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Intramolecular Diels–Alder reactions are commonly employed for the synthesis of polycyclic natural products, but the use of aldehydes as dienophiles is an underexplored facet of the intramolecular cycloaddition. The intramolecular nature of this reaction allowed the use of aldehydes as dienophiles without the use of highly activated dienes, as is often necessary for intermolecular Diels–Alder reactions with aldehydes. A synthetic route to maoecrystal V is explored utilizing this new chemistry.

Background The Patient Protection and Affordable Care Act of 2010 includes patient satisfaction scores in the calculation of reimbursement for services provided. The Medicare and Medicaid Electronic Health Care Record Incentive Program mandate that physicians provide electronic communication with patients. Little data exists regarding patient preferences that might guide the physician adhering to these guidelines. We performed a survey study to examine patients' attitudes regarding the delivery of their health care. Methods We provided an anonymous survey to all outpatient hand surgery patients within a 1-month period at our level I academic center. The survey was structured to ascertain patients' attitudes toward outpatient wait times as well as delivery of patient-specific healthcare-related information. One-hundred and ninety-six surveys were available for review. Results Of the 196 patients surveyed, 106 (54 %) were between the ages of 45 and 64. Patients aged 25 to 44 were the least willing to wait for an initial outpatient appointment. The majority of patients in all age groups demonstrated unwillingness to wait more than 1 week for evaluation of a new problem. One hundred and forty patients (71 %) were willing to wait longer for an appointment with an upper extremity specialist rather than have an earlier appointment with a non-upper extremity specialist. Wait times of 30 min after arrival in the office were acceptable to 174 patients (89 %) while 40 patients (20 %) were willing to wait an hour or more. Patients preferred a typed handout detailing their specific problem as opposed to referral to a website or an e-mail containing information. Conclusions The results of our study indicate that patients prefer typed information as opposed to e-mail or websites regarding their health care. Our study also suggests that patients are willing to endure longer wait times if they can be given a sooner appointment, and most prefer a specialist for their problems. These results will provide some guidance to the physician regarding what patients find most appealing.

Methods for synthetically manipulating protein structure enable greater flexibility in the study of protein function. Previous characterization of the Escherichia coli aminoacyl tRNA transferase (AaT) has shown that it can modify the N-terminus of a protein with an amino acid from a tRNA or a synthetic oligonucleotide donor. Here, we demonstrate that AaT can efficiently use a minimal adenosine substrate, which can be synthesized in one to two steps from readily available starting materials. We have characterized the enzymatic activity of AaT with aminoacyl adenosyl donors and found that reaction products do not inhibit AaT. The use of adenosyl donors removes the substrate limitations imposed by the use of synthetases for tRNA charging and avoids the complex synthesis of an oligonucleotide donor. Thus, our AaT donors increase the potential substrate scope and reaction scale for N-terminal protein modification under conditions that maintain folding.

Due to the great increase of international travel and emigration, physicians the world over may face serious diagnostic challenges, resulting from the inability to recognize diseases totally alien to their culture, and diseases common to their culture but presenting with previously unseen complications. Over the past 50 years, the frequency of Mycobacterium tuberculosis (MT) infections, arising in the native populations of the United States and other industrialized countries, has been declining. However, the rate of infections in under-developed nations remains at a very high rate. Tuberculosis (TB) can occur in any organ or tissue and can mimic many other diseases. We present the case of a 95-year-old male immigrant from India, with abdominal pain and chronic anemia. Investigation of his abdominal pain revealed a large pancreatic mass with possible hepatic metastases consistent with pancreatic cancer. Fine-needle aspiration biopsy of the mass obtained by endoscopic ultrasound, demonstrated granulomatous inflammation and yielded cultures positive for MT. Antitubercular therapy resulted in progressive resolution of the pancreatic mass and the anemia. The initial clinical impression and radiological findings, in a 95-year-old patient, may well have prompted a harmful decision to opt for comfort care only. This was avoided in our patient by adherence to the strict standard of pursuing a definitive tissue diagnosis for all “masses of unknown origin.” The merits of this case report are in the thorough discussion and illustration of the unusual pathogenesis of TB of the elderly, the imperative of assessing socioeconomic status of patients, and the diagnostic considerations required to evaluate extrapulmonary TB. The following core competencies are addressed in this article: Patient care and Medical knowledge.

Fluorescent probe pairs that can be selectively excited in the presence of Trp and Tyr are of great utility in studying conformational changes in proteins. However, the size of these probe pairs can restrict their incorporation to small portions of a protein sequence where their effects on secondary and tertiary structure can be tolerated. Our findings show that a thioamide bond—a single atom substitution of the peptide backbone—can quench fluorophores that are red-shifted from intrinsic protein fluorescence, such as acridone. Using steady-state and fluorescence lifetime measurements, we further demonstrate that this quenching occurs through a dynamic electron-transfer mechanism. In a proof-of-principle experiment, we apply this technique to monitor unfolding in a model peptide system, the villin headpiece HP35 fragment. Thioamide analogues of the natural amino acids can be placed in a variety of locations in a protein sequence, allowing one to make a large number of measurements to model protein folding.

We report a rare cause of isolated acute traumatic aortic injury in a 58-year-old woman with a body mass index (BMI) of 19.4, following cardiopulmonary resuscitation (CPR). Our case is unique in that CPR was performed by a single CPR provider, no significant trauma occurred with the preceding syncope, and aortic injury occurred in isolation without fractures or other traumatic injury. Healthcare providers need to be aware that although chest compression of at least 2 inches depth is needed for effective CPR, the force required to achieve this compression is much less in an individual with a BMI of around 20 as opposed to a BMI of 40. Excessive chest compression can lead to acute traumatic aortic injury. We review appropriate resuscitation and chest compression depth, CPR associated injuries including aortic injuries and mechanisms of acute traumatic aortic injury. The following core competencies are addressed in this article: Patient care and medical knowledge.

We report a 45-year-old African-American female who presented with 20/400 acuity in the right eye and no light perception in the left eye. Based upon a magnetic resonance imaging displaying periventricular white matter enhancement and a lymph node biopsy revealing noncaseating granulomas, we made the diagnosis of neurosarcoidosis which is the only diagnosis that can explain both. Neurosarcoidosis is difficult to diagnose, has high rates of treatment failure, significant morbidity, and 5–10% mortality. We review the differential diagnosis for periventricular white matter and granulomas, presentation of neurosarcoidosis, ocular involvement of neurosarcoidosis, treatment, and patient outcomes. The following core competencies are addressed in this article: Patient care and medical knowledge.