James J. Nawarskas, PharmD, BCPS
- Associate Professor, Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, University of New Mexico, Albuquerque, New Mexico
In further preferred embodiments erectile dysfunction drug related order genuine cialis soft on-line, the invention provides a composition comprising a bacterial strain of the species Enterococcus faecium erectile dysfunction review cialis soft 20 mg with visa, for use in a method of treating or preventing cancer erectile dysfunction after 70 proven 40mg cialis soft, such as breast impotence treatment drugs buy cheap cialis soft 20 mg online, lung or liver cancer. Compositions comprising a bacterial strain of the species Enterococcus faecium may reduce tumour growth in mouse models of breast, lung and liver cancer. In certain embodiments, the composition is for use in a method of reducing tumour size or preventing tumour growth in the treatment of cancer. The effect shown for Enterococcus faecium on uveitis, which is strongly associated with the Thl7 inflammatory response, means that Enterococcusfaecium strains may be particularly beneficial for such patients. In preferred embodiments of the invention, the bacterial strain in the composition is of Enterococcus faecium. In certain embodiments, the composition of the invention is for oral administration. Also, oral administration is convenient for patients and practitioners and allows delivery to and / or partial or total colonisation of the intestine. In certain embodiments, the composition of the invention comprises one or more pharmaceutically acceptable excipients or carriers. In certain embodiments, the composition of the invention comprises a bacterial strain that has been lyophilised. Lyophilisation is an effective and convenient technique for preparing stable compositions that allow delivery of bacteria. In certain embodiments, the invention provides a food product comprising the composition as described above. In certain embodiments, the invention provides a vaccine composition comprising the composition as described above. In developing the above invention, the inventors have identified and characterised a bacterial strain that is particularly useful for therapy. The Enterococcusfaecium strain of the invention is shown to be effective for treating the diseases described herein, such as uveitis. The invention also provides compositions comprising such cells, or biologically pure cultures of such cells. The invention provides a composition comprising a bacterial strain of the species Enterococcus faecium for use in therapy, for example, for use in treating or preventing an inflammatory and/or autoimmune disease. In certain embodiments, the compositions of the invention comprise Enterococcusfaecium and do not contain any other bacterial species. In certain embodiments, the compositions of the invention comprise a single strain of Enterococcusfaecium and do not contain any other bacterial strains or species. Enterococcusfaecium is a Gram-positive, alpha-hemolytic or nonhemolytic bacterium in the genus Enterococcus that often occurs in pairs (diplococci) or short chains. In certain embodiments, the compositions of the invention comprise one of these strains, or a derivative or biotype thereof. The genomic sequence of this bacterium consists of a chromosome and three plasmids. A biotype is a closely related strain that has the same or very similar physiological and biochemical characteristics. For example, substantially the whole genome may be sequenced and a biotype strain for use in the invention may have at least 95%, 96%, 97%, 98%, 99%, 99. For example, in some embodiments, a biotype strain has at least 98% sequence identity across at least 98% of its genome or at least 99% sequence identity across 99% of its genome. In some embodiments, a biotype strain has a sequence with at least 95%, 96%, 97%, 98%, 99%, 99. In preferred embodiments, such techniques may be used to identify other Enterococcusfaecium strains. In some embodiments, the bacterial strain used in the invention is: (i) Positive for at least one of. In particular, a biotype strain will elicit comparable effects on the uveitis disease models to the effects shown in the Examples, which may be identified by using the culturing and administration protocols described in the Examples. A derivative of a strain of the invention may be modified, for example at the genetic level, without ablating the biological activity. In particular, a derivative strain will elicit comparable effects on the uveitis disease models to the effects shown in the Examples, which may be identified by using the culturing and administration protocols described in the Examples. In some embodiments, the bacterial strain for use in the invention has a chromosome with at least 90% sequence identity. In preferred embodiments, the bacterial strains in the compositions of the invention are viable and capable of partially or totally colonising the intestine. Therapeutic uses As demonstrated in the examples, the bacterial compositions of the invention are effective for reducing the Thl7 inflammatory response. These cytokines and others form important parts of the Thl7 pathway, which is a well-established inflammatory signalling pathway that contributes to and underlies a number of inflammatory and autoimmune diseases (as described in, for example, [25-30]). Diseases wherein the Thl7 pathway is activated are Thl7 pathway mediated diseases. Thl7 pathway-mediated diseases can be ameliorated or alleviated by repressing the Thl7 pathway, which may be through a reduction in the differentiation of Thl7 cells or a reduction in their activity or a reduction in the level of Thl7 pathway cytokines. Diseases mediated by the Thl7 pathway may be associated with increased levels of Thl7 cells. In preferred embodiments, the compositions of the invention are used for treating or preventing one or more of these conditions or diseases. In some embodiments, the pathogenesis of the disease or condition affects the intestine. In some embodiments, the pathogenesis of the disease or condition does not affect the intestine. In some embodiments, the pathogenesis of the disease or condition is not localised at the intestine. In some embodiments, the treating or preventing occurs at a site other than at the intestine. In some embodiments, the treating or preventing occurs at the intestine and also at a site other than at the intestine. In certain embodiments, the compositions of the invention are for use in treating or preventing an inflammatory or autoimmune disease, wherein said treatment or prevention is achieved by reducing or preventing elevation of the Thl7 inflammatory response. In certain embodiments, the patient may have been diagnosed with a chronic inflammatory or autoimmune disease or condition, or the composition of the invention may be for use in preventing an inflammatory or autoimmune disease or condition developing into a chronic inflammatory or autoimmune disease or condition. These uses of the invention may be applied to any of the specific disease or conditions listed in the preceding paragraph. In certain embodiments, the compositions are for use in patients with chronic disease. In certain embodiments, the compositions are for use in preventing the development of chronic disease. Uveitis In preferred embodiments, the compositions of the invention are for use in treating or preventing uveitis. The examples demonstrate that the compositions of the invention achieve a reduction in disease incidence and disease severity in an animal model of uveitis and so they may be useful in the treatment or prevention of uveitis. It can present in different anatomical forms (anterior, intermediate, posterior or diffuse) and result from different, but related, causes, including systemic autoimmune disorders. Posterior uveitis presents primarily with inflammation of the retina and choroid and the examples demonstrate that the compositions of the invention are effective for reducing retinal inflammation and damage. In certain embodiments, treatment with the compositions of the invention results in a reduction in retinal damage. In certain embodiments, the compositions of the invention are for use in reducing or preventing retinal damage in the treatment of uveitis. In certain embodiments, the compositions are for use in treating patients with severe uveitis that are at risk of retinal damage. In certain embodiments, treatment with the compositions of the invention results in a reduction in optic disc inflammation. In certain embodiments, the compositions of the invention are for use in reducing or preventing optic disc inflammation. In certain embodiments, treatment with the compositions of the invention results in a reduction in retinal tissue infiltration by inflammatory cells.
For pediatric patients with compromised skin strated with use of chlorhexidine-impregnated dress integrity causes of erectile dysfunction in 20s best purchase for cialis soft, remove dried povidone-iodine with ings impotence reasons and treatment cheapest cialis soft. Risk factors associated with catheter caution in premature neonates and among related upper extremity deep vein thrombosis in patients with patients with fragile skin and/or complicated skin peripherally inserted central venous catheters: a prospective observational cohort study: part 2 erectile dysfunction pills review order genuine cialis soft online. Monitor for erythema and dermatitis at the 5 erectile dysfunction treatment michigan purchase cialis soft 20mg mastercard,18-20 ter-related infections after switching from povidone-iodine to dressing site. Consider bathing patients over 2 months of age with catheters in children on hemodialysis. Consider the use of a hemostatic agent to reduce iodine for long-term central venous catheter care in hematology initial site bleeding if other methods (eg, pressure) departments: a prospective study. When the subcutaneous tunnel is well healed, con MedWatch/SafetyInformation/Safety-RelatedDrugLabeling sideration may be given to no dressing with a tun Changes/ucm307251. Best practice guidelines in the Note: All electronic references in this section were accessed September care and maintenance of pediatric central venous catheters. Infusion Gauze and tape and transparent polyurethane dressings for cen Nursing: An Evidence-Based Approach. Dressing disruption is a major risk factor for Corrigan A, Gorski L, Hankins J, Perucca R. Guidelines for the impregnated dressing for prevention of catheter-related blood prevention of intravascular catheter-related infections. The use of midline nated central-line dressings and necrosis in complicated skin dis catheters in the adult acute care setting: clinical implications and order patients. Chlorhexidine with a latex allergy (refer to Standard 14, Latex bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability. Label admin ing to reduce bacteraemia in critically ill children: a multicentre, istration sets used for medications that are adminis cluster-randomised, crossover trial. Chlorhexidine gluconate bathing: administration route and device, and place the label does it decrease hospital-acquired infections Arterial catheters as before connecting or reconnecting any infusion/ a source of bloodstream infection: a systematic review and meta device, at each care transition to a new setting or analysis. Replace primary and secondary continuous adminis intervention for tunneled central catheter exit sites. Change a secondary administration set that is Standard detached from the primary administration set every 24 hours as it is now a primary intermittent admin 42. Primary Intermittent Infusions set is changed whenever the peripheral catheter site is A. Change intermittent administration sets every 24 changed or when a new central vascular access device hours. Aseptically attach a new, sterile, compatible cover Practice Criteria ing device to the male luer end of the administration I. Replace administration sets for parenteral nutrition injection, infusion, and medication vial practices in health care. In: Alexander M, amino acid/dextrose formulations) at least every 24 Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion hours; there are also recommendations to change the Nursing: An Evidence-Based Approach. Core Curriculum for Change the administration set with each new con Infusion Nursing. Use administration sets free of di-ethylhexyl-phtha AlertsandNotices/TubingandLuerMisconnections/default. Optimal timing for intravas natal, pediatric, and long-term home care cular administration set replacement. Strategies to prevent central line-asso ciated bloodstream infections in acute care hospitals: 2014 A. Replacement of administra integrity of the product or system has been compro tion sets (including transducers) for peripheral arterial catheters: mised. Drawing blood samples based on clinical need errors in the preanalytic phase before the sample rather than a routine schedule. Using small-volume collection tubes (eg, requir decisions due to spurious lab values, enhance the ing less than 2 mL of blood). Assess the patient for fasting prior to collection of using an appropriate delivery method; or if delivery blood samples, if appropriate for the requested labo 5-7 must be delayed (eg, home-drawn specimens), prop ratory values. Use the same unique numbers for both patient iden risk for inaccurate laboratory values and the poten tification and specimen labeling to reduce preana 5-7 tial for hemolysis. Blood Sampling via Direct Venipuncture ment, transparency of data on mislabeled and unla A. Perform venipuncture for phlebotomy on the oppo beled specimens, process changes, root cause analy site extremity of an infusion. An electronic sys performed on the extremity with infusing solutions, tem (eg, bar-code or radio-frequency technology) for a vein below or distal to the site of infusion should patient identification and sample container labeling be used. Perform all infection prevention practices including lymphedema, compromised circulation associated hand hygiene, appropriate use of gloves, single with radiation therapy, paralysis, or hemiparesis patient tourniquets, single-use venipuncture and from a cerebrovascular accident. When possible, sampling devices, use of safety-engineered devices, restrict venipuncture to the dorsum of the hand in and appropriate skin antisepsis (see Standard 16, patients with an actual or planned dialysis fistula or Hand Hygiene; Standard 18, Medical Waste and graft. Perform venipuncture for phlebotomy with a straight the tubes as methods to decrease blood exposure, or winged needle on veins in the antecubital fossa accidental needlestick injury, and error in sample (eg, median cubital, cephalic, and basilic veins) due analysis. Contact the clinical labo chlorhexidine in alcohol solution, tincture of iodine, ratory about parameters for the free hemoglobin level and povidone-iodine. Employ blood conservation strategies to reduce however, 1 study has shown this to not be a cause phlebotomy-associated blood loss, which is a sig (see Standard 33, Vascular Access Site Preparation nificant cause of hospital-acquired anemia in patients and Device Placement). Use additional precautions for obtaining blood cul for blood transfusion and its inherent risks. Use a dedicated phlebotomy team to reduce in patients receiving anticoagulants or with blood culture contamination. Disinfect the rubber stopper of the blood culture list combined with periodic direct observations for bottles using 70% alcohol. There not recommended as they can degrade the stop is no consensus on the exact contents of such a 49,50 per material. Draw a quantity of blood that is sufficient for these specific techniques are found for peripheral or isolating organisms (ie, 20-30 mL for adults; no midline catheters. Discard the initial blood sample (eg, 5 mL) when surement outcomes when compared to a 5-mL drawing from a direct venipuncture. Discard volumes of 6 mL from nontunneled cath and closing the fist to prevent pseudohyper eters and 9 mL from tunneled cuffed catheters 30,31 kalemia. Use a straight or winged needle instead of obtain although the discard volume for implanted ports 50,51 ing the sample during the procedure to insert a could not be established. Avoid use of a tourniquet or blood pressure cuff outcomes for measuring levels of actinomycin-D if possible. These studies do not provide consensus um from increased venous pressure and hypoxia. Perform venipuncture in neonates by a skilled indwelling short peripheral catheter for pediatric phlebotomist instead of heel lance methods patients, adults with difficult venous access, pres due to the increased pain from the heel ence of bleeding disorders, and the need for lance. Risks of venipuncture include anxiety, pain, catheters at insertion or during the dwell is not damage to skin and nearby nerves, and hematoma recommended. Research has not a short peripheral catheter is associated with established the length of time for stopping fluid higher rates of hemolysis and spurious lab val flow or the amount of flush solution. One study ues, regardless of whether the sample was drawn suggests a wait time of 10 minutes after stopping 46 directly from the catheter hub or from an the infusion before drawing the sample. Use the largest lumen for blood sampling from 4,11,14,24 on the outcome of the catheter is unknown. Veins of the antecubital fossa produce the lowest from the lumen exiting at the point farthest away rates of hemolysis. One study suggests larger vol catheters inserted for infusion into veins of the umes (10-20 mL) of flush solution provide more antecubital fossa are not recommended due to accurate peak levels of antibiotics when com 46,69 higher catheter complication rates in areas of pared to smaller volumes (3 mL).
Any over a bur should be used in the initial stages the facial surface toward the mesial and hangs were removed with the surgical 44 November/December 2014 General Dentistry The shape and other details of the restora the finishing of a composite restoration finished interproximal surfaces will also tions erectile dysfunction doctor near me purchase cialis soft 20mg online. One must ensure prevent the bonding of the adjacent tooth return to the office approximately 3 weeks that all surfaces are polished completely from sticking to the finished tooth erectile dysfunction treatment hypnosis cialis soft 40 mg free shipping. The central follow-up visit minor modifications were anterior teeth with direct resin veneers incisors are the cornerstone of the smile made to the incisal embrasures and the may make the mistake of not giving the and should always be completed first does erectile dysfunction cause low libido generic cialis soft 40 mg online. The final step in finishing stage a high priority male erectile dysfunction statistics purchase discount cialis soft, when it is Determining the length of the interproxi completion of the composites was polish at this critical stage that close attention mal area is always addressed after both ing the teeth with a Cosmedent FlexiBuff to detail produces a final restoration that central incisors are completed. According wheel utilizing Enamelize composite pol appears as a natural, polished tooth. The incisal embrasure drastically improved not only his smile, handpiece was then turned down to 2500 can be altered for the desired length. His existing tooth rpm and the corrections were done with a connector size between the lateral and structure was maintained, which was very delicate touch, in an effort to avoid central would then be 40%, and 30% especially important due to his young age. The Leaving the enamel intact, the treatment the final restoration, the light should be incisal embrasures increase as one pro ensured that the teeth remain strong reflecting off of the line angles and other gresses to the posterior. The depressions on the facial surface pleted, knowing that the gingival heights could be readily accomplished. Laterals do not need to be mirror invasive, and provide an excellent treat facial anatomy of a central incisor that images of each other, but optimally should ment for many patients. For instance, when these the facial surface, additional faint lines important that everything was explained veneers are applied over dark or tetracy were placed in the surface which served to to the patient in advance so there were no cline-stained teeth, the control of color break up the light reflections and make the unrealistic expectations. Esthetics of Anterior Fixed technician using only a description and many situations in which direct resin is Prosthodontics. A polychromatic composite layering ap the exact colors necessary to achieve avoid it. A new resin technology: a glaze/composite sealant that cures without forming an oxygen-inhibit and contour can also be determined with be thinking about being minimally inva ed layer. Author information ing techniques on surface roughness and color stabili Many brands of dental resin composites Dr. Diagnosis and Treatment comfortable with and understand the dentistry: smile reconstruction using direct resin bond Evaluations in Cosmetic Dentistry: a Guide to Accredi interaction of the various colors in order ing. Mopper, B, Louisiana State University Esthetic Contin understanding of the material strength, tocols for maximum success. Bonded Porcelain Restorations in with the existing tooth color is a great noninvasive-and-minimally-invasive-protocols-for the Anterior Dentition. Composite resin place tive approach for the restoration of abrasion and ero 888. Results showed statistically signifcant the need for advanced training; this discomfort may lead to unsatisfac differences between the groups (76. Shade matching were developed to simplify daily color matching procedures and to by clinicians using the instrumental method presented more agreement, provide better esthetic outcomes. This study compared the accuracy of and was more effective than shade matching by clinicians using the shade matching by both visual and instrumental methods to determine visual method. Visual shade matching was performed by 4 dentists using a Revised: July 8, 2014 classic shade guide; instrumental shade matching was performed with a Accepted: August 5, 2014 spectrophotometer by a previously calibrated examiner. Shade matching was conducted in a dental clinic under controlled illumination on the Key words: tooth color, spectrophotometry, visual shade middle third of the right central incisor tooth of 30 subjects. Data were selection, dental porcelain, fxed partial denture ental shade matching is a challeng between the dental shade guides and the Materials and methods ing and difficult task for clinicians. Visual shade guides and more precise than visual measure consisted of 30 volunteer dental students and spectrophotometers were developed to ments. The 4 is the standard for tooth color matching capable of predicting some of the optical dentists were classified as D1, D2, D3, of prosthetic restorations. The visual assessment of tooth visual color assessment is subjective and is difficult to achieve and could lead to shade was done under a corrected light relies on a series of visual evaluations errors. A previ difficulty of visual shade matching for instrumental method would provide signifi ously calibrated examiner performed oral rehabilitations. The agreement found for Despite not presenting the entire gamut of for statistical analysis. A Discussion 1998 study by Okubo et al found that the Results the accuracy of dental shade matching chosen colorimeter was precise in 50% of Table 1 presents the proportion distribu between visual and instrumental methods shade matching cases, whereas the visual tion of the tooth colors that were selected for tooth color selection was evaluated in method showed a precision rate of 48% by the different examiners using the visual this study. The selection of the tooth color the tested null hypothesis, since the instru the methods. Kappa inter-rater trophotometer can be a valuable aid to tional visual and spectrophotometric methods for shade selection. Effect of indi study by Paul et al used 3 operators that design, and based on the results that were vidual shades on reliability and validity of observers in independently assessed the best match found, it can be concluded that dental colour matching. The influence of porcelain layer thickness on same tooth color was measured 3 times compared to the visual method. Sources of agreement between the operators was only fore recommended for adequate tooth color variation on firing porcelain. Dental color shade assessment for porcelain-fused-to Education Program, Implantology and matching instruments and systems. Tiossi is an assistant professor, Reproducibility of tooth color gradation using a com puter color-matching technique applied to ceramic res the spectrophotometric shade selections Department of Prosthodontics, School of torations. Advances in color match compared the reliability of shade-matching Niteroi, Rio de Janeiro, Brazil. Repeatability and reliability value) or darker (less value) colors were of human eye in visual shade selection. Anteriores A Beleza Natural dos Dentes and that intermediate shades were less Anteriores. A Socio Unico, Verona, Italy tional visual vs spectrophotometric shade taking for 39. The program helps fa Received: August 22, 2013 cilitate dental treatment and support services for adults who have suffered Accepted: October 1, 2013 dental injuries to the smile zone as a result of domestic or sexual violence. Complications in the treat bimanual manipulation revealed interfer services at no charge to adults whose smiles ment plan were expected due to the mul ence at tooth No. Upon closure, the jaw have been damaged as a result of domestic tiple missing teeth, the impacted condylar moved markedly to the left and forward abuse. There partial edentulousness and the discoloration on treating occlusion after fractures. The patient also reported occasional key elements: temporomandibular joint bleeding on probing. This was considered to be a result of the pressure in the ear canal upon jaw opening Pulp testing revealed that teeth No. The patient responded well patients, with success rates comparable caries could further compromise the treat to hygiene instructions, and it was felt to other implant-supported prosthetic ment plan (Fig. Another concern was the use of sive as the majority of these cases used Esthetics a cantilever at the tooth No. This was an acceptable ments would be low, because the cantilever serious misgivings regarding this tech level, requiring no treatment. It was determined that treatment provided the patient with immediate the Acknowledgments section agreed to would involve placing maxillary fixed pros function and long-term bone maintenance donate materials and labor.
It happens all the time and everywhere erectile dysfunction book buy 40 mg cialis soft free shipping, in the classroom experimental erectile dysfunction drugs buy generic cialis soft, online impotence at 75 discount cialis soft online amex, at home erectile dysfunction treatment charlotte nc order cialis soft no prescription, and through lived experience. Learning is per sonal, changing in form based on the unique personality, interests, skills, at tributes, circumstances, and beliefs of each individual. First, as its name implies, it considers learning a continuous, lifelong experience. Rather, we must recognize learning as an interplay among cognitive, social, emotional, and physical skills, attributes, and capabilities. Today, we primarily measure and accredit knowledge and skills acquired in formal settings and assessed within similar structures. Still a work-in-progress, the framework is being developed by a community of experts, school networks, teachers, students, youth groups, parents, universities, local organizations, and social partners. Its vision is to help every learner develop as a whole person, able to fulfill his or her potential and contribute to worldwide wellbeing. Although cortical thickness, mass, and connectivity seem to8 decrease with age, adults can compensate by activating interdependent neural mechanisms gained from life experience. What and how much individuals9 learn depend on a variety of micro and macro-level factors. Micro-level fac tors include individual choices, motivations, and the ability to self-regulate, particularly outside of formal education settings. Clar ity of interests and goals, and greater self-awareness make this time-frame conducive to personal growth and often encourage a greater motivation to learn. Adults also have a greater wealth of experiences to draw upon, which 10 How can help them synthesize new information more deeply and effciently. Otherwise, we risk having deep experts embedded within stovepiped knowl edge communities who lack a general understanding of how the pieces ft together to work within a holistic, effcient system. To date, much of the human-development has focused on the early stages of life (prior to adult hood). Discussions of cognitive development usually point back to 12 the foundations built by Jean Piaget (1936) and Lev Vygotsky (1978). People who reach this fnal stage (and not all do, according to Piaget) are able to think abstractly. Since we now know that learning occurs throughout an entire lifetime, what happens after reaching this stage Expectations are not enable humans to work with more always where they need to information (without task shedding) be, from teachers or leaders; but to also better digest and com consistently higher expecta prehend wider amounts of infor tions are needed. Across its lifetime, the brain will continue to develop and learn but also, as new generations are born, they will increasingly have the beneft of access to accumulated knowledge and experiences of those who came before. In a twist of irony, while the stage theories of Piaget and Vy gotsky have been overcome, the basic belief that cognitive development as a mixture of human natural capacity building and social-historical infuence remains correct. We used to give them a spoon and a pot, and they were creative with what they had. Social development research ers have primarily studied younger ages or special needs populations.
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