Kathleen P. Ismond

Enhanced low oxygen survival in Arabidopsis through increased metabolic flux in the fermentative pathway.

We manipulated the enzyme activity levels of the alcohol fermentation pathway, pyruvate decarboxylase (PDC), and alcohol dehydrogenase (ADH) in Arabidopsis using sense and antisense overexpression of the corresponding genes (PDC1, PDC2, and ADH1). Transgenic plants were analyzed for levels of fermentation and evaluated for changes in hypoxic survival. Overexpression of either Arabidopsis PDC1 or PDC2 resulted in improved plant survival. In contrast, overexpression of Arabidopsis ADH1 had no effect on flooding survival. These results support the role of PDC as the control step in ethanol fermentation. Although ADH1 null mutants had decreased hypoxic survival, attempts to reduce the level of PDC activity enough to see an effect on plant survival met with limited success. The combination of flooding survival data and metabolite analysis allows identification of critical metabolic flux points. This information can be used to design transgenic strategies to improve hypoxic tolerance in plants.

Functional analysis of lactate dehydrogenase during hypoxic stress in Arabidopsis

During waterlogging conditions plants switch from aerobic respiration to anaerobic fermentation to cope with the lack of available oxygen. Plants have two main fermentation pathways: ethanol and lactic acid fermentation. In this paper we carry out a functional analysis of the Arabidopsis lactate dehydrogenase gene, LDH1. Our results indicate that LDH1, like some other anaerobic genes, is expressed in a root-specific manner and is affected by a variety of abiotic stresses (hypoxia, drought, cold) and mechanical wounding. Functional analysis of LDH1 was carried out using transgenic Arabidopsis overexpressing the gene (35S promoter) and a T-DNA knockout line. Overexpression of LDH1 resulted in improved survival of low oxygen stress conditions in roots but not in shoots. Increased lactic acid fermentation also resulted in significantly higher activities of pyruvate decarboxylase (PDC). Knockout mutants of LDH1 showed reduced survival under low oxygen conditions and PDC activity levels were not changed compared with the wild type. Our data suggest that there is an interdependency between the lactic and ethanol fermentation pathways and that lactic acid fermentation may play a role in stimulating ethanol fermentation and improving plant survival. We show also that Arabidopsis plants are able to exude lactate efficiently into the medium, preventing it accumulating to toxic levels in the cells.

Molecular Basis of the Anaerobic Response in Plants

The response of plants to flooding is complex and involves the induction of specific gene sets. A multidisciplinary approach by several research teams has led to a reasonably good understanding of the low oxygen response, and many of the genes and proteins that are involved are known. But the factors that are critical in determining tolerance or intolerance remain unknown. Microarray technology offers renewed hope to unravel the complex changes in gene expression occurring in plants upon low oxygen treatment and what mechanisms are involved in the response.

The medical digital library landscape

Purpose – The purpose of this paper is to identify two medical digital libraries from each of the following three countries: Canada, the USA and the UK. It aims to discuss strengths and weaknesses in system design in an effort to provide a basis on which to improve both the organisation of, and the access to, electronic, scholarly information.Design/methodology/approach – Inclusion criteria for identifying the medical digital libraries were, those who: had primarily text‐based collections, intended for use by researchers or healthcare professionals; were freely accessible, and fulfilled the authors definition of a digital library as opposed to an online database. (Medical digital libraries with either a historical focus or that had primarily image/video collections were excluded.) To identify suitable medical digital libraries, the following resources were used: scholarly databases, online search engines, government and national library web sites, lists of online medical resources, and university web sit...

Exercise in cirrhosis: Translating evidence and experience to practice

Physical inactivity, sarcopenia, and frailty are highly prevalent, independent predictors of morbidity and mortality in patients with cirrhosis. Across a range of chronic diseases, exercise training is a key recommendation supported by guidelines and, for some conditions, even by governmental funding of exercise programmes. Consistent with the broader chronic disease literature, the evidence for a benefit of exercise in cirrhosis is promising. Several small trials have reported significant improvements in muscle health (mass, strength, functional capacity), quality of life, fatigue, and reductions in the hepatic venous pressure gradient, without adverse events. With strong emerging evidence surrounding the substantial risks of sarcopenia/frailty and our first-hand experiences with liver pre-transplant exercise programmes, we contend that routine patient care in cirrhosis should include an exercise prescription. Some clinicians may lack the resources and necessary background to translate the existing evidence into a practicable intervention. Our team, comprised of physiotherapists, exercise physiologists, hepatologists, transplant specialists, and knowledge translation experts from six North American centres, has distilled the essential background information, tools, and practices into a set of information ready for immediate implementation into clinics ranging from a family practice setting to specialty cirrhosis clinics. Augmenting the rationale and evidence are supplementary materials including video and downloadable materials for both patients and the physician. Supporting the exercising patient is a section regarding information about nutrition, providing practical tips suitable for all patients with cirrhosis.

Advance care planning (ACP) for specialists managing cirrhosis: A focus on patient‐centered care

Advance care planning (ACP) and goals of care designation (GCD) are being integrated into modern health care. In cirrhosis, uptake and adoption of these practices have been limited with physicians citing many perceived barriers and limitations. Recognizing the many tangible benefits of ACP and GCD processes in patients with life‐limiting chronic diseases, the onus is on health practitioners to initiate and direct these conversations with their patients and surrogates. Drawing upon the literature and our experiences in palliative care and cirrhosis, we provide an actionable framework that can be readily implemented into a busy clinical setting by a practitioner. Conversation starters, visual aids, educational resources (for patients and practitioners), and videos of mock physician‐patient scenarios are presented and discussed. Importantly, we have customized each of these tools to meet the unique health care needs of patients with cirrhosis. The inherent flexibility of our approach to ACP discussions and GCD can be further modified to accommodate practitioner preferences. Conclusion: In our clinics, this assemblage of “best practice tools” has been well received by patients and surrogates enabling us to increase the number of outpatients with cirrhosis who have actively contributed to their GCD before acute health events and are supported by well‐informed surrogates. (Hepatology 2018;67:2025‐2040).

Practical Considerations and the Intestinal Microbiome in Disease: Antibiotics for IBD Therapy

The inflammatory bowel diseases, Crohns and ulcerative colitis, have been treated with a range of antibiotics for inducing and maintaining remission, as well as the prevention of post-operative symptoms. To date, many studies have been performed assessing the efficacy of antibiotics when used alone, in combination with other antibiotics, or as an adjunctive therapy to other pharmaceutical treatments. Literature evidence supporting the use of antibiotics in IBD can be ambiguous, especially when considering the potential role of dysbiosis in the gastrointestinal tract. The review considers the systemic effect of antibiotics and the evidence base for their efficacy in the treatment of IBD.

Mindfulness-Based Therapy and Heart Health

Abstract Cardiovascular disease is a leading cause of mortality in all countries around the world. The health-care burden associated with disease prevention and treatment is considerable. Mindfulness-based therapy is emerging as an effective intervention for a range of conditions, such as depression and anxiety. Ongoing research has been investigating the use of mindfulness to modify unhealthy human behaviors, such as tobacco smoking and overeating, which have proved resistant to traditional or pharmacological approaches. This review summarizes randomized controlled trials published since 2012 that measure the effect of mindfulness-based therapy on a modifiable risk factor for the development of cardiovascular disease: tobacco smoking, glucose regulation in diabetes mellitus, hypertension, obesity, nutrition, and physical inactivity.

Innovative Online Educational Portal Improves Disease-Specific Reproductive Knowledge Among Patients With Inflammatory Bowel Disease

Background Inflammatory bowel disease (IBD) is often diagnosed in early adulthood, affecting patients through their reproductive years. Many patients, lacking knowledge about IBD and reproduction, make uninformed decisions. Although patients have turned to the Internet for information, it remains unclear if online resources are effective for improving and retaining IBD-specific reproductive knowledge. We aimed to elucidate if a multimedia vs text-only online educational intervention could improve IBD-specific reproductive knowledge for more than 6 months. Methods We developed a website covering genetics, fertility, surgery, pregnancy, medications, delivery, and postpartum in the context of IBD. Adult IBD patients were randomized into study groups (multimedia or text-only) and provided 60-day access. Participants completed pre-, post-, and 6+ month-postintervention pregnancy knowledge (CCPKnow) questionnaires. Results were compared using nonparametric tests. Results Of 111 registered participants, 78 (70.3%) completed pre- and postintervention questionnaires, and 37 (47.4%) subsequently completed the 6+ month questionnaire. Demographics were as follows: median age (interquartile range [IQR]) 29.3 (25.6-32.9) years, Crohns disease n = 54 (69.2%), females n = 63 (80.3%), of which n = 5 (7.9%) were pregnant and n = 19 (30.2%) had previously been pregnant. The median CCPKnow scores (/17) (IQR) were 8.0 (3.0-10.0) pre-intervention, 16.0 (13.00-17.00) postintervention, and 14.0 (12.0-15.0) 6+ months postintervention. The median within-subject increase in score was 6.5 pre- to postintervention, and 4.0 pre- to 6+ months postintervention (both P < 0.001). The median increase in score (pre- to post-) was 8.0 for the multimedia group and 6.0 for the text-only group (P = 0.216). Conclusions An evidence-based, online educational portal can significantly improve and maintain IBD-specific reproductive patient knowledge for more than 6 months.

Patient Views on Advance Care Planning in Cirrhosis: A Qualitative Analysis

Aim To investigate patient experiences and perceptions of advance care planning (ACP) process in cirrhosis. Methods Purposive sampling was used to identify and recruit participants (N = 17) from discrete patient groups: compensated with no prior decompensation, decompensated and not yet listed for transplant, transplant wait listed, medical contraindications for transplant, and low socioeconomic status. Review and discussion of local ACP videos, documents, and experiences with ACP occurred in two individual interviews and four focus groups. Data were analyzed using inductive content analysis including iterative processes of open coding, categorization, and abstraction. Results Three overarching categories emerged: (1) lack of understanding about disease trajectories and ACP processes, (2) roles of alternate decision makers, and (3) preferences for receiving ACP information. Most patients desired advanced care-planning conversations before the onset of decompensation (specifically hepatic encephalopathy) with a care provider with whom they had a trusting, preexisting relationship. Involvement of the alternate decision makers was of critical importance to participants, as was the use of direct, easy to understand patient education tools that address practical issues. Conclusion Our findings support the need for early advance care planning in the outpatient setting. Outpatient clinicians may play a key role in facilitating these discussions.