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Background There are an overwhelming number of patients suffering from low back pain (LBP) resulting from disc pathology. Although several strategies are being developed pre-clinically, simple strategies to treat the large number of patients currently affected is still needed. One option is to use concentrated bone marrow aspirate (cBMA), which may be effective due to its intrinsic stem cells and growth factors. Methods Thirty-three patients who received intradiscal injections of cBMA to relieve LBP were followed up based on Numeric Rating Scale (NRS), Oswestry Low Back Pain Disability Index (ODI), and Short Form-36 Health Survey (SF-36) scores. Patients were also subdivided into those with a pre-injection NRS > 5 and pre-injection NRS ≤ 5. The proportion of patients demonstrating at least 50% improvement (and 95% confidence intervals) from baseline at five follow-up visits for each outcome was evaluated. Results At least 50% improvement in NRS was observed for 13.8, 45.8, 41.1, 23.5, and 38.9% of patients across five follow-up visits, out to 1 year. When stratified by high (> 5) versus low (≤ 5) baseline NRS scores, the values were 14.3, 45.5, 71.4, 22.2, and 44.4% among those with high baseline pain, and 13.3, 46.2, 20.0, 25.0, and 33.3% among those with low baseline pain. The 50% improvement rates across visits were 4.3, 28.6, 30.0, 22.2, and 30.8% for SF-36, and 4.2, 26.7, 36.4, 55.6, and 30.8% for ODI. Conclusions Intradiscal cBMA injections may be effective to reduce pain and improve function. Patients with relatively higher initial pain may have potential for greatest improvement.

Artykul powstal jako efekt projektu ,,Demokracja bezpośrednia w Europie Środkowej i Wschodniej po 1989 roku. Wymiar formalnoprawny i praktyczny. Analiza politologiczna”, finansowanego przez Narodowe Centrum Nauki – 2014/15/B/HS5/01866.

Resume Le burnout (BO) ou syndrome d’epuisement professionnel est un phenomene d’actualite etudie par de nombreux auteurs mais aucun ne s’est interesse jusqu’ici aux chirurgiens orthopedistes suisses. Notre etude a consiste a mesurer la prevalence du BO et a preciser les facteurs favorisants et protecteurs de cette population. Le BO touche de la meme maniere et selon des facteurs similaires toutes les specialites chirurgicales. Le Maslach Burnout Inventory-Human Services Survey (MBI-HSS) et un questionnaire additionnel ont ete remplis par les chirurgiens orthopedistes diplomes ou passant l’examen dans l’annee. Ont ainsi ete determines la prevalence et le degre de BO dans ses differentes dimensions : l’epuisement emotionnel (EE), la depersonnalisation (DP) et l’accomplissement personnel (AP), ainsi que l’influence des facteurs etudies sur les scores du MBI. La prevalence du BO est pour l’EE de 23,68 %, pour la DP de 27,42 %, et pour l’AP de 42,76 %. Le statut marital, la pratique d’un sport et les relations sociales en dehors du milieu de travail sont les principaux facteurs protecteurs. Les facteurs favorisants clefs sont la sensation d’exploitation, une ambiance de competition et une sensation de pression au travail. La population de cette etude presente une prevalence similaire dans le degre de DP a la population des chirurgiens generaux suisses. La baisse de l’AP est moins importante que celle retrouvee parmi les chirurgiens americains, mais plus forte que chez les chirurgiens suisses. Les chirurgiens orthopedistes suisses sont atteints par le BO. Les 3 scores du MBI, differents selon les populations etudiees, semblent ainsi caracteriser les specificites des specialites chirurgicales etudiees. L’âge, l’existence d’une vie sociale, la pratique d’un sport et une ambiance de cooperation au travail sont confirmes comme facteurs protecteurs. Niveau de preuve 4, etude de cohorte.

The subject of this study is the phase composition evolution of Ni50Ti50􀀀xMox (x = 10, 25, 40 at.%) systems prepared by mechanical alloying in as-milled state and after subsequent heat treatment. During milling a mechanically induced solid state reaction between nickel, titanium and molybdenum was observed leading to the formation of nanocrystalline disordered solid solutions. As a result of heat treatment a creation of NiMo intermetallic phase was observed as well as structure relaxation of previously formed solid solutions.

While the cis-acyltransferase modular polyketide synthase assembly lines have largely been structurally dissected, enzymes from within the recently discovered trans-acyltransferase polyketide synthase assembly lines are just starting to be observed crystallographically. Here we examine the ketoreductase (KR) from the first polyketide synthase module of the bacillaene nonribosomal peptide synthetase/polyketide synthase at 2.35-A resolution. This KR naturally reduces both α- and β-keto groups and is the only KR known to do so during the biosynthesis of a polyketide. The isolated KR not only reduced an N-acetylcysteamine-bound β-keto substrate to a D-β-hydroxy product, but also an N-acetylcysteamine-bound α-keto substrate to an L-α-hydroxy product. That the substrates must enter the active site from opposite directions to generate these stereochemistries suggests that the acyl-phosphopantetheine moiety is capable of accessing very different conformations despite being anchored to a serine residue of a docked acyl carrier protein. The features enabling stereocontrolled α-ketoreduction may not be extensive since a KR that naturally reduces a β-keto group within a cis-acyltransferase polyketide synthase was identified that performs a completely stereoselective reduction of the same α-keto substrate to generate the D-α-hydroxy product. A sequence analysis of trans-acyltransferase KRs reveals that a single residue, rather than a three-residue motif found in cis-acyltransferase KRs, is predictive of the orientation of the resulting β-hydroxyl group.

Modular polyketide synthase ketoreductases often set two stereocenters when reducing intermediates in the biosynthesis of a complex polyketide. Here we report the 2.60 Å-resolution structure of an A2-type ketoreductase from the eleventh module of the amphotericin polyketide synthase that sets a combination of l-α-methyl and l-β-hydroxyl stereochemistries and represents the final catalytically-competent ketoreductase type to be structurally elucidated. Through structure-guided mutagenesis a double mutant of an A1-type ketoreductase was generated that functions as an A2-type ketoreductase on a diketide substrate analog, setting an α-alkyl substituent in an l- orientation rather than in the d-orientation set by the unmutated ketoreductase. When the activity of the double-mutant was examined in the context of an engineered triketide lactone synthase, the anticipated triketide lactone was not produced even though the ketoreductase-containing module still reduced the diketide substrate analog as expected. These findings suggest that re-engineered ketoreductases may be catalytically outcompeted within engineered polyketide synthase assembly lines.

PURPOSE The purpose of this study was to evaluate a primary care practice–based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates. METHODS The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up. RESULTS Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients’ colorectal cancer screening rates. Qualitative analyses provide insights into practices’ QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates. CONCLUSIONS Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.

SummaryChiral building blocks are valuable intermediates in the syntheses of natural products and pharmaceuticals. A scalable chemoenzymatic route to chiral diketides has been developed that includes the general synthesis of α-substituted, β-ketoacyl N-acetylcysteamine thioesters followed by a biocatalytic cycle in which a glucose-fueled NADPH-regeneration system drives reductions catalyzed by isolated modular polyketide synthase (PKS) ketoreductases (KRs). To identify KRs that operate as active, stereospecific biocatalysts, 11 isolated KRs were incubated with 5 diketides and their products were analyzed by chiral chromatography. KRs that naturally reduce small polyketide intermediates were the most active and stereospecific toward the panel of diketides. Several biocatalytic reactions were scaled up to yield more than 100 mg of product. These syntheses demonstrate the ability of PKS enzymes to economically and greenly generate diverse chiral building blocks on a preparative scale.

Summary Complex polyketides are characterized by multiple chiral centers harboring hydroxyl and alkyl substituents. To investigate the mechanisms by which these stereocenters are set, several high-resolution structures of the ketoreductase (KR) domain from the second module of the amphotericin modular polyketide synthase (PKS) were solved. This first structural analysis of an A-type KR helps reveal how these KRs direct polyketide intermediates into their active sites from the side opposite that used by B-type KRs, resulting in a β-hydroxyl group of opposite stereochemistry. A comparison of structures obtained in the absence and presence of ligands reveals an induced fit mechanism that is important for catalysis. Activity assays of mutants of KRs from the first and second modules of the amphotericin PKS reveal the relative contributions of several active site residues toward catalysis and stereocontrol. Together, these results highlight the possibility of region-specific modification of polyketides through active site engineering of KRs.

Background: The Chronic Care Model (CCM) was developed to improve chronic disease care, but it may also inform delivery of other types of preventive care. Using hierarchical analyses of service delivery to patients, we explored associations of CCM implementation with diabetes care and counseling for diet or weight loss and physical activity in community-based primary care offices. Methods: Secondary analysis focused on baseline data from 25 practices (with an average of 4 physicians per practice) participating in an intervention trial targeting improved colorectal cancer screening rates. This intervention made no reference to the CCM. CCM implementation was measured through staff and clinical management surveys and was associated with patient care indicators (chart audits and patient questionnaires). Results: Overall, practices had low levels of CCM implementation. However, higher levels of CCM implementation were associated with better diabetes assessment and treatment of patients (P = .009 and .015, respectively), particularly among practices open to “innovation.” Physical activity counseling for obese and, particularly, overweight patients was strongly associated with CCM implementation (P = .0017), particularly among practices open to “innovation”; however, this association did not hold for overweight and obese patients with diabetes. Conclusions: Very modest levels of CCM implementation in unsupported primary care practices are associated with improved care for patients with diabetes and higher rates of behavioral counseling. Incremental incorporation of CCM components is an option, especially for community practices with stretched resources and with cultures of “innovativeness.”

The biocatalytic employment of modular polyketide synthase enzymes in cell lysate has become a viable route to preparative quantities of synthetically valuable polyketide fragments. We report the quantitative, uninvasive, and continuous monitoring of such biocatalytic reactions by observing trifluoromethyl-bearing substrates via 19 F NMR spectroscopic analysis. To demonstrate the utility of this technique, we followed reactions catalyzed by a thioesterase and several ketoreductases.

While the cis-acyltransferase modular polyketide synthase assembly lines have largely been structurally dissected, enzymes from within the recently discovered trans-acyltransferase polyketide synthase assembly lines are just starting to be observed crystallographically. Here we examine the ketoreductase from the first polyketide synthase module of the bacillaene nonribosomal peptide synthetase/polyketide synthase at 2.35-Å resolution. This ketoreductase naturally reduces both α- and β-keto groups and is the only ketoreductase known to do so during the biosynthesis of a polyketide. The isolated ketoreductase not only reduced an N-acetylcysteamine-bound β-keto substrate to a D-β-hydroxy product, but also an N-acetylcysteamine- bound α-keto substrate to an L-α-hydroxy product. That the substrates must enter the active site from opposite directions to generate these stereochemistries suggests that the acyl-phosphopantetheine moiety is capable of accessing very different conformations despite being anchored to a serine residue of a docked acyl carrier protein. The features enabling stereocontrolled α-ketoreduction may not be extensive since a β-ketoreductase from a cis-acyltransferase polyketide synthase was identified that performs a completely stereoselective reduction of the same α-keto substrate to generate the D-α-hydroxy product. A sequence analysis of trans-acyltransferase ketoreductases reveals that a single residue, rather than a three-residue motif found in cis-acyltransferase ketoreductases, is predictive of the orientation of the resulting β-hydroxyl group.

The adoption of electronic medical records (EMRs) in ambulatory settings has been widely recommended. It is hoped that EMRs will improve care; however, little is known about the effect of EMR use on care quality in this setting. This study compares EMR versus paper medical record documentation of basic health history and preventive service indicators in 47 community-based practices. Differences in practice-level documentation rates between practices that did and did not use an EMR were examined using the Kruskal-Wallis nonparametric test and robust regression, adjusting for practice-level covariates. Frequency of documentation of health history and preventive service indicator items were similar in the 2 groups of practices. Although EMRs provide the capacity for more robust record keeping, the community-based practices here do not use EMRs to their full capacity. EMR usage does not guarantee more systematic record keeping and thus may not lead to improved quality in the community practice setting.

In recent Polish legislation the first reference to direct democracy was made in 1987 when, as part of the preparations for a referendum, the Constitution was amended to provide a possibility for the working people to express their views in a referendum. This issue was regulated in detail by the simultaneously adopted Public Consultation and Referendum Act. At the local level, a referendum could be held only on the initiative of a territorial organ of state administration.

PURPOSE The Using Learning Teams for Reflective Adaptation (ULTRA) study used facilitated reflective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show significant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed. METHODS We analyzed field notes and interviews from a multimethod practice assessment, as well as field notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach. RESULTS Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practice-wide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines. CONCLUSION Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence.

Extremely obese women are less likely than nonobese women to receive breast and cervical cancer screening examinations. Reasons for this disparity are unclear and may stem from patient and/or physician barriers. This sequential mixed-methods study used individual in-depth interviews of 15 family physicians followed by a mail survey of 255 family physicians (53% response rate) to understand the barriers they faced in performing cancer screening examinations in extremely obese women. Barriers fell into three main areas: (i) difficulty doing pelvic and breast exams; (ii) inadequate equipment; and (iii) challenges overcoming patient barriers and refusal. This led some physicians to avoid performing breast and pelvic examinations on extremely obese women. Having more knowledge about specific examination techniques was associated with less difficulty in palpating lumps on breast and pelvic examinations (P < 0.005). Physicians perceived that embarrassment, aversion to undressing, and avoidance of discussions related to their weight were the most frequent barriers extremely obese women had with getting physical examinations. Educating and/or motivating patients and addressing fears were strategies used most frequently when patients refused mammograms or Pap smears. Interventions focusing on physician barriers, such as educating them on specific examination techniques, obtaining adequate equipment and supplies, and providing resources to assist physicians in dealing with patient barriers and refusal, may be fruitful in increasing cancer screening rates in extremely obese patients. Future research studies testing the effectiveness of these strategies are needed to improve cancer outcomes in this high-risk population.

Random sequence nucleic acid pools can be used in a variety of applications, including the selection of functional nucleic acids such as protein binding sites, aptamers, and ribozymes. while the design, synthesis, and purification of pools is relatively straightforward, keeping track of the size and complexity of a nucleic acid pool can sometimes task even an experienced researcher. The following protocol takes the reader through the steps necessary for the preparation of a pool of known complexity.

Despite the growing epidemic of extreme obesity in the United States, weight management is not adequately addressed in primary care. This study assessed family physicians' practices and attitudes regarding care of extremely obese patients and factors associated with them. A cross-sectional, self-administered survey was mailed to 500 family physicians in New Jersey (NJ) during March-May 2008. Measures included knowledge, weight management approaches, attitudes toward managing obesity, challenges with examinations, availability of supplies, and strategies to improve care. Response rate was 53% (N = 255). Bariatric surgery and weight loss medications were infrequently recommended, particularly in physicians with higher volume of extremely obese patients (odds ratio (OR) 0.38; 95% confidence interval (CI) 0.23, 0.62 and OR 0.51; 95% CI 0.31, 0.85 for surgery and medications, respectively). Higher knowledge was associated with increased frequency of recommendations of weight loss medications (P < 0.0001) and bariatric surgery (P < 0.0001). There was a high prevalence of negative attitudes, particularly in younger physicians and those with lower patient volume. Increased knowledge of weight-loss diets was associated with less dislike in discussing weight loss (P < 0.0001), less frustration (P = 0.0001), less belief that treatment is often ineffective (P < 0.0001), and less pessimism about patient success (P = 0.0002). Many providers encountered challenges performing examinations on extremely obese patients. More education of primary care physicians, particularly on bariatric surgery, specific examination techniques, and availability of community resources for obese persons is needed. Further research is needed to determine if interventions to increase knowledge of physicians will lead to less negative attitudes toward weight loss and extremely obese patients.

The K0 meson production by pi(-) mesons of 1.15 GeV/c momentum on C, Al, Cu, Sn, and Pb nuclear targets was measured with the FOPI spectrometer at the Schwer-Ionen-Synchrotron accelerator of GSI. Inclusive production cross sections and the momentum distributions of K0 mesons are compared to scaled elementary production cross sections and to predictions of theoretical models describing the in-medium production of kaons. The data represent a new reference for those models, which are widely used for interpretation of the strangeness production in heavy-ion collisions. The presented results demonstrate the sensitivity of the kaon production to the reaction amplitudes inside nuclei and point to the existence of a repulsive KN potential of 20+/-5 MeV at normal nuclear matter density.

Random sequence nucleic acid pools can be used in a variety of applications, including the selection of functional nucleic acids such as protein binding sites, aptamers, and ribozymes. while the design, synthesis, and purification of pools is relatively straightforward, keeping track of the size and complexity of a nucleic acid pool can sometimes task even an experienced researcher. The following protocol takes the reader through the steps necessary for the preparation of a pool of known complexity.

We report here preliminary results of experiments concerning the influence of “weak” channels on fusion and quasielastic barrier distributions. Some results of measurements of these distributions in the 20Ne+208Pb system and of transfer probabilities for 20Ne+natNi, 90,92Zr, 118Sn and 208Pb backscattering at near‐barrier energies will be presented.

The Vanderbilt Center for Better Health conducted a workflow analysis study to determine the benefits of implementing a computerized provider order entry system in the adult Emergency Department. Time savings by role was 1619 hours/year for nurses, 815 for medical receptionist, −95 for attendings, and −100 for residents. Translating time savings into bottom line savings (FTE/overtime reduction, additional charges) resulted in $31,424 in time savings and $40,000 cost savings (paper forms).

Breast cancer is one of the most common neoplasms of women in Poland. The study presents the diagnostic possibilities for early detection of neoplastic lesions and their differentiation from the radiologist point of view. Advantages and restrictions of individual methods and current views on prophylactic and diagnostic algorithms have been considered. The study has been based on long-term observation of patients coming to Breast Diseases Outpatient Clinic as well as on scientific reports. The importance of cooperation between radiologists and physicians with other specializations who deal with breast diseases has been stressed.

Two hundred and eleven Indian skulls originating from medieval times, South of Peru, were studied in respect to variability of the mastoid emissary. Occurrence and localisation of the external orifice of the mastoid emissary were studied in three distinct and well-separated populations, living in the three different places: Villa el Salvador, Tablada de Lurin and Paracas. Most of the skulls presented considerable degree of artificial deformation. External orifice of the mastoid emissary was multiple in most of the skulls, especially in Villa el Salvador and Paracas populations. Mastoid emissaries in Indian were situated generally higher than in European, especially regarding the Paracas population. Significant sex differences were present in this material, regarded as a whole (summarized results for the three populations), what is in agreement with previous observations on European skulls. It indicates that even in cases of relatively deep deformation, some characteristic features of sex dimorphism of the human skull are noticeable. Additionally, the three studied populations, which were well separated from each other and lived alone, differed significantly regarding localization of the mastoid emissaries.

The purpose of the study was establishing differences in the situation of the external orifice of the emissary, its size and angle at which it leaves the skull. It is necessary for optimizaing of position for the internal coil of the speech processor of cochlear implant. As yet, the variability of external foramen of this emissary have not been sufficiently studied, especially in the clinical aspect with respect to the use of cochlear implants. The authors examined 200 skulls of adults of both sexes. The statistically significant differences were observed between sexes and between sides of the body, and they showed a definite regularity. The variability of the site of the emissary is presented in a form useful for clinical purposes.

The authors describe the structure of principles of function of a measuring-recording instruments, so called craniopantograph. The instrument of own design serves for examination of the spatial variability of the orbit. The obtained measurements of the internal shape of the orbit can be processed later by microcomputer technique. For construction of craniopantograph the principles of function of two typical instruments--craniometer and pantograph were used.

In this paper a fuzzy relation ‘less than’ and fuzzy probability spaces on the real line are defined. Fuzzy σ-algebras of events are introduced in an analogous way to the classical theory of probability by means of the above relation. Furthermore, specific properties of the fuzzy probability measures presented here are given.

Craniometric methods for measurement of orbital cavity as a three-dimensional form have been discussed. The authors notice their deficiency and lack of possibility of their practical utilization. It has been stated that works at a new measurement technique whose results would apply in the teaching hospital should be undertaken in the presence of repeatedly existed injuries of the middle and upper storey of facial skeleton.

Inclusion complexes of isomeric chloronitrobenze-nes with β —cyclodextrin in water + ethanol containing 0.1M phosphate buffer have been studied by Polarographic method. The stability constants and the diffusion coefficients of the corresponding complexes have been determined. Taking into account the change in the cyclodextrin concentration due to the simultaneous complexation of the solvent we have derived an equation which allows to calculate both stability constants.

This paper is a preliminary account of field research carried out by the authors in June and October, 1980 and in May, 1981. The search was made for astronomical alignments at three sites. One such alignment has been found, and it is shown that Muller's results, previously thought to be correct, differ considerably from the actual situation. In conclusion some general remarks are made on the origin of the rings and their connections with the migrations of the Goths. THE SITES Wesiory (ϕ = 54° 13′. 3 N, λ = 17°51′. 0 E) This site was first mentioned in 1938 (Petsch 1938), but was not excavated until the late 1950s (Kmiecinski 1958–1968). It consists of 4 rings (2 of which are incomplete) and 20 barrows situated on the shores of a picturesque lake. Odry (ϕ = 53° 54′. 0 N, λ = 17° 59′. 7 E) The stone rings at Odry have been, very well known for more than 100 years. Therefore we do not want to repeat everything that has been written about them. All that we can state here is that this cemetrey consists of 10 rings and 27 burial barrows, but there are many more graves with no recognizable marking on the surface. Odry is best known, of course, because of P. Stephan's (1914) astronomical theory and more recent work by R. Muller (1934, 1970), where it is pointed out that the structure of this site is oriented to the four cardinal points as well as to the solstices.