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The adenovirus genome is much larger (about 35 kb) and its organization is much more complex than retroviruses discount dapoxetine 60mg without prescription erectile dysfunction definition. Genes introduced into cells using adenoviral vectors are maintained in the nucleus episomally and provide transsient expression of transgenes purchase 30 mg dapoxetine with visa erectile dysfunction questions to ask. Compared to viral vectors purchase dapoxetine 30 mg overnight delivery erectile dysfunction pump infomercial, gene medicines present several potential advantages, including: • low cost; • non-infectivity; • absence of immunogenicity; • good compliance; 337 • well-defined characteristics; • possibility of repeated clinical administration. Plasmids encode bacterial origin of replication, usually derived from a high copy plasmid and a selectable marker, usually a gene that confers resistance to an antibiotic, such as kanamycin or neomycin. These “prokaryotic” plasmid segments permit the production of large quantities of a given plasmid in bacteria. The minimal transcription unit required for the expression of a therapeutic protein consists of 5′ enhancer/promoter upstream of the gene encoding for the therapeutic protein and a poly(A) signal downstream of the gene. Tissue- specific promoters are designed to interact with transcription factors or other nuclear proteins present in the desired target cells. The chicken skeletal a-actin promoter contains positive as-acting elements required for efficient transcriptional activity in myogenic cells. Therefore, an a-actin promoter could direct high expression of recombinant protein in skeletal muscle. The efficiency of polyadenylation is important for gene expression, as transcripts that fail to be cleaved and polyadenylated are rapidly degraded in the nuclear compartment. Therefore, in vivo pulsatile production of certain therapeutic proteins may be beneficial for their clinical applications. This can be achieved by including gene switches in a gene expression system to turn on or off the transcription of an administered gene. A gene switch is designed to be part of a gene expression system that contains both the gene switch and a therapeutic gene. In the positive system, the target gene will be inactive until the administration of an exogenous compound or ligand. Such inducing agents or drugs include progesterone antagonists, tetracycline, ecdysone and rapamycin. This section describes the development of several lipid, peptide and polymer-based gene delivery systems. However, the encapsulation efficiency of plasmids is very low, because of the large dimension of plasmids compared to the internal diameter of the vesicles. The pH-sensitive immunoliposomes have been shown to mediate 6~8 times higher levels of transgene expression into mouse lymphoma cells, compared to non-pH-sensitive immunoliposomes. A negatively charged phospholipid such as phosphatidylserine, phosphatidic acid or phosphatidyl glycerol, in the absence or presence of cholesterol, are utilized to produce a suspension of multilamellar vesicles containing plasmids, which are then converted to small unilamellar vesicles by sonication. Cochleates have been shown to encapsulate plasmid and enhance plasmid stability and transfection efficiency. A cationic lipid consists of: • a hydrophobic lipid anchor group • a linker group • a positively charged headgroup. Lipid anchors help in forming liposomes (or micellar structures) and determine the physical properties of a lipid bilayer, such as membrane rigidity and rate of lipid exchange between lipid 341 membranes. The linker group is an important component, which determines the chemical stability and biodegradability of a cationic lipid. The head groups of cationic lipid appear to be critical for transfection and cytotoxicity of corresponding liposome formulations. The cationic amphiphiles differ markedly in structure and may be single or multiple charged as primary, secondary, tertiary and/or quaternary amines. Examples are lipospermine, cationic cholesterol, cationic detergent or lipopolysine. The relative proportions of each component and the structure of the head group influence the physicochemical properties of plasmid/lipid complexes. Many effective cationic lipids contain protonatable polyamines linked to dialkyl or cholesterol anchors. To increase the biodegradability of cationic lipids, a series of cationic lipids have been synthesized in which the ether bonds were replaced with ester bonds. Cationic lipid-based gene delivery systems lack target specificity, which results in low transfection efficiency in certain tissues due to the interference from cationic lipid-binding macromolecules either in the circulation or in the extracellular matrix. To circumvent this problem, neutral plasmid/lipospermine complexes containing a trigalactolipid have been prepared and shown to efficiently transfect hepatoma HepG2 cells bearing asialoglycoprotein receptor. Addition of 25% (mol mol−1) of the triantennary galactolipid increased the transfection efficiency by a thousand fold, compared to the lipid-based system with no targeting ligand. An efficient transfection of β-galactosidase into HeLa cells has been shown with the combination of transferrin and cationic liposome Lipofectin, whereas Lipofectin alone had low transfection efficiency. Asialofetuin is an asialoglycoprotein containing terminal galactosyl residues that have been used to target liposomes to the liver. The resulting complexes retain their ability to interact specifically with target cell receptors, leading to receptor-mediated internalization of the complex into the cells. It is known that the active sites of enzymes, receptor ligands and antibodies usually involve about 5 to 20 amino acids. One example of such a gene delivery system comprises: 343 • a galactosylated peptide that both condenses the plasmid into monodisperse nanoparticles of about 100 nm in diameter and enables specific recognition and binding to asialoglycoprotein receptors; • an amphipathic, pH-selective peptide that enables the plasmid to leave the endosomes prior to their fusion with lysosomes and entry into the cytoplasm. Two general classes of lipopeptide analogs of Tyr-Lys-Ala-Lys -n Trp-Lys peptides have been prepared by including a hydrophobic anchor. The general structures are N, N- dialkyl-Gly-Tyr-Lys-Ala-Lys -Trp-Lys and N,N -diacyl-Lys-Lys -Trp-Lys. These peptides differ from theα n n parent structures in that they self-associate to form micelles in aqueous solutions. The lytic characteristics are revealed as the carboxyl groups of the aspartyl and glutamyl side chains are protonated, which allows the peptides to assume a a-helical conformation that can be inserted into the membrane bilayer. The hydrophobic face contains only strongly apolar amino acids, while negatively charged glutamic acid residues dominate the hydrophilic face at physiological pH. At a given charge ratio of condensing peptide to plasmid, the transfection efficiency has been shown to be proportional to the concentration of the endosomolytic peptide added to the complex. The increased hydrophobicity of the complex may enhance interaction with cell membranes and facilitate cell uptake. However, these polymers cannot be used for in vivo application due to their poor transfection efficiency and high cytotoxicity. The effect of colloidal and surface characteristics of plasmid/ dendrimer complexes on gene transfer has been examined. These complexes were monodisperse, with a mean hydrodynamic diameter of about 200 nm.

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Kingella kingae can best be differentiated from Eikenella corrodens using which medium? Kingella kingae is usually associated with which Answers to Questions 13–17 type of infection? Infection is seen primarily in patients having underlying heart disease generic 30 mg dapoxetine with visa erectile dysfunction prevents ejaculation in most cases, poor oral hygiene purchase dapoxetine 90mg visa erectile dysfunction medication risks, Microbiology/Apply fundamental biological or iatrogenic mucosal ulcerations (e buy dapoxetine 30mg visa erectile dysfunction from anxiety. Microbiology/Evaluate laboratory data to make are also catalase and oxidase positive but can be identifications/Bacteria/3 ruled out because they grow on MacConkey agar and do not produce indole. Smooth gray colonies showing no hemolysis are recovered from an infected cat scratch on blood 16. Te organisms are gram-negative pleomorphic round colonies resembling droplets of mercury. It is rods that are both catalase and oxidase positive fastidious and does not grow on chocolate or and strongly indole positive. Bordet–Gengou agar agar slant is simultaneously coated with the blood (or bone marrow). Brucella is the cause of undulant Microbiology/Select methods/Reagents/Media/Bacteria/ fever and is responsible for many cases of fever of Identification/2 unknown origin. Which medium is recommended for the recovery intracellular organisms and grow very slowly, usually of Brucella spp. Histidine and tryptophan prepared chocolate agar because it contains X factor and is supplemented with a growth enrichment Microbiology/Apply fundamental biological (IsoVitaleX) that contains cysteine. Haemophilus species that require the V factor before it can be assimilated by Haemophilus spp. Blood agar made with sheep red cells available to those Haemophilus species requiring it. Blood agar made with horse red cells Chocolate agar also contains the X factor (hemin). Xylose agar require V factor, while X factor is required by Microbiology/Select methods/Reagents/Media/Bacteria/ H. Which of the following products is responsible Answers to Questions 23–24 for satellite growth of Haemophilus spp. Which of the following plates should be used in these two species from other Haemophilus with the order to identify Haemophilus haemolyticus and same X and V requirements. Sheep blood agar and chocolate agar yeast extract, supports the growth of Haemophilus B. Sheep blood agar is not used because it X and V strips contains growth inhibitors for some Haemophilus C. The chart on the next page summarizes the added characteristics of the Haemophilus spp. Chocolate agar and Mueller–Hinton agar with X factor added Microbiology/Select methods/Reagents/Media/Bacteria/ Identification/2 412 Chapter 7 | Microbiology H. Te majority of Haemophilus influenzae infections Answers to Questions 25–28 are caused by which of the following capsular serotypes? Serotyping of Haemophilus is Microbiology/Correlate clinical and laboratory data/ performed by mixing colonies with agglutinating Bacteria/Haemophilus/2 antibodies available as commercial agglutination kits. Which Haemophilus species is difficult to isolate genital lesions referred to as “soft chancres. Most specimens are recovered from Microbiology/Correlate clinical and laboratory heterosexuals, and outbreaks in the United States data/Bacteria/Haemophilus/2 are traced to female prostitutes. All of these options Microbiology/Apply fundamental biological characteristics/Bacteria/1 7. A The X factor requirement for growth is the cause of Which is the most likely identification? Haemophilus aphrophilus colonies transferred from primary media containing Microbiology/Evaluate laboratory data to make blood. Nasopharyngeal swabs were cultured on 15% blood, chocolate, Bordet–Genjou, and Regan–Lowe (with 10% charcoal) agars. Bordetella bronchiseptica Microbiology/Evaluate laboratory data to make identifications/Bacteria/3 414 Chapter 7 | Microbiology 33. Francisella tularensis Answers to Questions 33–36 Microbiology/Evaluate laboratory data to make identifications/Bacteria/3 33. Tularemia is one of the most common organism grew on 5% sheep blood and chocolate laboratory-acquired infections, and it is recommended agars displaying a yellow pigment. On MacConkey that specimens be sent to a reference laboratory for agar, it appeared as a non–lactose fermenter. Acinetobacter baumannii septicemia and meningitis in neonates and immunocompromised adults. The ability to Microbiology/Evaluate laboratory data to make encapsulate, produce proteases, and survive in identifications/Bacteria/3 chlorinated tap water are factors that contribute to 35. A 46-year-old dog warden was admitted to the hospital-acquired infections with this bacterium. Pseudomonas aeruginosa cases caused by gram-negative rods result from one Microbiology/Evaluate laboratory data to make of them. A suspected case of Legionnaires’ disease was Answer to Question 37 noted on the request form for a culture and sensitivity ordered on a sputum sample. Te test used most often to separate the Answers to Questions 1–3 Micrococcaceae family from the Streptococcaceae family is: 1. Members of the Microbiology/Select methods/Reagents/Media/Bacteria/ Streptococcaceae family are negative. Micrococcus and Staphylococcus species are endocarditis following cardiac catheterization; they differentiated by which test(s)? A Both micrococci and staphylococci are catalase-positive and gram-positive cocci. On Microbiology/Select methods/Reagents/Media/Bacteria/ direct smears, they both appear as pairs, short Identification/1 chains (resembling Streptococcus spp.

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A Serological analysis using immunofluorescence or Microbiology/Apply knowledge of fundamental an enzyme immunoassay is the method of choice biological characteristics/Spirochetes/1 for diagnosis of Lyme disease buy dapoxetine 30mg with visa erectile dysfunction doctors in maine. Te diagnostic method most commonly used for be cultured directly from lesions 30mg dapoxetine amex erectile dysfunction nitric oxide, and darkfield the identification of Lyme disease is: microscopy can be used for detection of spirochetes A buy dapoxetine 60mg lowest price erectile dysfunction pills side effects. Primary atypical pneumonia is caused by: from the upper and lower respiratory tracts onto A. Which organism typically produces “fried-egg” is grown on “M” agar containing arginine and colonies on agar within 1–5 days of culture from a phenol red. Treponema pallidum Colonies of Ureaplasma are small and golden brown on A7/A8 agar. Te manganous chloride–urea test is used for the utilizes manganous chloride (MnCl2) in the presence identification of which organism? Borrelia burgdorferi is observed under a dissecting microscope and is a Microbiology/Select methods/Reagents/Media/ rapid test for the identification of U. A gram-positive (gram-variable), beaded organism Answers to Questions 18–22 with delicate branching was recovered from the sputum of a 20-year-old patient with leukemia. D All of the listed organisms produce mycelium (aerial Te specimen produced orange, glabrous, waxy or substrate), causing them to appear branched colonies on Middlebrook’s agar that showed when Gram stained, but only the Nocardia spp. What is the most likely opportunistic pathogen, and cultures typically have a identification? A The “whiff” test is used for a presumptive diagnosis stained with Loeffler methylene blue stain showed of an infection with G. Culture using McCoy and Hela cells produce antibodies especially in extra respiratory D. Which test is the most reliable for the detection of to produce an IgM response especially in recurrent Mycoplasma pneumonia in serum and for the infections, so the best confirmatory approach is a confirmation of diagnosis? Complement fixation Microbiology/Select test/Identification/Mycoplasma/2 432 Chapter 7 | Microbiology 23. Identify the following bacterium and specimen Answers to Questions 23–25 pairing that is mismatched (specimen not appropriate for isolation). Chlamydia (Chlamydophila) psittaci: fecal swab classification for Chlamydia psittaci. Chlamydia trachomatis: first voided urine found naturally in psittacine birds and other avian C. Chlamydia pneumonia: throat swab or sputum contact with pet birds, or from occupational contact in poultry farming or processing. Inhalation of the Microbiology/Apply knowledge of standard operating organisms from aerosols, fecal material, or feather procedure/Specimen collection/Chlamydia/1 dust causes a respiratory infection and the specimen 24. Which of the following organisms are transmitted of choice is a throat swab or sputum. He removed the tick, diagnosis can be made by direct observation of the but 2 weeks later noticed a circular, bull’s eye rash basophilic inclusions (morulae) in leukocytes of at the site of the bite. Which specimen(s) should Giemsa’s or Wright’s stained blood or buffy coat be obtained to establish a diagnosis of Lyme smears. Obligate anaerobes, facultative anaerobes, and Answers to Questions 1–4 microaerophiles are terms referring to bacteria that require: 1. Microaerophilic organisms do Microbiology/Apply principles of fundamental not grow in an aerobic incubator on solid media and biological characteristics/Anaerobes/1 only minimally under anaerobic conditions. Glucose agents such as thioglycollate and L-cysteine are added to anaerobic transport and culture media in Microbiology/Apply principles of fundamental order to maintain a low Eh. Certain anaerobes do not biological characteristics/Anaerobes/1 grow in the media above a specific critical Eh level. Urinary tract infections not cultured routinely under anaerobic conditions Microbiology/Apply principles of fundamental unless obtained surgically (e. Methods other than packaged microsystems used Answers to Questions 5–9 to identify anaerobes include: A. Enzyme immunoassay with Gram staining characteristics, spore formation, and cellular morphology in order to make the Microbiology/Select methods/Reagents/Media/ identification. Which broth is used for the cultivation of carbohydrates support the growth of anaerobic anaerobic bacteria in order to detect volatile fatty bacteria. Clostridium difficile lecithinase negative and does not produce a Microbiology/Evaluate laboratory data to make double zone of β-hemolysis. Egg yolk agar is used to detect which enzyme egg yolk agar) is used to determine the presence of produced by Clostridium species? All of these options Microbiology/Evaluate laboratory data to make identifications/Bacteria/2 7. Which spore type and location is found on Answers to Questions 10–13 Clostridium tetani? Recognition of Microbiology/Apply principles of fundamental spores is particularly important because C. B Spores are generally not demonstrated from clinical cultures from a 60-year-old diabetic patient gave specimens containing C. The Spores seen = Neg Hemolysis = + (double zone) reactions in the chart above distinguish the four Motility = Neg Lecithinase = + species listed. Clostridium sporogenes multiplies in the gut of the infant and produces the Microbiology/Evaluate laboratory data to make neurotoxin in situ. Which mechanism is responsible for botulism in by ingestion of the preformed toxin (botulinum infants caused by Clostridium botulinum? Ingestion of preformed toxin in food the growing phase and released during lysis of the C. Lipase activity of the organism demonstration of the toxin in serum, gastric, or stool Microbiology/Apply principles of fundamental specimens. All of these options Microbiology/Apply principles of fundamental biological characteristics/Anaerobes/2 436 Chapter 7 | Microbiology 14. Which test is performed in order to confirm an Answers to Questions 14–19 infection with Clostridium botulinum? Gelatin hydrolysis test by the toxin neutralization test for its neurotoxins in serum or feces.

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This question should be answered yes if you description of the groups and see a table of data on the study participants order 90 mg dapoxetine amex whey protein causes erectile dysfunction, the distribution of prognostic usually Table 1 at the front end of the article dapoxetine 60mg lowest price erectile dysfunction treatment dallas. This question only applies to studies of at a similar point in their people who have a condition cheap dapoxetine 90 mg erectile dysfunction meds list. Is there a description of the medication intervention/treatment reliably management or health information ascertained? Again look for data in Tables that gives data comparable on all important on how comparable the groups were. You will not likely see this information as it adjustment for the effects of refers to adjustment in the analyses. Use common sense here--for example, were enough for the outcomes to the errors assessed say within the first month, occur? Say no if there is not time for the intervention (or new system) to have an effect on the situation. This question is asking “why” did people drop reasons for drop-out similar out or why they were “lost” to the study. Sum quality score for above (automatic [this will not show in the interface, but be done 10 questions summation by the computer system independently) of 10 items “yes”) 6. Often members in the groups are “matched” in relation to things like age or experience. See the question and methods section to the outcome) definition ascertain if the people who are the cases (e. If a disease or disorder mentioned, did they the cases been reliably tell how it was ascertained--often using rules assessed and validated? Look for the word randomly selected from the “random” or some mention of how the controls source of population of the were selected. Look for Table 1 or in the first paragraph of cases and controls with the results section. If some information on the respect to potential comparability of the groups is listed answer confounding factors? Were measurements taken the same for the other exposures assessed in controls and the case groups? Were the non-response Yes/no/n/a Not applicable rates and reasons for non- response the same in both groups? Is it possible that over­ Yes/no/n/a Not applicable matching has occurred in that cases and controls were matched on factors related to exposure? Was an appropriate Yes/no/n/a Not applicable statistical analysis used (matched or unmatched)? Sum score (automatic [this will not show in the interface, but be done summation by the computer system independently) of 9 items “yes”) 6. Answer yes if the article explains why and representative sample how these cases were chosen. Answer yes if a disease is present and they survey at a similar point in provide any information on how long the their disease progression? The outcomes such as error rates need to be using objective criteria or was assessed in a blinded manner to suit blinding used? If the series are being made, was analysis of the cases was down broken down there sufficient description of into subcategories, such as men and women, the series and the distribution children and adolescents, young or old…. B-25 Version 10-07-09 Question Methods Assessments Options Instructions Sum score (automatic [[this will not show in the interface, but be summation done by the computer system independently) of 6 items “yes”) 6. Daily and one-time orders accounted for the majority of this change, increasing almost threefold in percent total time (2. At 00/0000 followup, the rates were statistically different, with lower proportions for intervention residents after adjustment for baseline rates (0. Note that the control group prescribing degraded over time while the intervention group was stable. Using decisions/orders the system Implementation: significantly 00/0000 increased Study Start: actual 00/0000 compliance to Study End: 85. At baseline, the control group rate was statistically lower than the intervention group (8. Education alone (42%) or alerts alone (39%) did not change rates of gastroprotectio n. There 12/2001 was no significant difference between the Herfindahl- Hirschman Index for both groups (40. Study End: During each 07/1999 intervention period, the proportion of appropriate prescriptions ordered increased significantly. There was an increase in the use of antiinfectives following the intervention reminder (67% vs. There were non significant changes in the proportion of patients receiving preoperative antibiotics (64% vs. The alerts also significantly changed the trend in the interacting prescription rate, with a preintervention increasing rate of 1. Integrated specified 1*, rates of prescribing, prescriptions 2433-2439) Formulary, tier 2*, rates of written by Design: Before- Insurance prescribing, tier 3* intervention after physicians N = 12,625,276 completed prescriptions using e-Rx Implementation: intervention 10/2003 group Study Start: prescribed 10/2003 1. Two of 8 non-medication related preventive care recommendatio ns were significantly improved as well. Dispensing care/tertiary, prescriptions*, error rate prescription C-30 Evidence Table 1. Study End: asynchronous alerts* Supplementatio 03/2002 n of Mg at 1 hour was significantly improved, but not at 24 hrs. Synchronous alerts resulted in improved compliance at 1 hr and 24 hrs for both K and Mg supplementatio n (p <0. For 00/0000 the 226 alerts received by housestaff, the alert compliance rate was 42%; for the remaining clinicians the compliance rate was 38% (p = 0. Significantly fewer strength overdosing errors occurred in the postintervention group (8. No patients adjusted difference was Implementation: seen across all 00/0000 4 groups for Study Start: blood pressure 07/2003 readings: Usual Study End: care vs. Hollingworth e-Rx Ambulatory time spent on writing Prescribers at + (2007) Integrated care tasks (min/hr), paper vs. Overall time on writing tasks and computer tasks together were not different among C-39 Evidence Table 1.