St. John's University

The Reactome Knowledgebase (www.reactome.org) provides molecular details of signal transduction, transport, DNA replication, metabolism and other cellular processes as an ordered network of molecular transformations-an extended version of a classic metabolic map, in a single consistent data model. Reactome functions both as an archive of biological processes and as a tool for discovering unexpected functional relationships in data such as gene expression pattern surveys or somatic mutation catalogues from tumour cells. Over the last two years we redeveloped major components of the Reactome web interface to improve usability, responsiveness and data visualization. A new pathway diagram viewer provides a faster, clearer interface and smooth zooming from the entire reaction network to the details of individual reactions. Tool performance for analysis of user datasets has been substantially improved, now generating detailed results for genome-wide expression datasets within seconds. The analysis module can now be accessed through a RESTFul interface, facilitating its inclusion in third party applications. A new overview module allows the visualization of analysis results on a genome-wide Reactome pathway hierarchy using a single screen page. The search interface now provides auto-completion as well as a faceted search to narrow result lists efficiently.

The Reactome Knowledgebase (https://reactome.org) provides molecular details of signal transduction, transport, DNA replication, metabolism, and other cellular processes as an ordered network of molecular transformations-an extended version of a classic metabolic map, in a single consistent data model. Reactome functions both as an archive of biological processes and as a tool for discovering unexpected functional relationships in data such as gene expression profiles or somatic mutation catalogues from tumor cells. To support the continued brisk growth in the size and complexity of Reactome, we have implemented a graph database, improved performance of data analysis tools, and designed new data structures and strategies to boost diagram viewer performance. To make our website more accessible to human users, we have improved pathway display and navigation by implementing interactive Enhanced High Level Diagrams (EHLDs) with an associated icon library, and subpathway highlighting and zooming, in a simplified and reorganized web site with adaptive design. To encourage re-use of our content, we have enabled export of pathway diagrams as 'PowerPoint' files.

The role of microbiota in health and diseases is being highlighted by numerous studies since its discovery. Depending on the localized regions, microbiota can be classified into gut, oral, respiratory, and skin microbiota. The microbial communities are in symbiosis with the host, contributing to homeostasis and regulating immune function. However, microbiota dysbiosis can lead to dysregulation of bodily functions and diseases including cardiovascular diseases (CVDs), cancers, respiratory diseases, etc. In this review, we discuss the current knowledge of how microbiota links to host health or pathogenesis. We first summarize the research of microbiota in healthy conditions, including the gut-brain axis, colonization resistance and immune modulation. Then, we highlight the pathogenesis of microbiota dysbiosis in disease development and progression, primarily associated with dysregulation of community composition, modulation of host immune response, and induction of chronic inflammation. Finally, we introduce the clinical approaches that utilize microbiota for disease treatment, such as microbiota modulation and fecal microbial transplantation.

The Reactome Knowledgebase (https://reactome.org), an Elixir core resource, provides manually curated molecular details across a broad range of physiological and pathological biological processes in humans, including both hereditary and acquired disease processes. The processes are annotated as an ordered network of molecular transformations in a single consistent data model. Reactome thus functions both as a digital archive of manually curated human biological processes and as a tool for discovering functional relationships in data such as gene expression profiles or somatic mutation catalogs from tumor cells. Recent curation work has expanded our annotations of normal and disease-associated signaling processes and of the drugs that target them, in particular infections caused by the SARS-CoV-1 and SARS-CoV-2 coronaviruses and the host response to infection. New tools support better simultaneous analysis of high-throughput data from multiple sources and the placement of understudied ('dark') proteins from analyzed datasets in the context of Reactome's manually curated pathways.

Abstract The Reactome Knowledgebase (https://reactome.org) provides molecular details of signal transduction, transport, DNA replication, metabolism and other cellular processes as an ordered network of molecular transformations in a single consistent data model, an extended version of a classic metabolic map. Reactome functions both as an archive of biological processes and as a tool for discovering functional relationships in data such as gene expression profiles or somatic mutation catalogs from tumor cells. To extend our ability to annotate human disease processes, we have implemented a new drug class and have used it initially to annotate drugs relevant to cardiovascular disease. Our annotation model depends on external domain experts to identify new areas for annotation and to review new content. New web pages facilitate recruitment of community experts and allow those who have contributed to Reactome to identify their contributions and link them to their ORCID records. To improve visualization of our content, we have implemented a new tool to automatically lay out the components of individual reactions with multiple options for downloading the reaction diagrams and associated data, and a new display of our event hierarchy that will facilitate visual interpretation of pathway analysis results.

Ferroptosis is form of regulated nonapoptotic cell death that is involved in diverse disease contexts. Small molecules that inhibit glutathione peroxidase 4 (GPX4), a phospholipid peroxidase, cause lethal accumulation of lipid peroxides and induce ferroptotic cell death. Although ferroptosis has been suggested to involve accumulation of reactive oxygen species (ROS) in lipid environments, the mediators and substrates of ROS generation and the pharmacological mechanism of GPX4 inhibition that generates ROS in lipid environments are unknown. We report here the mechanism of lipid peroxidation during ferroptosis, which involves phosphorylase kinase G2 (PHKG2) regulation of iron availability to lipoxygenase enzymes, which in turn drive ferroptosis through peroxidation of polyunsaturated fatty acids (PUFAs) at the bis-allylic position; indeed, pretreating cells with PUFAs containing the heavy hydrogen isotope deuterium at the site of peroxidation (D-PUFA) prevented PUFA oxidation and blocked ferroptosis. We further found that ferroptosis inducers inhibit GPX4 by covalently targeting the active site selenocysteine, leading to accumulation of PUFA hydroperoxides. In summary, we found that PUFA oxidation by lipoxygenases via a PHKG2-dependent iron pool is necessary for ferroptosis and that the covalent inhibition of the catalytic selenocysteine in Gpx4 prevents elimination of PUFA hydroperoxides; these findings suggest new strategies for controlling ferroptosis in diverse contexts.

Reactome (http://www.reactome.org) is a manually curated open-source open-data resource of human pathways and reactions. The current version 46 describes 7088 human proteins (34% of the predicted human proteome), participating in 6744 reactions based on data extracted from 15 107 research publications with PubMed links. The Reactome Web site and analysis tool set have been completely redesigned to increase speed, flexibility and user friendliness. The data model has been extended to support annotation of disease processes due to infectious agents and to mutation.

Reactome (http://www.reactome.org) is a collaboration among groups at the Ontario Institute for Cancer Research, Cold Spring Harbor Laboratory, New York University School of Medicine and The European Bioinformatics Institute, to develop an open source curated bioinformatics database of human pathways and reactions. Recently, we developed a new web site with improved tools for pathway browsing and data analysis. The Pathway Browser is an Systems Biology Graphical Notation (SBGN)-based visualization system that supports zooming, scrolling and event highlighting. It exploits PSIQUIC web services to overlay our curated pathways with molecular interaction data from the Reactome Functional Interaction Network and external interaction databases such as IntAct, BioGRID, ChEMBL, iRefIndex, MINT and STRING. Our Pathway and Expression Analysis tools enable ID mapping, pathway assignment and overrepresentation analysis of user-supplied data sets. To support pathway annotation and analysis in other species, we continue to make orthology-based inferences of pathways in non-human species, applying Ensembl Compara to identify orthologs of curated human proteins in each of 20 other species. The resulting inferred pathway sets can be browsed and analyzed with our Species Comparison tool. Collaborations are also underway to create manually curated data sets on the Reactome framework for chicken, Drosophila and rice.

CONTEXT: Severe sepsis is typically characterized by initial cytokine-mediated hyper-inflammation. Whether this hyperinflammatory phase is followed by immunosuppression is controversial. Animal studies suggest that multiple immune defects occur in sepsis, but data from humans remain conflicting. OBJECTIVES: To determine the association of sepsis with changes in host innate and adaptive immunity and to examine potential mechanisms for putative immunosuppression. DESIGN, SETTING, AND PARTICIPANTS: Rapid postmortem spleen and lung tissue harvest was performed at the bedsides of 40 patients who died in intensive care units (ICUs) of academic medical centers with active severe sepsis to characterize their immune status at the time of death (2009–2011). Control spleens (n=29) were obtained from patients who were declared brain-dead or had emergent splenectomy due to trauma; control lungs (n=20) were obtained from transplant donors or from lung cancer resections. MAIN OUTCOME MEASURES: Cytokine secretion assays and immunophenotyping of cell surface receptor-ligand expression profiles were performed to identify potential mechanisms of immune dysfunction. Immunohistochemical staining was performed to evaluate the loss of immune effector cells. RESULTS: The mean ages of patients with sepsis and controls were 71.7 (SD, 15.9) and 52.7 (SD, 15.0) years, respectively. The median number of ICU days for patients with sepsis was 8 (range, 1–195 days), while control patients were in ICUs for 4 or fewer days. The median duration of sepsis was 4 days (range, 1–40 days). Compared with controls, anti-CD3/anti-CD28–stimulated splenocytes from sepsis patients had significant reductions in cytokine secretion at 5 hours: tumor necrosis factor, 5361 (95% CI, 3327–7485) pg/mL vs 418 (95% CI, 98–738) pg/mL; interferon γ, 1374 (95% CI, 550–2197) pg/mL vs 37.5 (95% CI, −5 to 80) pg/mL; interleukin 6, 3691 (95% CI, 2313–5070) vs 365 (95% CI, 87–642) pg/mL; and interleukin 10, 633 (95% CI, −269 to 1534) vs 58 (95% CI, −39 to 156) pg/mL; (P<.001 for all). There were similar reductions in 5-hour lipopolysaccharide-stimulated cytokine secretion. Cytokine secretion in sepsis patients was generally less than 10% that in controls, independent of age, duration of sepsis, corticosteroid use, and nutritional status. Although differences existed between spleen and lung, flow cytometric analysis showed increased expression of selected inhibitory receptors and ligands and expansion of suppressor cell populations in both organs. Unique differences in cellular inhibitory molecule expression existed in immune cells isolated from lungs of sepsis patients vs cancer patients and vs transplant donors. Immunohistochemical staining showed extensive depletion of splenic CD4, CD8, and HLA-DR cells and expression of ligands for inhibitory receptors on lung epithelial cells. CONCLUSIONS: Patients who die in the ICU following sepsis compared with patients who die of nonsepsis etiologies have biochemical, flow cytometric, and immunohistochemical findings consistent with immunosuppression. Targeted immune-enhancing therapy may be a valid approach in selected patients with sepsis.

PRELIMINARY REMARKS (INTENT OF GUIDELINES) A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. The mission of SCCM is to secure the highest quality care for all critically ill and injured patients. Guideline Limitations: These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, practice guidelines are not intended as absolute requirements. The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. The guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality. The population of critically ill patients in an intensive care unit (ICU) is not homogeneous. Many of the studies on which the guidelines are based are limited by sample size, patient heterogeneity, variability in disease severity, lack of baseline nutritional status, and insufficient statistical power for analysis. Periodic Guideline Review and Update: This particular report is an update and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 (1). Governing bodies of both A.S.P.E.N. and SCCM have mandated that these guidelines be updated every three to five years. The database of randomized controlled trials (RCTs) that served as the platform for the analysis of the literature was assembled in a joint "harmonization process" with the Canadian Clinical Guidelines group. Once completed, each group operated separately in their interpretation of the studies and derivation of guideline recommendations (2). The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature searches by the authors through December 31, 2013. Although the committee was aware of landmark studies published after this date, these data were not included in this manuscript. The process by which the literature was evaluated necessitated a common end date for the search review. Adding a last-minute landmark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript. Target Patient Population for Guideline: The target of these guidelines is intended to be the adult (≥ 18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical ICU (MICU) or surgical ICU (SICU). The current guidelines were expanded to include a number of additional subsets of patients who met the above criteria, but were not included in the previous 2009 guidelines. Specific patient populations addressed by these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese. These guidelines are directed toward generalized patient populations but, like any other management strategy in the ICU, nutrition therapy should be tailored to the individual patient. Target Audience: The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill, primarily physicians, nurses, dietitians, and pharmacists. Methodology: The authors compiled clinical questions reflecting key management issues in nutrition therapy. A committee of multidisciplinary experts in clinical nutrition composed of physicians, nurses, pharmacists, and dietitians was jointly convened by the two societies. Literature searches were then performed using key words (critically ill, critical care, intensive care, nutrition, enteral, parenteral, tube feeding, and those related to assigned topics such as pancreatitis, sepsis, etc.) to evaluate the quality of evidence supporting a response to those questions, which were then used to derive a subsequent treatment recommendation. The literature search included MEDLINE, PubMed, Cochrane Database of Systemic Reviews, the National Guidelines Clearing House and an Internet search using the Google search engine for scholarly articles through an end date of December 31, 2013 (including ePub publications). While preference was given to RCTs, other forms of resource material were used to support the response, including nonrandomized cohort trials, prospective observational studies, and retrospective case series. Use of publications was limited to full-text articles available in English on adult humans. For all included RCTs, two readers completed data abstraction forms (DAFs) examining the data and assessing the quality of the research methodology to produce a shared evaluation achieved by consensus for each study (example of DAF provided in the supplemental data, Supplemental Digital Content 1, https://links.lww.com/CCM/B571). DAFs were constructed only for RCTs. When the strongest available evidence was a published meta-analysis, the studies from the meta-analysis were used to determine the quality of the evidence and assessed by two evidence assessors. The data from included trials were entered into Review Manager 5.2 software to create forest plots aggregating the effect size for each intervention and outcome (3). The key forest plots supporting the recommendation are included throughout the text and in the supplement data (Supplemental Digital Content 1, https://links.lww.com/CCM/B571). No new forest plots were created when a meta-analysis was evaluated. Since release of the 2009 A.S.P.E.N. and SCCM Clinical Guidelines, the concepts of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group have been adopted (4–7). A full description of the methodology has been previously published (4). The data from the Review Manager analysis was uploaded to GRADEPro software (8), where the body of evidence for a given intervention and outcome was evaluated for overall quality. One analyst created each GRADE table that was then independently confirmed by a second analyst. The GRADE tables are provided in the supplement data (Supplemental Digital Content 1, https://links.lww.com/CCM/B571). Due to the inordinately large number of RCTs evaluated, observational studies were critically reviewed, but not utilized to construct the GRADE tables. However, in the few cases where observational studies were the only available evidence in a population, their quality of evidence was reviewed, using GRADE (Table 1). When no RCT or observational study was available to answer a question directly, consensus of the author group on the best clinical practice approach was used, and the recommendation was designated "based on expert consensus."TABLE 1: Type of EvidenceA recommendation for clinical practice was based on both the best available evidence and the risks and benefits to patients. While small author teams developed each recommendation and provided the supporting rationale, a full discussion by the entire author group followed, and every committee member was polled anonymously for their agreement with the recommendation. Achievement of consensus was arbitrarily set at 70% agreement of authors with a particular recommendation. Only one recommendation (H3a) did not meet this level of agreement, with a final consensus of 64%. All other consensus-based recommendations reached a level of agreement of 80% or higher. As with all A.S.P.E.N. and SCCM clinical guidelines, this manuscript was subjected to rigorous peer review by clinical content experts from all the practice disciplines that would use the guidelines, both internal and external to the organizations. A summary of the guidelines is presented in the supplement data (Supplemental Digital Content 1, https://links.lww.com/CCM/B571). A nutrition bundle based on the top guidelines (as voted on by the committee) for the bedside practitioner is presented in Table 2.TABLE 2: Bundle StatementsCONFLICT OF INTEREST All authors completed both an A.S.P.E.N. and SCCM conflict of interest form for copyright assignment and financial disclosure. There was no input or funding from industry, nor were any industry representatives present at any of the committee meetings. DEFINITIONS Nutrition Therapy refers specifically to the provision of either enteral nutrition (EN) by enteral access device and/or parenteral nutrition (PN) by central venous access. Standard therapy (STD) refers to provision of IV fluids, no EN or PN, and advancement to oral diet as tolerated. INTRODUCTION The significance of nutrition in the hospital setting (and especially the ICU) cannot be overstated. Critical illness is typically associated with a catabolic stress state in which patients demonstrate a systemic inflammatory response coupled with complications of increased infectious morbidity, multiple organ dysfunction, prolonged hospitalization, and disproportionate mortality. Over the past three decades, exponential advances have been made in the understanding of the molecular and biological effects of nutrients in maintaining homeostasis in the critically ill population. Traditionally, nutrition support in the critically ill population was regarded as adjunctive care designed to provide exogenous fuels to preserve lean body mass and support the patient throughout the stress response. Recently this strategy has evolved to represent nutrition therapy, in which the feeding is thought to help attenuate the metabolic response to stress, prevent oxidative cellular injury, and favorably modulate immune responses. Improvement in the clinical course of critical illness may be achieved by early EN, appropriate macro- and micronutrient delivery, and meticulous glycemic control. Delivering early nutrition support therapy, primarily by the enteral route, is seen as a proactive therapeutic strategy that may reduce disease severity, diminish complications, decrease LOS in the ICU, and favorably impact patient outcomes. A. NUTRITION ASSESSMENT Question: Does the use of a nutrition risk indicator identify patients who will most likely benefit from nutrition therapy? A1. Based on expert consensus, we suggest a determination of nutrition risk (for example, Nutritional Risk Score [NRS-2002], NUTRIC score) be performed on all patients admitted to the ICU for whom volitional intake is anticipated to be insufficient. High nutrition risk identifies those patients most likely to benefit from early EN therapy. Rationale: Poor outcomes have been associated with inflammation generated by critical illness that leads to deterioration of nutrition status and malnutrition (9). However, malnutrition in the critically ill has always been difficult to define. An international consensus group modified definitions to recognize the impact of inflammation. Objective measures of baseline nutrition status have been described by A.S.P.E.N. and the Academy of Nutrition and Dietetics (10, 11). On the other hand, nutrition risk is easily defined and more readily determined by evaluation of baseline nutrition status and assessment of disease severity. All hospitalized patients are required to undergo an initial nutrition screen within 48 hours of admission. However, patients at higher nutrition risk in an ICU setting require a full nutrition assessment. Many screening and assessment tools are used to evaluate nutrition status, such as the Mini Nutritional Assessment (MNA), the Malnutrition Universal Screening Tool (MUST), the Short Nutritional Assessment Questionnaire (SNAQ), the Malnutrition Screening Tool (MST), and the Subjective Global Assessment (SGA) (12). However, only the NRS-2002 and the NUTRIC score determine both nutrition status and disease severity. Although both scoring systems were based on retrospective analysis, they have been used to define nutrition risk in RCTs in critically ill patients (13–16). Patients at "risk" are defined by an NRS-2002 > 3 and those at "high risk" with a score ≥ 5; or a NUTRIC score ≥ 5 (if interleukin-6 is not included, otherwise ≥ 6) (13, 18). Interleukin-6 is rarely available as a component for the NUTRIC score; therefore, Heyland et al has shown a NUTRIC score ≥ 5 still indicates high nutrition risk (19). Two prospective nonrandomized studies show that patients at high nutrition risk are more likely to benefit from early EN with improved outcome (reduced nosocomial infection, total complications, and mortality) than patients at low nutrition risk (13, 18). While widespread use and supportive evidence is somewhat lacking to date, improvement in these scoring systems may increase their applicability in the future by providing guidance as to the role of EN and PN in the ICU. Question: What additional tools, components or surrogate markers provide useful information when performing nutrition assessments in critically ill adult patients? A2. Based on expert consensus, we suggest that nutritional assessment include an evaluation of comorbid conditions, function of the gastrointestinal (GI) tract, and risk of aspiration. We suggest not using traditional nutrition indicators or surrogate markers, as they are not validated in critical care. Rationale: In the critical care setting, the traditional serum protein markers (albumin, prealbumin, transferrin, retinol-binding protein) are a reflection of the acute phase response (increases in vascular permeability and reprioritization of hepatic protein synthesis) and do not accurately represent nutrition status in the ICU setting (20). Anthropometrics are not reliable in assessment of nutrition status or adequacy of nutrition therapy (21). Individual levels of calcitonin, C-reactive protein (CRP), IL-1, tumor necrosis factor (TNF), IL-6, and citrulline are still investigational and should not be used as surrogate markers. Ultrasound is emerging as a tool to expediently measure muscle mass and determine changes in muscle tissue at bedside in the ICU, given its ease of use and availability (22, 23). A CT scan provides a precise quantification of skeletal muscle and adipose tissue depots; however it is quite costly unless a scan taken for other purposes is used to determine body composition (24, 25). Both may be valuable future tools to incorporate into nutrition assessment; however, validation and reliability studies in ICU patients are still pending. Assessment of muscle function is still in its infancy. Its measurement, reproducibility, and applicability are still being validated for use in critically ill patients, and may be of value in the future. Question: What is the best method for determining energy needs in the critically ill adult patient? A3a. We suggest that indirect calorimetry (IC) be used to determine energy requirements, when available and in the absence of variables that affect the accuracy of measurement. [Quality of Evidence: Very Low] A3b. Based on expert consensus, in the absence of IC, we suggest that a published predictive equation or a simplistic weight-based equation (25–30 kcal/kg/day) be used to determine energy requirements. (See section Q for obesity recommendations.) Rationale: Clinicians should determine energy requirements in order to establish the goals of nutrition therapy. Energy requirements may be calculated either through simplistic formulas (25–30 kcal/kg/day), published predictive equations, or IC. The applicability of IC may be limited at most institutions by availability and cost. Variables in the ICU that affect the timing and accuracy of IC measurements include the presence of air leaks or chest tubes, supplemental oxygen (e.g., nasal cannula, bilevel positive airway pressure), ventilator settings (fractional inspiratory oxygen and positive end-expiratory pressure), continuous renal replacement therapy (CRRT), anesthesia, physical therapy, and excessive movement (26). More than 200 predictive equations have been published in the literature, with accuracy rates ranging from 40–75% when compared to IC, and no single equation emerges as being more accurate in an ICU (27–32). Predictive equations are less accurate in obese and underweight patients (33–36). Equations derived from testing hospital patients (Penn State, Ireton-Jones, Swinamer) are no more accurate than equations derived from testing normal volunteers (Harris-Benedict, Mifflin St. Jeor) (37). The poor accuracy of predictive equations is related to many non-static variables affecting energy expenditure in the critically ill patient, such as weight, medications, treatments, and body temperature. The only advantage of using weight-based equations over other predictive equations is simplicity. However, in critically ill patients following aggressive volume resuscitation or in the presence of edema or anasarca, clinicians should use dry or usual body weight in these equations. Additional energy provided by dextrose-containing fluids and lipid-based medications such as propofol should be accounted for when deriving nutrition therapy regimens to meet target energy goals. Achieving energy balance as guided by IC measurements compared to predictive equations may lead to more appropriate nutrition intake. While two RCTs (38, 39) that met our inclusion criteria (with data from 161 patients) showed that higher mean intake of energy and protein were provided in IC-directed study patients compared to controls whose nutrition therapy was directed by predictive equations, issues with study design prevent a stronger recommendation for use of IC. In a study of burn patients, use of IC-directed nutrition therapy helped provide the minimal effective intake, avoiding the excesses of overfeeding seen in controls whose therapy was directed by the Curreri formula. Complications between groups (diarrhea and hyperglycemia) were no different, but traditional outcome parameters were not evaluated (38). A second study in general ICU patients used both EN and PN to meet target energy goals determined by IC measurement or a weight-based predictive equation (25 kcal/kg/day) (39). While the IC-directed energy goal was no different than the value obtained by predictive equation (1976 ± 468 vs 1838 ± 468 kcal/day, respectively, p = 0.60), only study patients were monitored vigilantly by an ICU dietitian, while controls were managed by standard of care (less frequent ICU dietitian monitoring), which led to significantly more energy and protein per in the study patients. The toward in study patients compared to controls = p = is difficult to in of their increased with to ICU LOS vs p = and of vs p = (38, by IC or by predictive equations, energy expenditure should be more than per and to energy and protein intake should be used Question: protein provision be monitored independently from energy provision in critically ill adult patients? Based on expert consensus, we suggest an evaluation of adequacy of protein provision be Rationale: In the critical care setting, protein to be the most for supporting immune and maintaining lean body For most critically ill patients, protein requirements are higher than energy requirements and are not easily met by provision of enteral have a high Patients with EN to frequent may benefit from protein The to protein should be based on an assessment of adequacy of protein intake. equations (e.g., may be used to adequacy of protein provision by the of protein to that especially when balance studies are not available to needs section protein markers (albumin, prealbumin, transferrin, are not validated for determining adequacy of protein provision and should not be used in the critical care setting in this EN Question: What is the benefit of early EN in critically ill adult patients compared to or this therapy? We that nutrition support therapy in the form of early EN be within hours in the critically ill patient who is to volitional intake. [Quality of Evidence: Very Low] Rationale: EN the of the by maintaining between the and the release of as and EN by maintaining and supporting the mass of and that the tissue and in to tissue at such as the and in permeability from of is a that is within hours of the major or The of the permeability changes include increased of with risk for systemic infection, and greater of multiple organ As disease in permeability are and the enteral of feeding is more likely to favorably impact outcome parameters of infection, organ and hospital LOS The specific for providing EN are to modulate stress and the systemic immune response, and attenuate disease Additional of EN therapy may include use of the as a for the of and use of enteral as an effective for stress previous data from RCTs early One meta-analysis of trials by Heyland showed a toward = p = when EN was within 48 hours compared to of EN after that A second meta-analysis of trials by showed in infectious = p = and hospital LOS p = when early EN was on within hours of ICU A meta-analysis of trials by showed a in = p = and = p = but no in multiple organ failure when early EN was within hours of to the ICU, compared to EN after that an updated meta-analysis of RCTs that met our inclusion criteria the provision of early EN EN, all on with on of early EN was associated with a in = p = and infectious = p = compared to early EN EN or 1: enteral nutrition (EN) vs EN, 2: enteral nutrition (EN) vs EN, infectious a in outcome between the use of EN or PN for adult critically ill patients? We suggest the use of EN over PN in critically ill patients who require nutrition support therapy. [Quality of Evidence: to Very Low] Rationale: In the of critically ill patients it is and to use EN of The effects of EN compared to PN are in RCTs a of patient populations in critical including injury, major surgery, and acute While few studies have shown a effect on the most outcome effect from EN is a in infectious and central in most patient and in patients) and ICU previous EN to PN showed in infectious with use of EN complications = p = and hospital LOS mean = p = were seen with use of EN compared to PN in one of the by of the showed no in between the two of nutrition support therapy One meta-analysis by showed a significantly = p = a significantly higher of infectious complications = p = with use of PN compared to EN In studies patients that met our inclusion criteria, on which was shown to be significantly less with EN than PN = p ICU LOS was with EN compared to PN by one full = to p = LOS and were not significantly These in outcome from the of feeding from studies and may diminish in the future with in glycemic medical management and new nutrition (EN) vs parenteral nutrition infectious the clinical evidence of required to EN in critically ill adult patients? Based on expert consensus, we suggest in the of and patient while should be evaluated when EN, of should not be required to of Rationale: The literature the that and evidence of or are not required for of in the ICU setting in of patients, on the medications, and metabolic state of ICU and postoperative are related to of the and mass of has been defined (e.g., absence or high etc.) and to in to of patients on are only of and do not to or The for EN of the of is based on studies of which critically ill surgical patients) the and of EN within the initial hours of to the ICU. or may greater disease and Patients with normal have been shown to have ICU than those with or vs vs ICU LOS has been shown to increase with greater number of of days when to days with of of EN is with a greater number of of A greater number of of may increased as EN is and may clinical Question: What is the level of of EN within the for critically ill patients? does the level of of EN affect patient We that the level of be in the in those critically ill patients at high risk for section or those who have shown to [Quality of Evidence: to Based on expert consensus we suggest in most critically ill patients, it is to EN in the Rationale: EN therapy in the is and may decrease the to of The of level of the of the feeding tube is in the different of the or or the within the may be determined by patient within ICU and of small enteral access and

Purpose This paper develops a research model to examine the relationship among e‐service quality dimensions and overall service quality, customer satisfaction and purchase intentions. Design/methodology/approach Data from a survey of 297 online consumers were used to test the research model. Confirmatory factor analysis was conducted to examine the reliability and validity of the measurement model, and the structural equation modelling technique was used to test the research model. Findings The analytical results showed that the dimensions of web site design, reliability, responsiveness, and trust affect overall service quality and customer satisfaction. Moreover, the latter in turn are significantly related to customer purchase intentions. However, the personalization dimension is not significantly related to overall service quality and customer satisfaction. Research limitations/implications Future research can use different methodologies, such as longitudinal studies, focus groups and interviews, to examine the relationship between service quality and customer purchase behaviour in online shopping contexts. Practical implications This study suggests that to enhance customer purchase intentions, online stores should develop marketing strategies to better address the trustworthiness, reliability, and responsiveness of web‐based services. Online stores can devote valuable corporate resources to the important e‐service quality attributes identified by this study. Originality/value This study developed the instrument dimensions of e‐service quality by modifying the SERVQUAL model to consider online shopping context. Moreover, the results of this study provide a valuable reference for managers of online stores, as well as for researchers interested in internet marketing.

The Reactome Knowledgebase (https://reactome.org), an Elixir and GCBR core biological data resource, provides manually curated molecular details of a broad range of normal and disease-related biological processes. Processes are annotated as an ordered network of molecular transformations in a single consistent data model. Reactome thus functions both as a digital archive of manually curated human biological processes and as a tool for discovering functional relationships in data such as gene expression profiles or somatic mutation catalogs from tumor cells. Here we review progress towards annotation of the entire human proteome, targeted annotation of disease-causing genetic variants of proteins and of small-molecule drugs in a pathway context, and towards supporting explicit annotation of cell- and tissue-specific pathways. Finally, we briefly discuss issues involved in making Reactome more fully interoperable with other related resources such as the Gene Ontology and maintaining the resulting community resource network.

Vascular permeability factor (VPF) is an Mr 40-kD protein that has been purified from the conditioned medium of guinea pig line 10 tumor cells grown in vitro, and increases fluid permeability from blood vessels when injected intradermally. Addition of VPF to cultures of vascular endothelial cells in vitro unexpectedly stimulated cellular proliferation. VPF promoted the growth of new blood vessels when administered into healing rabbit bone grafts or rat corneas. The identity of the growth factor activity with VPF was established in four ways: (a) the molecular weight of the activity in preparative SDS-PAGE was the same as VPF (Mr approximately 40 kD); (b) multiple isoforms (pI greater than or equal to 8) for both VPF and the growth-promoting activity were observed; (c) a single, unique NH2-terminal amino acid sequence was obtained; (d) both growth factor and permeability-enhancing activities were immunoadsorbed using antipeptide IgG that recognized the amino terminus of VPF. Furthermore, 125I-VPF was shown to bind specifically and with high affinity to endothelial cells in vitro and could be chemically cross-linked to a high-molecular weight cell surface receptor, thus demonstrating a mechanism whereby VPF can interact directly with endothelial cells. Unlike other endothelial cell growth factors, VPF did not stimulate [3H]thymidine incorporation or promote growth of other cell types including mouse 3T3 fibroblasts or bovine smooth muscle cells. VPF, therefore, appears to be unique in its ability to specifically promote increased vascular permeability, endothelial cell growth, and angio-genesis.

Several species of protozoa, during their logarithmic phases of growth, produce substances that prolong the logarithmic phase in other species. The effect is not as striking as the inhibition of growth caused by antibiotics, but a consistent 50-percent increase in growth has been obtained with Tetrahymena pyriformis in response to a factor produced by Colpidium campylum.

The standard nomenclature that has been used for many telencephalic and related brainstem structures in birds is based on flawed assumptions of homology to mammals. In particular, the outdated terminology implies that most of the avian telencephalon is a hypertrophied basal ganglia, when it is now clear that most of the avian telencephalon is neurochemically, hodologically, and functionally comparable to the mammalian neocortex, claustrum, and pallial amygdala (all of which derive from the pallial sector of the developing telencephalon). Recognizing that this promotes misunderstanding of the functional organization of avian brains and their evolutionary relationship to mammalian brains, avian brain specialists began discussions to rectify this problem, culminating in the Avian Brain Nomenclature Forum held at Duke University in July 2002, which approved a new terminology for avian telencephalon and some allied brainstem cell groups. Details of this new terminology are presented here, as is a rationale for each name change and evidence for any homologies implied by the new names. Revisions for the brainstem focused on vocal control, catecholaminergic, cholinergic, and basal ganglia-related nuclei. For example, the Forum recognized that the hypoglossal nucleus had been incorrectly identified as the nucleus intermedius in the Karten and Hodos (1967) pigeon brain atlas, and what was identified as the hypoglossal nucleus in that atlas should instead be called the supraspinal nucleus. The locus ceruleus of this and other avian atlases was noted to consist of a caudal noradrenergic part homologous to the mammalian locus coeruleus and a rostral region corresponding to the mammalian A8 dopaminergic cell group. The midbrain dopaminergic cell group in birds known as the nucleus tegmenti pedunculopontinus pars compacta was recognized as homologous to the mammalian substantia nigra pars compacta and was renamed accordingly; a group of gamma-aminobutyric acid (GABA)ergic neurons at the lateral edge of this region was identified as homologous to the mammalian substantia nigra pars reticulata and was also renamed accordingly. A field of cholinergic neurons in the rostral avian hindbrain was named the nucleus pedunculopontinus tegmenti, whereas the anterior nucleus of the ansa lenticularis in the avian diencephalon was renamed the subthalamic nucleus, both for their evident mammalian homologues. For the basal (i.e., subpallial) telencephalon, the actual parts of the basal ganglia were given names reflecting their now evident homologues. For example, the lobus parolfactorius and paleostriatum augmentatum were acknowledged to make up the dorsal subdivision of the striatal part of the basal ganglia and were renamed as the medial and lateral striatum. The paleostriatum primitivum was recognized as homologous to the mammalian globus pallidus and renamed as such. Additionally, the rostroventral part of what was called the lobus parolfactorius was acknowledged as comparable to the mammalian nucleus accumbens, which, together with the olfactory tubercle, was noted to be part of the ventral striatum in birds. A ventral pallidum, a basal cholinergic cell group, and medial and lateral bed nuclei of the stria terminalis were also recognized. The dorsal (i.e., pallial) telencephalic regions that had been erroneously named to reflect presumed homology to striatal parts of mammalian basal ganglia were renamed as part of the pallium, using prefixes that retain most established abbreviations, to maintain continuity with the outdated nomenclature. We concluded, however, that one-to-one (i.e., discrete) homologies with mammals are still uncertain for most of the telencephalic pallium in birds and thus the new pallial terminology is largely devoid of assumptions of one-to-one homologies with mammals. The sectors of the hyperstriatum composing the Wulst (i.e., the hyperstriatum accessorium intermedium, and dorsale), the hyperstriatum ventrale, the neostriatum, and the archistriatum have been renamed (respectively) the hyperpallium (hypertrophied pallium), the mesopallium (middle pallium), the nidopallium (nest pallium), and the arcopallium (arched pallium). The posterior part of the archistriatum has been renamed the posterior pallial amygdala, the nucleus taeniae recognized as part of the avian amygdala, and a region inferior to the posterior paleostriatum primitivum included as a subpallial part of the avian amygdala. The names of some of the laminae and fiber tracts were also changed to reflect current understanding of the location of pallial and subpallial sectors of the avian telencephalon. Notably, the lamina medularis dorsalis has been renamed the pallial-subpallial lamina. We urge all to use this new terminology, because we believe it will promote better communication among neuroscientists. Further information is available at http://avianbrain.org

The development of eco-friendly technologies in material synthesis is of considerable importance to expand their biological applications. Nowadays, a variety of inorganic nanoparticles with well-defined chemical composition, size, and morphology have been synthesized by using different microorganisms, and their applications in many cutting-edge technological areas have been explored. This paper highlights the recent developments of the biosynthesis of inorganic nanoparticles including metallic nanoparticles, oxide nanoparticles, sulfide nanoparticles, and other typical nanoparticles. Different formation mechanisms of these nanoparticles will be discussed as well. The conditions to control the size/shape and stability of particles are summarized. The applications of these biosynthesized nanoparticles in a wide spectrum of potential areas are presented including targeted drug delivery, cancer treatment, gene therapy and DNA analysis, antibacterial agents, biosensors, enhancing reaction rates, separation science, and magnetic resonance imaging (MRI). The current limitations and future prospects for the synthesis of inorganic nanoparticles by microorganisms are discussed.

Two studies investigated the relationship between transformational leadership, the meaning that individuals ascribe to their work, and their psychological well-being. In Study 1, the perceptions of meaningful work partially mediated the relationship between transformational leadership and positive affective well-being in a sample of Canadian health care workers (N=319). In Study 2, the meaning that a separate sample of service workers (N=146) ascribed to their work fully mediated the relationship between transformational leadership and psychological well-being, after controlling for humanistic work beliefs. Overall, these results support and add to the range of positive mental health effects associated with transformational leadership and are suggestive of interventions that organizations can make to improve well-being of workers.

CHAPTER 1 Psychological Testing and Assessment CHAPTER 2 Historical, Cultural, and Legal/Ethical Considerations CHAPTER 3 A Statistics Refresher CHAPTER 4 Of Tests and Testing CHAPTER 5 Reliability CHAPTER 6 Validity CHAPTER 7 Utility CHAPTER 8 Test Development CHAPTER 9 Intelligence and Its Measurement CHAPTER 10 Tests of Intelligence CHAPTER 11 Assessment for Education CHAPTER 12 Personality Assessment: An Overview CHAPTER 13 Personality Assessment Methods CHAPTER 14 Clinical and Counseling Assessment CHAPTER 15 Neuropsychological Assessment CHAPTER 16 Assessment, Careers, and Business References Credits Name Index Glossary/Index

Cancer is rapidly becoming the top killer in the world. Most of the FDA approved anticancer drugs are organic molecules, while metallodrugs are very scarce. The advent of the first metal based therapeutic agent, cisplatin, launched a new era in the application of transition metal complexes for therapeutic design. Due to their unique and versatile biochemical properties, ruthenium-based compounds have emerged as promising anti-cancer agents that serve as alternatives to cisplatin and its derivertives. Ruthenium(iii) complexes have successfully been used in clinical research and their mechanisms of anticancer action have been reported in large volumes over the past few decades. Ruthenium(ii) complexes have also attracted significant attention as anticancer candidates; however, only a few of them have been reported comprehensively. In this review, we discuss the development of ruthenium(ii) complexes as anticancer candidates and biocatalysts, including arene ruthenium complexes, polypyridyl ruthenium complexes, and ruthenium nanomaterial complexes. This review focuses on the likely mechanisms of action of ruthenium(ii)-based anticancer drugs and the relationship between their chemical structures and biological properties. This review also highlights the catalytic activity and the photoinduced activation of ruthenium(ii) complexes, their targeted delivery, and their activity in nanomaterial systems.

Recently, there has been an increasing use of the cyclopropyl ring in drug development to transition drug candidates from the preclinical to clinical stage. Important features of the cyclopropane ring are, the (1) coplanarity of the three carbon atoms, (2) relatively shorter (1.51 Å) C–C bonds, (3) enhanced π-character of C–C bonds, and (4) C–H bonds are shorter and stronger than those in alkanes. The present review will focus on the contributions that a cyclopropyl ring makes to the properties of drugs containing it. Consequently, the cyclopropyl ring addresses multiple roadblocks that can occur during drug discovery such as (a) enhancing potency, (b) reducing off-target effects, (c) increasing metabolic stability, (d) increasing brain permeability, (e) decreasing plasma clearance, (f) contributing to an entropically more favorable binding to the receptor, (g) conformational restriction of peptides/peptidomimetics to prevent proteolytic hydrolysis, and (h) altering drug pKa to reduce its P-glycoprotein efflux ratio.