfraction (TE-M2F1) which can be scaled up under Good Manufacturing Practice (GMP) conditions for evaluation in human subjects. We demonstrate that TE-M2 and TE-M2F1 retain the anti-metastatic properties of TE. Conclusions: These studies provide further support for the continued examination of biologically active components of Colocasia esculenta as potential new therapeutic entities and identify a method to isolate sufficient quantities under GMP conditions to conduct early phase clinical studies.