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It is well-known that West Virginia (WV) is one of the states most affected by the opioid epidemic. Recently, WV has implemented a program to expand buprenorphine use as part of a multi-prong approach to treat opioid use disorder accompanied by positive outcomes. However, buprenorphine can be diverted and obtained outside of a medical provider's guidance. Given the prevalence of buprenorphine use in WV, we aim to present original clinical data prompting clinicians to recognize buprenorphine as a potential cause of toxic leukoencephalopathy. We describe the case of a 28-year-old female who presented with catatonia believed to be secondary to buprenorphine, and we discuss the diagnostic challenges and therapeutic management of buprenorphine-induced toxic leukoencephalopathy.

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Pancreatic ductal adenocarcinoma (PDA) is one of the most lethal cancers, in part, due to resistance to both conventional and targeted therapeutics. TRAIL directly induces apoptosis through engagement of cell surface Death Receptors (DR4 and DR5), and has been explored as a molecular target for cancer treatment. Clinical trials with recombinant TRAIL and DR-targeting agents, however, have failed to show overall positive outcomes. Herein, we identify a novel TRAIL resistance mechanism governed by Hu antigen R (HuR, ELAV1), a stress-response protein abundant and functional in PDA cells. Exogenous HuR overexpression in TRAIL-sensitive PDA cell lines increases TRAIL resistance whereas silencing HuR in TRAIL-resistant PDA cells, by siRNA oligo-transfection, decreases TRAIL resistance. PDA cell exposure to soluble TRAIL induces HuR translocation from the nucleus to the cytoplasm. Furthermore, it is demonstrated that HuR interacts with the 3′-untranslated region (UTR) of DR4 mRNA. Pre-treatment of PDA cells with MS-444 (Novartis), an established small molecule inhibitor of HuR, substantially increased DR4 and DR5 cell surface levels and enhanced TRAIL sensitivity, further validating HuR's role in affecting TRAIL apoptotic resistance. NanoString analyses on the transcriptome of TRAIL-exposed PDA cells identified global HuR-mediated increases in antiapoptotic processes. Taken together, these data extend HuR's role as a key regulator of TRAIL-induced apoptosis.Implications: Discovery of an important new HuR-mediated TRAIL resistance mechanism suggests that tumor-targeted HuR inhibition increases sensitivity to TRAIL-based therapeutics and supports their re-evaluation as an effective treatment for PDA patients. Mol Cancer Res; 14(7); 599–611. ©2016 AACR.

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Downcoding at nonprofit healthcare institutions can account for significant revenue losses that, in turn, can affect the amount and quality of care they provide. Using the inpatient medical note to assess the complexity of care, we wanted to quantify the visit coding distribution at the largest tertiary care center in West Virginia and to improve the documentation and coding if found to be below national benchmarks.We measured the number of encounters and associated documentation of level 1, 2, and 3 visits among hospitalists. We compared our data to national benchmark data. We then implemented a multifaceted, multidisciplinary intervention to improve documentation and coding.We found a significant average increase of level 3 admission history and physical visits of 76% ( plt; .0001) and 112% ( plt; .001) for subsequent encounters compared with baseline preintervention visit types. With team-based coding interventions in place, documentation accurately now reflects the complexity of care delivered. Based on Medicare reimbursement rates, this new accuracy has led to an increase in revenue of $233, 988.79 per 10,000 encounters.Provider knowledge of medical billing and coding guidelines is essential. In particular, large academic institutions typically operate on small margins, so even simple adjustments and quality improvement efforts in billing and coding can help immensely by accurately representing the amount and quality of medical services. An institution can markedly improve revenues by coding notes to reflect the true complexity of care that is delivered.

Background Coronavirus 19 (COVID-19) affected healthcare workers (HCW) in ways more than increasing the volume of patients needing care. Increased numbers of patients at younger ages required support with extracorporeal membrane oxygenation (ECMO). Providing this care requires an interdisciplinary team. Aim This study explored the experiences of HCW caring for patients with COVID-19 on ECMO. Methods Face-to-face semi-structured interviews were conducted via videoconferencing, and transcript comparison was used for the analysis. Findings Open coding of the data generated 7 categories including (1) fearing the unknown, (2) confronting challenges in patient and/or family interactions, (3) encountering barriers to providing care, (4) facing moral distress, (5) working through exhaustion, (6) persevering by strengthening teamwork, (7) and acknowledging frustration with non-believers. Discussion HCW balanced pessimism and optimism while caring for patient with COVID-19 on ECMO. They used negative experiences caring for these patients to strength teamwork and bonding among peers. Conclusion The practice implications for caring for patients with COVID-19 on ECMO include viligance by clinician and organization to protect the wellbeing of healthcare providers, particularly in ICU and ECMO units were moral distress and burnout can be high.

We here test the concept that disease states may result not from a single cause but from small changes in a network that are collectively significant. We recently showed that development of hypertension (HTN) in the spontaneously hypertensive rat (SHR) model of human essential hypertension is accompanied by changes in microRNA expression levels in the brainstem tracking the development of HTN 1,2. This led to the hypothesis that preventing the change in microRNA levels could prevent the development of HTN. We propose that hypertension emerges from a network that has been pushed out of a normotensive equilibrium into a compensatory, pathological state. We show that small perturbations in the gene regulatory networks in the brainstem by selectively blocking two microRNAs highlighted in our previous results, miR-135a and miR-376a, is sufficient to prevent development of hypertension in the SHR model. This effect appears driven by only modest changes in the expression of rate-limiting genes, many of which are targets of these miRNAs, suggesting that the combination of genes that are targeted in the network is responsible for the effect. The demonstration that hypertension is an emergent property of an underlying regulatory network suggests that a new treatment paradigm altogether is needed.One Sentence SummaryA brief summary of the main result of your paper, without excessive jargon.

Key points Evidence indicates an association between hypertension and chronic systemic inflammation in both human hypertension and experimental animal models. Previous studies in the spontaneously hypertensive rat (SHR) support a role for leukotriene B4 (LTB4 ), a potent chemoattractant involved in the inflammatory response, but its mode of action is poorly understood. In the SHR, we observed an increase in T cells and macrophages in the brainstem; in addition, gene expression profiling data showed that LTB4 production, degradation and downstream signalling in the brainstem of the SHR are dynamically regulated during hypertension. When LTB4 receptor 1 (BLT1) receptors were blocked with CP-105,696, arterial pressure was reduced in the SHR compared to the normotensive control and this reduction was associated with a significant decrease in systolic blood pressure (BP) indicators. These data provide new evidence for the role of LTB4 as an important neuro-immune pathway in the development of hypertension and therefore may serve as a novel therapeutic target for the treatment of neurogenic hypertension. Abstract Accumulating evidence indicates an association between hypertension and chronic systemic inflammation in both human hypertension and experimental animal models. Previous studies in the spontaneously hypertensive rat (SHR) support a role for leukotriene B4 (LTB4 ), a potent chemoattractant involved in the inflammatory response. However, the mechanism for LTB4 -mediated inflammation in hypertension is poorly understood. Here we report in the SHR, increased brainstem infiltration of T cells and macrophages plus gene expression profiling data showing that LTB4 production, degradation and downstream signalling in the brainstem of the SHR are dynamically regulated during hypertension. Chronic blockade of the LTB4 receptor 1 (BLT1) receptor with CP-105,696, reduced arterial pressure in the SHR compared to the normotensive control and this reduction was associated with a significant decrease in low and high frequency spectra of systolic blood pressure, and an increase in spontaneous baroreceptor reflex gain (sBRG). These data provide new evidence for the role of LTB4 as an important neuro-immune pathway in the development of hypertension and therefore may serve as a novel therapeutic target for the treatment of neurogenic hypertension.

Evidence indicates an association between hypertension and chronic systemic inflammation in both human hypertension and experimental animal models.Previous studies in the spontaneously hypertensive rat (SHR) support a role for leukotriene B4 (LTB4), a potent chemoattractant involved in the inflammatory response, but its mode of action is poorly understood.In the SHR, we observed an increase in T cells and macrophages in the brainstem; in addition, gene expression profiling data showed that LTB4 production, degradation and downstream signalling in the brainstem of the SHR are dynamically regulated during hypertension.When LTB4 receptor 1 (BLT1) receptors were blocked with CP‐105,696, arterial pressure was reduced in the SHR compared to the normotensive control and this reduction was associated with a significant decrease in systolic blood pressure (BP) indicators.These data provide new evidence for the role of LTB4 as an important neuro‐immune pathway in the development of hypertension and therefore may serve as a novel therapeutic target for the treatment of neurogenic hypertension.

Pancreatic ductal adenocarcinoma (PDA) is one of the most lethal cancers, in part, due to resistance to both conventional and targeted therapeutics. TRAIL directly induces apoptosis through engagement of cell surface Death Receptors (DR4 and DR5), and has been explored as a molecular target for cancer treatment. Clinical trials with recombinant TRAIL and DR-targeting agents, however, have failed to show overall positive outcomes. Herein, we identify a novel TRAIL resistance mechanism governed by Hu antigen R (HuR, ELAV1), a stress-response protein abundant and functional in PDA cells. Exogenous HuR overexpression in TRAIL-sensitive PDA cell lines increases TRAIL resistance whereas silencing HuR in TRAIL-resistant PDA cells, by siRNA oligo-transfection, decreases TRAIL resistance. PDA cell exposure to soluble TRAIL induces HuR translocation from the nucleus to the cytoplasm. Furthermore, it is demonstrated that HuR interacts with the 3′-untranslated region (UTR) of DR4 mRNA. Pre-treatment of PDA cells with MS-444 (Novartis), an established small molecule inhibitor of HuR, substantially increased DR4 and DR5 cell surface levels and enhanced TRAIL sensitivity, further validating HuR's role in affecting TRAIL apoptotic resistance. NanoString analyses on the transcriptome of TRAIL-exposed PDA cells identified global HuR-mediated increases in antiapoptotic processes. Taken together, these data extend HuR's role as a key regulator of TRAIL-induced apoptosis. Implications: Discovery of an important new HuR-mediated TRAIL resistance mechanism suggests that tumor-targeted HuR inhibition increases sensitivity to TRAIL-based therapeutics and supports their re-evaluation as an effective treatment for PDA patients. Mol Cancer Res; 14(7); 599–611. ©2016 AACR.

Hypertension is a major chronic disease whose molecular mechanisms remain poorly understood. We compared neuroanatomical patterns of microRNAs in the brain stem of the spontaneous hypertensive rat (SHR) to the Wistar Kyoto rat (WKY, control). We quantified 419 well-annotated microRNAs in the nucleus of the solitary tract (NTS) and rostral ventrolateral medulla (RVLM), from SHR and WKY rats, during three main stages of hypertension development. Changes in microRNA expression were stage- and region-dependent, with a majority of SHR vs. WKY differential expression occurring at the hypertension onset stage in NTS versus at the prehypertension stage in RVLM. Our analysis identified 24 microRNAs showing time-dependent differential expression in SHR compared with WKY in at least one brain region. We predicted potential gene regulatory targets corresponding to catecholaminergic processes, neuroinflammation, and neuromodulation using the miRWALK and RNA22 databases, and we tested those bioinformatics predictions using high-throughput quantitative PCR to evaluate correlations of differential expression between the microRNAs and their predicted gene targets. We found a novel regulatory network motif consisting of microRNAs likely downregulating a negative regulator of prohypertensive processes such as angiotensin II signaling and leukotriene-based inflammation. Our results provide new evidence on the dynamics of microRNA expression in the development of hypertension and predictions of microRNA-mediated regulatory networks playing a region-dependent role in potentially altering brain-stem cardiovascular control circuit function leading to the development of hypertension.

This study aims to elucidate the mechanisms by which microRNAs (miRNA) regulate autonomic control networks driving hypertension development. Using a high-throughput assay for 419 miRNAs in the Spontaneously Hypertensive Rat (SHR) and Wistar-Kyoto (WKY) control at three stages of hypertension development, significant differences in expression occurred in 9 miRNAs of the nucleus tractus solitarius (NTS) and rostral ventrolateral medulla (RVLM). Alterations were stage- and region-dependent, differing at hypertension onset in NTS vs prehypertension stage in RVLM. 144 gene targets corresponding to catecholaminergic processes and neuromodulation were predicted using miRWALK and RNA22 databases and tested with high-throughput qPCR. Using correlational relationships between miRNAs and mRNAs, we observed a double-negative regulatory motif consisting of a miRNA down-regulating a negative regulator of a pro-hypertensive signaling pathway like Angiotensin II signaling or leukotriene-based inflammation. We observe dur...

Many binary late transition metal systems have large bulk miscibility gaps, and a variety of synthetic strategies have been developed to generate these non-equilibrium alloys as nanoparticles. While many of these methods strive to co-nucleate both elements by exploiting fast reduction kinetics or co-sequestration within a confined space, we show here that simple room-temperature borohydride co-reduction of appropriate aqueous metal salt solutions yields alloy nanoparticles in the bulk-immiscible Au–Rh, Au–Pt, Pt–Rh, and Pd–Rh systems. The compositions can be tuned across the entire Au1−xRhx, Au1−xPtx, Pt1−xRhx, and Pd1−xRhx solid solutions by varying the ratio of metal salt reagents, and they form in the presence of a variety of molecular and polymeric surface stabilizers. Reaction pathway studies on the model Au–Rh system suggest that the alloy nanoparticles form via a “conversion chemistry” mechanism: Au nanoparticle templates nucleate first, followed by diffusion of Rh to form homogeneous Au–Rh alloy nanoparticles. The alloy nanoparticles tend to be agglomerated, but this can be minimized by forming the nanoparticles directly on catalytically relevant high surface area carbon and biological supports, e.g. Vulcan carbon and wild-type M13 bacteriophage.