In Salmonella typhimurium and Escherichia coli, the virulence determining two-component system PhoQ/PhoP regulates the transcription of mgtA gene by sensing Mg2+ concentrations in the periplasm. However, the factors that affect MgtA function are not known. This study demonstrates, for the first time, that MgtA is highly dependent on anionic phospholipids and in particular, cardiolipin. Colocalization studies confirm that MgtA is found in the cardiolipin lipid domains in the membrane. The head group of cardiolipin plays major role in activation of MgtA suggesting that cardiolipin may act as a Mg2+ chaperone for MgtA. We further show that MgtA is highly sensitive to free Mg2+ (Mg2+free) levels in the solution. MgtA is activated when the Mg2+free concentration is reduced below 10 μM and is strongly inhibited above 1 mM, indicating that Mg2+free acts as product inhibitor. Combined, our findings conclude that MgtA may act as a sensor as well as a transporter of Mg2+.The magnesium transporter A (MgtA) is a specialized P-type ATPase, believed to import MgDOI:http://dx.doi.org/10.7554/eLife.11407.001 Magnesium is an essential element for living cells, meaning that organisms from bacteria to humans need magnesium to survive. All cells are surrounded by a membrane made of fatty molecules called lipids, which is also embedded with proteins. Magnesium, like other metal ions, is transported inside cells across the cell’s membrane by specific membrane proteins.E. coli has two separate magnesium transport systems: one that works at high concentrations of magnesium and one at lower concentrations. The latter system involves a membrane protein called magnesium transporter A (or MgtA for short), which works like a molecular pump. However, it was not known exactly how this transporter was affected by magnesium nor how sensitive it was to this divalent metal ion. It was also unclear whether MgtA worked alone in the bacterial membrane or if it worked in conjunction with other molecules.A species of gut bacteria called E. coli suggesting that the two do indeed work together.Now Subramani et al. have managed to show that MgtA can sense magnesium ions down to micromolar concentrations, which is the equivalent to a pinch (1 gram) of magnesium salt in 10,000 liters of water. The experiments also showed that this detection system depended on a specific lipid molecule in the membrane called cardiolipin. MgtA and cardiolipin were found together in the membrane of living The discovery that a membrane transporter that pumps ions needs cardiolipin to work suggests that cells could indirectly control the movement of ions by changing the levels of specific lipids in their membranes. Subramani et al. now hope to use techniques, such as X-ray crystallography, to visualize how magnesium and cardiolipin bind to MtgA and explore how the three molecules work together as a complete system. Information about these interactions could in the future help researchers understand how these bacteria try to protect themself in the hostile environment in the human gut or cells of the immune systems. Further studies of this system could be used to develop biological sensors for magnesium or to design antibiotics that interfere with the magnesium transporter to treat bacterial infections.DOI:http://dx.doi.org/10.7554/eLife.11407.002 Based on the Mg2+ transport studies, Snavely et al., proposed that CorA transports Mg2+ under normal Mg2+ levels, whereas MgtA and MgtB transport Mg2+ when bacteria faces low Mg2+ condition , which lacks the ability to induce a proton gradient. PH1 was proposed to support the proton pumping performed by the P3A proton pump PH5, but evidence for magnesium transport was not established (E. coli MgtA (ecMgtA), the phosphorylated aspartate corresponds to Asp 373. Phosphorylation induces domain rearrangements leading to the E2P state, which is now open to the periplasmic side. E2P has low affinity for the bound ions and high affinity for the counter ions (Mg2+ in case of MgtA). The exchange of counter ions dephosphorylates the enzyme and forms the E2 state. Further conformational changes return the enzyme back to the E1 state and the counterions are released into the cytoplasm, thus completing the transport cycle. A possible Post-Albers scheme with the four steps transport cycle can be visualized for MgtA and is given in 2+ into the cytoplasm, Mg2+ is predicted to have high affinity to the E2P state. However, the stoichiometry and electrogenic nature of magnesium transport by MgtA remains unknown.MgtA belongs to the P3 subfamily of P-type ATPases . The P3 n plants , while Pkaryotes . Recentlablished . In geneablished –2. MgtA ablished . The Posablished . During ablished . The E1 ablished . In E. cmgtA transcriptional regulation has provided a clear picture of the mechanisms through which S. typhimurium and E. coli tightly control mgtA gene expression  are crucial for in vitro activation of MgtA. Further the overexpressed MgtA colocalizes with CL in vivo. We also show that MgtA ATPase activity is highly sensitive to Mg2+free concentration and that Mg2+ acts as an inhibitor at higher concentrations. Our findings reveal for the first time, the effect of anionic lipids and free Mg2+ on MgtA function.Over the past two decades, detailed studies of pression . DespiteE. coli with yields up to 4 mg per liter of LB medium. The overexpression of MgtA is clearly visible as a band both in the cell lysate and membrane fraction as shown in SDS-PAGE gel  MgtA, with more than 90% loss of the ATPase activity after the final SEC purification . The graactivity . We inclactivity  and did E. coli inner membrane has been reported to consist of ~75% phosphatidyl ethanolamine (PE), ~20% phosphatidyl glycerol (PG) and ~5% CL (sn-glycero-3-phosphoethanolamine), DOPG  and CL (isolated from E. coli) and found that only anionic lipids such as DOPG and E. coli CL restored the ATPase activity in a concentration-dependent manner. DOPG activated MgtA by thirty-fold, while CL by hundred-fold, relative to the lipid-free condition , did not show any measureable effect on the ATPase activity. Apparent Vmax and Km calculated for MgtA in the presence of CL are given in The phospholipid composition of d ~5% CL . To testondition . DOPE inE. coli lipid extract (1.7 μM Pi min-1 mg-1) was lower than the maximum ATPase activity observed with pure CL. The possible reasons could either be the low availability of CL in E. coli lipid extract or other lipid types like PE and PG competing for the lipid binding site in MgtA. To test the latter possibility, we added increasing amounts of DOPE and DOPG to pre-incubated MgtA-CL mixture and measured ATP hydrolysis. Only a minor decrease in the ATPase activity (<20%) (12E8 (Octaethylene glycol monododecyl ether) in which the lipids are dissolved   was obseissolved . TherefoE. coli has a diverse fatty acid distribution, with 16:0–18:1 as the most dominant (~35%) and 16:0–17:0Δ as the second most dominant (~17%) species at positions 1 and 2 of sn-glycerol 3-phosphate  fused to GFP from GenoBase showed clear fluorescence localized at the poles. Since our biochemical data showed that MgtA is activated in the presence of CL, we hypothesized that MgtA could colocalize with the CL rich domains in E. coli. To further expand the analysis, we decided to include an N-terminal deletion mutant as well (NΔ31-MgtA). The N-terminal of ecMgtA is rich in positively charged residues and is predicted to harbor intrinsically disordered regions. Similar disordered regions are observed in MgtA and the ortholog MgtB from S. typhimurium. The deletion mutant served two purposes; 1) to test whether the positively charged residues were important for the interaction with CL, since activation by lipids binding at the N-terminus had been reported for another P-type ATPase, ATP13A2 of the P5 subfamily (E. coli C43(DE3) overexpressing MgtA-BFP confirmed that it was mainly concentrated at the poles and colocalized with the NAO-stained CL domains (E. coli and MgtA/B in S. typhimurium is not required for activation by lipids and do not play any role in membrane trafficking or targeting to the CL domains (Studies with the fluorescent dye 10-N-Nonyl Acridine Orange (NAO) has shown that CL exists as enriched domains at the poles and division septa in E. coli . NAO is E. coli . The onloli K-12 , reportsubfamily  and 2) t domains . The NΔ3 domains . As a co domains . Further domains  was obse domains .10.7554/In addition to the colocalization experiments described above, we also tested localization of the nonphosphorylable mutant MgtA D373N to understand whether the membrane trafficking and co-localization of MgtA with CL at the poles were dependent on the catalytically active MgtA. We observed that the nonphosphorylable mutant D373N fused to green fluorescent protein (GFP) at the C-terminus showed similar localization at the poles . This le2+ dependency of purified MgtA with an ATPase assay is complicated as it is difficult to decouple the inherent Mg2+ dependency of ATP from the vectorial transport of Mg2+ by MgtA. To estimate the sensitivity of MgtA to Mg2+, we have to make the assumption that Mg2+ must be free in solution to be transported through MgtA. The Mg2+free indicates that the Mg2+ ions are coordinated only by water and not by ATP, which is also present in the assay mix. It is not possible to perform an ATPase assay with the concentrations of Mg2+free, ATPfree and Mg2+-ATP acting independent of each other. Thus, it becomes inevitable to obtain the desired information from an assay where one ligand is fixed (e.g. ATP) while varying the concentration of other ligand (e.g. Mg2+).Studying the Mg2+  from 0 to 10.0 mM. This experiment showed steep activation of MgtA ATPase activity at low Mg2+total levels that peak when the molar ATP concentration is equivalent to the molar Mg2+total concentration . However, the activation profile was slightly shifted towards higher Mg2+total as the ATP concentration in assay buffer increased. This shift can be explained by the fact that higher ATP concentrations chelate more Mg2+ than lower ATP concentrations, thereby reducing the level of Mg2+free available for MgtA to transport, causing a delay in activation. This is verified by plotting the data from 2+free   for all three fixed ATP concentrations. Further, we observed that the ATPase activity peaked at 250 μM Mg2+free and was inhibited rapidly above 1.0 mM Mg2+free. Since the cytoplasmic Mg2+free concentration is ~1 mM  of ATP, with increasing concentrations of Mgntration . A rapidmethods) . We founis ~1 mM , the inhs tested , Table 1 at 37°C .10.7554/2+total concentrations with increasing ATP concentrations from 0–10.0 mM  ATPases, Pma1 (Arg 695) in yeast  to MgtA pre-incubated with CL did not affect the ATPase activity. This suggests that other lipid types do not interfere with CL binding to MgtA and hints that the head group of the lipids plays an important role in the activation. The preferential selection of CL in the presence of other lipid types hint that MgtA function may be regulated in vivo by changing the local concentration of CL. Since CL have been shown to form domains or rafts at the poles and division septa in E. coli , we hypoE. coli . However(E. coli . Considerylation .Our obseE. coli (2+) to MgtA. It has been shown that CL can bind divalent cations like Mg2+ and undergo lipid phase changes as a function of Mg2+ concentration was purchased from Nikko Chemicals, Tokyo, Japan. Adenoside 5’-triphosphate disodium salt hydrate (ATP) was purchased from Sigma-Aldrich, Norway. All other chemicals, including primers were purchased as grade (BioUltra) available from Sigma-Aldrich.Lipids were purchased from Avanti Polar Lipids, Alabaster, Alabama. Dodecyl- β-D- Maltopyranoside (DDM) was purchased from Chemical Point UG, Deisenhofen, Germany. Octaethylene glycol monododecyl ether  between NcoI and XhoI restriction sites. The D373N mutant was created using the Quickchange Lightning mutagenesis kit . The sequence of the resulting constructs was verified. Then the MgtA-pETM11 plasmid was transformed into E. coli C43 (DE3) cells and plated on Luria Bertani (LB) media with 1.5% Agar and 50 µg/ml kanamycin. Colonies of transformed C43 (DE3) cells were inoculated in LB media containing 50 μg/ml kanamycin and incubated at 37°C for 16 hr. The following day, 1% of the overnight culture was added to LB media with 50 μg/ml kanamycin and incubated with shaking at 37°C until OD600nm reached ~0.6. Protein expression was induced by adding 1 mM Isopropyl-β-D-1-thiogalactopyranoside and grown at 18°C with shaking (200 rpm). Cells were harvested after 16 hr by centrifuging at 7000 ×g for 10 min. Cell pellets were stored at -20°C until use.The ORF of 2S04, 10% glycerol, 1 mM Phenylmethylsulfonyl fluoride (PMSF), 5 mM β-mercaptoethanol) and lysed using High Pressure Homogenizer  at 15,000 psi. Unlysed cells and inclusion bodies were removed by centrifugation at 20,000 × g for 20 min. Resulting supernatant was centrifuged at 100,000 × g for 2 hr. Mixed membrane pellets were weighed and suspended at 1:10 ratio in buffer B  using a Dounce homogenizer (Sigma-Aldrich). Membranes were solubilized with 1% DDM for 4 hr. Solubilized membrane suspension was passed through His trap FF . The column was washed with 10 column volumes (CV) of buffer B supplemented with 20 mM Imidazole and ~3 critical micelle concentration (CMC) DDM (0.6 mM). Protein was eluted with buffer B supplemented with 250 mM Imidazole and 3 CMC DDM. Eluted fractions were pooled, concentrated and subjected to size exclusion chromatography (SEC) using a S200 sepharose 16/600 column with Buffer C , 3 CMC DDM). Fractions from SEC were pooled, concentrated, flash frozen and stored at -80°C until use. Protein concentration was measured using Bradford method. A description of how the critical steps in the purification was overcome, to yield monodisperse MgtA, was described in detail and published at Bio-protocol  and incubated for 10 min on ice. Then, 125 μl of solution II (3.5% sodium citrate and 3.5% bismuth citrate in 1.0 M HCl) was added and incubated at RT for 10 min. Absorbance was measured at 690 nm. The online web service MAXC (maxchelator.stanford.edu) was used to calculate Mg2+free levels in the presence of any given concentrations of ATP, pH at 37°C. Apparent Vmax, and Km, were calculated by fitting the curves (specific activity (SA) as a function of Mg2+free) using Michaelis Menten equation (Y = Vmax*X/Km+X) provided by GraphPad Prism6 (www.graphpad.com). Kcat was estimated using the formula Kcat = Vmax/[MgtA].ATP hydrolysis was measured by detecting the released inorganic phosphate following the protocol described by Cariani et, al., . ReactioThe sequences of the MgtA homologs were identified using the HMMER web server  using deBamHI and NcoI. E. coli C43(DE3) cells were transformed with MgtA-pRSET-BFP NΔ31MgtA-pRSET-BFP, MgtAD373N-GFP, empty pRSET-BFP or empty pCFGP vector. Cells were grown overnight in LB medium with 100 µg/ml ampicillin at 37°C, 180 rpm. Fresh overnight cultures were diluted 1:100 in LB medium with 100 µg/ml ampicillin and grown to OD600 of 0.6. IPTG at 1 mM was added to induce protein expression.MgtA and NΔ31MgtA were cloned into pRSET-BFP vector between When indicated, 200 nM nonyl acridine orange (NAO) was simultaneously added to the culture to visualize CL membrane domains. After 3 hr at 37°C, 500 µl of each culture was centrifuged for 5 min at 4000 rpm and 450 µl of the supernatant was removed. The cells were resuspended by pipetting and 2 µl was immobilized on a poly-D-lysine coated glass dish  covered with a 1% agarose-LB pad containing 1 mM IPTG.Fluorescent images were viewed with a LSM510 (Zeiss) microscope and a 63X oil immersion objective. To minimize the toxicity of high-energy excitation light, the focus was set under phase-contrast conditions and then fluorescence images were captured shortly after the shift to high-energy excitation light. Blue fluorescence from BFP tags  and red fluorescence from enriched and dimerized NAO in CL domains  were detected. Fluorescence from GFP was acquired at excitation 488 nm and emission 510–560 nm. Images were obtained and processed using ImageJ software . In the interests of transparency, eLife includes the editorial decision letter and accompanying author responses. A lightly edited version of the letter sent to the authors after peer review is shown, indicating the most substantive concerns; minor comments are not usually included.eLife. Your article has been favorably evaluated by Michael Marletta (Senior Editor) and two reviewers, one of whom, Eduardo Groisman, is a member of our Board of Reviewing Editors.Thank you for submitting your work entitled "MgtA is activated by cardiolipin and is highly sensitive to free magnesium in vitro" for consideration by The reviewers have discussed the reviews with one another and the Reviewing Editor has drafted this decision to help you prepare a revised submission.Summary:2+ transporter MgtA. The authors demonstrate that: 1) anionic phospholipids are required for the in vitro activity  of the MgtA protein; 2) MgtA co-localizes with anionic phospholipids in the poles of E. coli; and 3) the activity of MgtA is highly sensitive to the concentration of free Mg2+. This manuscript is well written. Moreover, the authors are cautious by not making more claims than their data and the literature allows. Furthermore, their findings nicely complement and are in agreement with the current knowledge of how expression of the MgtA protein is regulated.The manuscript by Morth and colleagues describes a set of experiments that show several important findings on the biology and regulation of the phylogenetically widespread MgEssential revisions:The mechanism by which cardiolipin alters MgtA function is unclear. The authors should at least include the autophosphorylation mutant D373N in their imaging analyses presented in  The mechanism by which cardiolipin alters MgtA function is unclear. The authors should at least include the autophosphorylation mutant D373N in their imaging analyses presented in E. coli CL. Both CL extractions share the same head group, however vary to a greater extent in their fatty acid composition. This experiment indicates that the head group primarily induced initial activation while the fatty acid chains affected the turnover number. Our observations are described in the section “The head group of CL plays a major role in MgtA activation” as well as in the Discussion. A graph that explains the effect of bovine heart CL has been added as An additional experiment has been added to shed more light on the molecular interaction between MgtA and CL. To establish whether the head group or the fatty acid chain of CL was most important for MgtA function, we performed an ATPase assay as a function of CL extracted from bovine heart vs. E. coli. We conclude from this that active transport through MgtA does not affect the localization of MgtA. This imaging experiment was performed with MgtA tagged with GFP. The BFP tagged D373N mutant show much lower expression for unknown reasons  that we used to detect GFP fluorescence. Our results on the GFP tagged constructs are described under ‘MgtA colocalizes with cardiolipin domains at the poles of


There is a serious shortage of skilled nutrition professionals in West Africa. Investing in nutrition training is one of the strategies for strengthening the human resource base in nutrition. However, little is known about how nutrition training in the region is financed and the levels of tuition fees charged. The purpose of this study was to provide a comprehensive assessment about the levels of tuition fees charged for nutrition training in the West Africa region and to determine to what extent this is of reach to the average student.The data for this study were obtained from 74 nutrition degree programs operating in nine West African countries in 2013 through semi-structured interviews during on-site visits or through self-administered questionnaires. They included the age of the programs, school ownership, tuition fees, financial assistance, and main sources of funding. Tuition fees (in 2013 US$) were expressed per program to enable uniformity and comparability. Simple descriptive and bivariate analyses were performed.p<0.05) in private institutions than in public institutions . The difference in the tuition fees between Francophone and Anglophone countries was not statistically significant . In most countries, the tuition fees appeared to be out of reach of the average student. Recent master's programs appeared to charge higher fees than older ones. We found a significant negative correlation between tuition fees and the age of the program, after controlling for school ownership .Results from 74 nutrition training programs in nine countries showed a wide variation in tuition fees within and between countries. The tuition fees for bachelor's, master's, and doctoral programs, respectively, ranged from 372 to 4,325 ; 162 to 7,678 ; and 369 to 5,600 . The tuition fees were significantly higher  per capita is barely 890$, the rising cost of tuition fees is likely to hinder access of students from poor background to nutrition training. Governments should institute financing mechanisms such as scholarships, public–private partnerships, credit facilities, and donor funding to facilitate access to tertiary-level nutrition training in the region. The West Africa region faces a serious shortage of skilled nutrition professionals. While it is estimated that about 2,500 nutrition graduates are needed every year in the whole region, the current output is just at 700 . This siTo address these challenges in a sustainable manner, it is imperative to bridge the current gap in manpower for the nutrition sector . InvestiThis study was conducted as part of a region-wide capacity needs assessment aimed at identifying the capacities that need to be developed to accelerate progress in nutrition in the West Africa region. The assessment was done within the framework of the West African Nutrition Capacity Development Initiative (WANCDI), implemented under the auspices of the West Africa Health Organization (WAHO). The current capacities for human nutrition training in West Africa as well as the capacity to act in nutrition in the region have been described elsewhere , 8, 9. IData were collected in 2013 in the West Africa region, which includes 16 countries according to the United Nations country classifications . These aBriefly, data were collected using an interviewer-administered or self-administered semi-structured, open-ended questionnaire . We estaAs reported in a previous paper, 83 nutrition degree programs were operating in 10 countries of the region at the time of data collection . Mauritat-test was used to determine if mean tuition fees differ according to school ownership or linguistic group of countries. The Pearson correlation test was used to assess whether there is an association between tuition fees and the age of the program, after controlling for school ownership. The level of significance was set at p<0.05 for all tests.Data were entered in MS Excel 2010, double-checked, and cleaned up. They were later exported and analyzed in SPSS 14.0. The student's Tuition fees (including registration fees) were the only elements considered in this study. We did not collect data on other direct and indirect costs besides tuition that influences access to nutrition training. In addition, only tuition fees for national students were considered. To enable uniformity and comparability, all data on tuition fees were converted into US$ (2013 dollars). Likewise, as the duration of the programs vary from one country to another and even within the same country, entire program tuition fees were presented. However, annual tuition fees, expressed as percentage of annual gross national income (GNI) per capita, were used to assess if the costs of nutrition training were within reach of the average student in the different countries .In this paper, ‘public institutions’ refers to organizations that are owned by the government and managed by a government body, regardless of the origin of their funding. In contrast, ‘private institutions’ refers to institutions that are managed by non-government affiliated organizations, regardless of their source of funding.All respondents were fully informed about the objectives of the assessment. They gave their full verbal consent prior to participating in the study.The list of universities that offered nutrition degree programs in West Africa at the time of data collection is presented in p<0.05) for bachelor's programs  . Most ofprograms . The difprograms .The tuition fees varied widely between programs within the same country and between countries . The meaThe annual tuition fees charged in the bachelor's programs ranged from 27 to 159% of annual GNI per capita . The cosp<0.05) for master's programs  . About 4programs . There wAs with the bachelor's programs, there was also a wide variation in the tuition fees for master's programs within the same country and between countries . The meaThe annual tuition fees charged in the master's programs ranged from 8 to 194% of annual GNI per capita . These fr=−0.33, p<0.001). The more recent the master's program, the higher the tuition fees charged. However, we found no correlation in the undergraduate and doctoral programs.We found a significant negative correlation between actual tuition fees for master's programs and the age of the program, after controlling for ownership of institution (p<0.05)  . Overallp<0.05) . There wThe mean tuition fees for doctoral programs varied from US$1,024 in Nigeria to US$5,600 in Ghana . There wThe annual tuition fees charged in the doctoral programs ranged from 14 to 121% of annual GNI per capita . The cosThe mean tuition fees were about the same or decreased slightly with increasing level of training . HoweverIn this study, we provide a comprehensive assessment about the levels of tuition fees charged for nutrition training in the West Africa region. Our results indicate a disparity in tuition fees charged for nutrition degree programs within and between countries. Currently, there is little regulation of the tuition fees charged for nutrition degree programs in the region, especially those run by private institutions. The government of Nigeria makes it mandatory for public universities to adopt a policy of no tuition fees for undergraduate students, but it has no control over the tuition fees charged by private institutions . As nutrWe found that private institutions offering nutrition programs charge higher fees than public ones. The fact that private institutions charge higher fees than public institutions is understandable as they had very little government support and relied heavily on tuition fees . WhereasWe found a rising trend in tuition fees for master's degree programs. Newer programs appeared to charge higher fees than older ones, probably because of a global trend toward higher fees. The increasing price of tuition fees for nutrition training is an issue of great concern. Interestingly, higher tuition fees do not necessarily equate to quality training . It is cOur study has some limitations. While great effort was made to assure total coverage, we could not cover all the training programs that may exist in the region. The data for the programs analyzed may therefore not be representative of all the programs in some countries. In addition, the focus was only on nutrition degree programs in this study. In-service nutrition training as well as non-university technical training, although equally important, was beyond the scope of this paper. Moreover, we could only obtain the data on tuition fees for 74 of the 83 nutrition degree programs that were found at the time of the survey. Additionally, we did not collect data on other direct and indirect costs besides tuition fees that influence access to nutrition training. Further research on this may be warranted. Finally, we used GNI per capita as a proxy for average income in the different countries. This may not reflect the true situation as indicated by the World Bank . These lThe tuition fees charged by training institutions offering nutrition degree programs in West Africa appeared to be out of reach for the average student in most countries. These fees were significantly higher in private institutions than in public ones. This calls for wider policy reforms on the financing of nutrition training in the region. Governments in the region need to take steps to establish or enforce benchmarks and regulate nutrition training costs, particularly in private institutions. The rising cost of tuition fees in West Africa is likely to limit access of students from a poor background to nutrition training. Governments should also explore innovative financing mechanisms that facilitate access to nutrition training and guarantee at the same time quality standards. It is critical to establish and institutionalize loan programs for tertiary-level nutrition training in the region. Foreign assistance  should also contribute to strengthening of local programs through providing scholarships for in-country training.


Inflammatory incompetence is characteristic of acute pediatric protein-energy malnutrition, but its underlying mechanisms remain obscure. Perhaps substantially because the research front lacks the driving force of a scholarly unifying hypothesis, it is adrift and research activity is declining. A body of animal-based research points to a unifying paradigm, the Tolerance Model, with some potential to offer coherence and a mechanistic impetus to the field. However, reasonable skepticism prevails regarding the relevance of animal models of acute pediatric malnutrition; consequently, the fundamental contributions of the animal-based component of this research front are largely overlooked. Design-related modifications to improve the relevance of animal modeling in this research front include, most notably, prioritizing essential features of pediatric malnutrition pathology rather than dietary minutiae specific to infants and children, selecting windows of experimental animal development that correspond to targeted stages of pediatric immunological ontogeny, and controlling for ontogeny-related confounders. In addition, important opportunities are presented by newer tools including the immunologically humanized mouse and outbred stocks exhibiting a magnitude of genetic heterogeneity comparable to that of human populations. Sound animal modeling is within our grasp to stimulate and support a mechanistic research front relevant to the immunological problems that accompany acute pediatric malnutrition. Moreover, this toll of mortality undoubtedly is exceeded numerically by an additional burden of infection-related morbidity. Immune depression is widely accepted as an important link between acute forms of malnutrition and susceptibility to infection )It would be shortsighted to dismiss the potential of the low-protein stunting model as a laboratory tool with which to probe immunological plasticity, but focusing on a detail of dietary composition rather than on details of a pathophysiology has produced a type of animal model bearing no clear relationship to any human pathology. By contrast with stunting models, appropriately crafted protocols that produce a negative nitrogen balance in rodents, albeit by means of dietary nitrogen levels uncharacteristic of human consumption patterns, nevertheless reproduce the diagnostic features of kwashiorkor in weanlings  and proEndocrinological considerations lead to the same conclusion regarding low-protein weanling rodent models, a point discussed elsewhere  in relatThis is a significant and controversial matter that extends far beyond the research front under consideration here. For example a prestigious international journal centered on basic nutritional science has recently adopted the policy that “Studies involving animal models of human nutrition and health or disease will only be considered for publication if the amount of a nutrient or combination of nutrients used could reasonably be expected to be achieved in the human population” . ClarityThe limited genetic diversity of animals used in modeling acute malnutrition, when compared to the diversity within and among human populations, is a longstanding and important concern. In particular, inbred strains of mice have been widely used for immunological studies because of the powerful array of available reagents. Panels of inbred strains can be used for the purpose of testing against a broader genetic background , althougOutbred strains offer the advantage of heterozygosity in which each animal is genetically unique, and examples of the use of outbred animals in modeling acute pediatric malnutrition are numerous. That said, the genetic diversity of standard outbred strains of mice does not model a fully outbred population and, hence, is limited relative to that of most human populations ,35. The It is important to acknowledge that many features of the immunopathology of acute pediatric malnutrition have been reproduced against diverse inbred and outbred genetic backgrounds and have been duplicated, also, across species. However, advancement beyond a largely descriptive phase toward a meaningful pursuit of mechanisms deserves a modeling strategy designed to account for the unknown scope and impact of a magnitude of genetic diversity comparable to that typical of human populations.Two basic dietary strategies predominate in animal modeling of acute protein and energy deficits, viz. restricted intake of a complete diet and ad libitum consumption of an imbalanced diet containing a low level of nitrogen relative to calories . Complete diets for rodents are sufficiently nitrogen-rich that, apart from the occasional strategy of acute withdrawal of all nutrients except water, a regimen sometimes imposed on adult animals e.g., ,39) but  but 39])Regardless of the basic type of model, effort is usually made to ensure that dietary levels of micronutrients at least meet the species-specific standards of a complete diet. In this respect, the diet formulations usually used in studies of experimental malnutrition differ from the micronutrient-poor diets associated with malnutrition in childhood , althougin vivo [Muroid rodents have been the most widely used experimental animals in studies pertaining to malnutrition and anti-infectious defences. This undoubtedly reflects the arsenal of reagents that has been available, and growing, for decades to probe the immunological defences of these species, particularly the mouse. Despite substantive broad similarities between the immune defences of humans and muroid rodents, however, there are a great many differences in points of detail as outlined elsewhere in relation to the laboratory mouse ,51. Thesin vivo ,53. This(a) Secretory IgA is released into the intestinal mucus of humans mainly by transport across the intestinal epithelium, whereas the liver of humans plays a negligible role in this function . Diverse(b) Invasive procedures are required to access macrophages in sufficient numbers for research purposes. For this reason most information pertaining to malnutrition and the mononuclear phagocyte system, with the exception of the blood monocyte, derives from studies of experimental animals, . In turnFive stages of mammalian immunological ontogeny are commonly recognized . A consein vivo in weanlings of both strains at the same chronological age following subjection to a standardized protocol of acute protein deficit. The response was profoundly depressed in the weanlings of the less ontogenetically advanced CBA/J strain [The importance of immunological ontogeny when attempting to model the immunopathology of pediatric malnutrition can be illustrated by means of a small cluster of reports involving two inbred mouse strains ,43,64,65J strain ,64, but J strain ,65.The decisive importance of immunological windows continues to escape notice in animal modeling of the immunopathology of pediatric malnutrition. For example, the potential of the suckling rat model has been outlined recently in convincing detail for the purpose of studies pertaining to the influences of pediatric nutrition on immunological development and competence , yet theWeanling models of acute malnutrition present the risk that diet-related influences may be confounded by ontogeny. Consequently a zero-time control has been used occasionally when modeling acute pediatric malnutrition-associated immune depression  Comparison with an age-matched control group emphasized the small sizes of both the splenic IgG-containing cellular compartment and the intestinal IgA-containing cellular compartment of acutely malnourished weanling mice . Many co+ subset [(b) Among the most striking immunological features of acute pediatric malnutrition is the small size and denuded architecture of T cell compartments in secondary lymphoid organs ,69. This+ subset . In turn+ subset ,72.(c) Acutely malnourished weanling mice exhibit some immunological characteristics that resemble neonatal forms of competence. For example, a type 2 cytokine polarization is reported on the part of both the effector/memory T cell compartment  and the To date, animal modeling of acute pediatric protein and energy deficits clearly leaves much to be desired, and skepticism regarding its real value is understandable. Nevertheless, attention to a modest shortlist of critical design features, notably prioritizing characteristics of human pathology rather than dietary minutiae specific to humans, recognizing the decisive importance of immunological ontogeny, and use of a zero-time control, has permitted some animal-based research to yield insights unavailable from clinical or epidemiological investigations. Arguably some uniquely animal-derived contributions can be characterized as sufficiently far-reaching and fundamental that, considered together, they provide a foundation for a unifying hypothesis to probe the mechanistic underpinning of malnutrition-associated immunopathology. The following commentary, elements of which can be found elsewhere ,6,13,69,i.e., not system-wide) decline in synthesis of inflammatory cytokines is reported in a rodent model of acute nitrogen deficiency [Malnutrition-induced depression in immune defences and infectious disease resistance is often portrayed as consequent to a disintegration of metabolic control, most notably a non-selective and systemic decline in protein synthesis ,13,69. Hficiency . Furtherficiency ,68,76,77ficiency ,49, an oin vivo, even during advanced stages of experimental malnutrition pathology. Importantly, the studies span three endocrine hormones  and four hematopoietic cytokines , seven independent research groups and eight distinct rodent models of acute malnutrition. None of the experimental systems used in these investigations could be characterized as sophisticated, but the weight and diversity of evidence is undeniable. An overriding implication is that rapid enhancement of infectious disease resistance can be achieved even without prior stabilization of severely malnourished patients. This realization could be seen as sufficient to justify application of research resources toward an understanding of the mechanisms underlying malnutrition-associated inflammatory immune depression.Intervention studies involving metabolically diverse forms of acute, experimental malnutrition reveal that infectious disease resistance and components of both innate and adaptive inflammatory immune competence can be sustained, or even restored, independently of ongoing weight loss and in the face of profound lymphoid involution ,39,42,78The animal-based findings cited herein demonstrate manipulation of immune competence independently of nutritional status even in the advanced stages of catabolic malnutrition, and provide proof-of-concept that immune regulation by way of soluble mediators continues uninterrupted in the face of acute forms of pediatric malnutrition. At this stage, the real value of this body of information is in its incompatibility with the classic and prevalent point of view that malnutrition-associated depression in immune competence reflects a chaotic attrition of inflammatory capacities. Collectively, the findings have given rise to an alternative unifying hypothesis dubbed the Tolerance Model ,41,77.The Tolerance Model is an animal-based challenge to the classic attritional paradigm and centers on the proposition that acute malnutrition elicits a regulated immunological revision toward a non-inflammatory form of competence that, even in pediatric stages of life, is sustained into advanced stages of wasting disease. The proposed immunomodulation is presented in the model as an attempt to adapt to the catabolic pathology of acute malnutrition, and a presumptive benefit is reduction in the risk of inflammatory autoimmune pathologies albeit at the cost of susceptibility to opportunistic infection. The model is far from static and can accommodate new information pertaining to immune regulation as it comes available. For example, the impact of short-term caloric withdrawal on B cell development appears to be mediated in significant measure through the central nervous system , an intrAs to hints of mechanism, one model of acute weanling malnutrition has been used in studies pointing to the dendritic cell as the primary limiting factor in the depressed adaptive cell-mediated immune competence that consistently accompanies acute pre-pubescent malnutrition ,72. AnotDespite obvious inadequacies, animal modeling has already challenged understanding of malnutrition-associated immunopathology in a fundamental way. In so doing, animal-based studies have provided some justification, together with specific possibilities, for pursuing mechanistic studies. Substantively improved modeling sophistication will be needed to proceed further, but one might hope to see research strategies that incorporate the design precautions outlined here in studies utilizing the immunological humanizing technology ,53 and aTwenty-five years ago, while summarizing an international conference under the sponsorship of the World Health Organization, the late Nevin Scrimshaw pointed out “There is still a large gap between what can be demonstrated by experimental single nutrient deficiencies in inbred strains of laboratory animals and evidence of relevance to the phenomenon of increased infection among malnourished human populations. It is still uncertain whether some experimental observations of this kind have any relevance at all to public health nutrition.” . This in


Previous studies of alcohol use have recognized several trends in consumption patterns among gender and age yet few have examined ethnic differences. This study examines the intra- and inter-ethnic differences in alcohol consumption among a population of patients seen in the emergency department.This is a cross-sectional study conducted in the emergency department in a large urban setting. Information on drinking behavior and ethnicity was collected using the Computerized Alcohol Screening and Brief Intervention (CASI) tool. We explored differences in drinking patterns using a multivariate multinomial logistic regression model.We analyzed the drinking habits of 2,444 patients surveyed between November 2012 and May 2014. The results indicate that when compared to non-Hispanic whites, Asians have the lowest odds of drinking within normal limits or excessively, followed by other Latinos, and Mexicans. Age and gender consistently showed statistically significant associations with alcohol-use. The odds of drinking within normal limits or excessively are inversely associated with age and were lower among females. The predicted probabilities show a marked gender-specific difference in alcohol use both between and within ethnic/racial groups. They also highlight an age-related convergence in alcohol use between men and women within ethnic groups.The results of this study show intra-racial/ethnic variability associated with sex and education. The highlighted differences within and between ethnic groups reinforce the need to use refined categories when examining alcohol use among minorities.The results of this study confirm some alcohol consumption trends among ethnic minorities observed in literature. It provides empirical evidence of the marked gender differences and highlights an age-related convergence for gender-specific alcohol use. Health-care personnel should be aware of these differences when screening and counseling. Alcohol is the world’s largest risk factor for premature mortality, disability, and loss of health, and results in 2.5 million deaths every year . In the Studies of alcohol use and alcohol-related injuries have identified several gender and age-related trends in consumption patterns , 7. Men This study aims to describe variability in drinking patterns across and within ethnic groups among patients seen at a level I trauma center in a large urban setting. Using the Computerized Alcohol Screening and Brief Intervention (CASI) tool, we collected sociodemographic and alcohol consumption data from patients seen in the ED. We hypothesize that there will be significant variation in ethnic/racial-, age-, and gender-specific drinking patterns.This is a cross-sectional study conducted in the university tertiary care ED. The ED is a located in a large urban setting and provides services to inhabitants of the surrounding areas. It is the only level I trauma center in Orange County and handles nearly 40,000 patient visits annually. The Institutional Review Board of the University of California, Irvine, approved this study.We recruited emergency department patients visiting a level I trauma center to participate in this study. Patients were eligible for inclusion in the study if they were i) adults age 18 and over; ii) medically stable; iii) not in custody or on a psychiatric hold; iv) not suspected of being intoxicated; v) English- or Spanish-speaking. The race and ethnicity questions were implemented in CASI in November 2012. This analysis includes patients screened between November 2012 and May 2014. Patient screening occurred between 8 am and midnight, Monday through Sunday because of the availability of research assistants.Patients were approached by trained research assistants to screen on a touchscreen tablet (Motion Computing® by Xplore) using the interactive Computerized Alcohol Screening and brief Intervention (CASI) program. CASI was developed by the Center for Trauma and Injury Prevention Research, University of California Irvine Health Affairs, and has successfully been used to identify and intervene with drinkers in the ED setting , 19. It The classification of alcohol consumption is based on the World Health Organization’s Alcohol Use Disorder Identification Test (AUDIT) used by the National Institute for Alcohol Abuse and Alcoholism (NIAAA) . Four tyCASI includes two questions used to identify the race and ethnicity of our respondents. We adopted these questions from the 2010 United States Census . The firIn our analysis, we used age as a categorical variable with the following categories, 18–20; 21–24; 25–29; 30–39; 40–49; 50–64; 65 and older. The 25–29 group (the highest RRR for drinking within recommended limits) was the reference category. We included three categories for level of education: Less than High school; High school/Some College; Associate Degree/4-year college degree/Advanced Degree . High school/Some College (the largest group) was designated the reference group. Race was divided into five categories as defined above. Non-Hispanic white was designated the reference group. For alcohol use, due to small numbers in the likely dependent group, we combined the last two categories (at-risk and likely dependent) creating three categories of alcohol use: (i) non-drinker; (ii) drinks within recommended limits; (iii) drinks excessively. We used non-drinkers as the reference group.We tested for crude differences in drinking patterns using the chi-squared rest for independence, Kruskal-Wallis test for ordinal variables, and analysis of variance for continuous variables. When the variation among groups was significant, comparisons between individual groups were assessed using the Sidak multiple-comparison test. We explored differences in drinking patterns using a multivariate multinomial logistic regression model. Our baseline model only included ethnicity as an independent variable. Our final model included ethnicity, age, gender, and level of education. We also tested for interactions between race/ethnicity and level of education, and race/ethnicity and gender. The results are expressed as a Relative Risk Ratio (RRR) and predicted probabilities.p < .00005). Thirty-three percent drank monthly or less. Only 7 % of our respondents indicated a drinking frequency of four to seven times per week. Among drinkers, non-Hispanic Whites drank more frequently than Mexicans (p = .01) and Asians (p < .00005). On an average day, the mean number of drinks consumed by our population was 3.2 with those classified as Mexican consuming the highest (3.7) and Asians the lowest (2.4). Mexicans reported more drinks per day than non-Hispanic Whites (p < .0005). Binge drinking was also more common among Mexicans than non-Hispanic Whites (p = .0001). The characteristics and alcohol use of the study population are presented in detail in Table Our study population included 2,444 patients screened using CASI . A large proportion of our respondents were between 30 and 39 (20 %) and 50–64 (20 %) years old. The mean age was 38 years with mean ages ranging from 34 years among Mexicans to 44 among Non-Hispanic White patients. Almost 56 % of the patients screened were male, and the majority of patients had received high school or some college education (57 %). Thirty-four percent of respondents had received an Associate, Bachelor or advanced degree. Thirty-five percent of our study population indicated that they did not drink. A higher percentage of Asians than non-Hispanic Whites did not drink (ns p = .0 and AsiaTable Table Figures Figures We observed ethnic, gender and age-specific differences in the alcohol consumption patterns. Asian respondents were consistently the least likely to engage in drinking behavior, and non-Hispanic white respondents the most likely. Drinking declines with age but at different rates between males and females. The odds of alcohol consumption appear to peak between the ages of 21 and 29, plateau between 30 and 49 and declines from age 50 onwards. This is in keeping with general assumptions and evidence about alcohol consumption during the life course. When compared to men, women have consistently lower odds of drinking either within recommended limits or excessively and higher odds of not drinking. Educational attainment appears to show a linear relationship with the odds of drinking within normal limits. Among the middle-aged and the elderly who drink within normal limits, the age-, gender, and ethnic-differences observed varied significantly.The multinomial logistic regression model shows that when compared to non-Hispanic whites, Asians have the lowest odds of drinking within normal limits or excessively, followed by Other Latino’s, and Mexicans. This order, non-Hispanics Whites, Mexicans, Other Latinos, Asians, non-Hispanic Other, persisted throughout the study. This relative ranking of the ethnic group remains the same across the age categories, with non-Hispanic Whites most likely to engage in drinking. The differences in the probability of drinking between the ethnic groups narrow as behavior progresses from not-drinking to drinking within recommended limits and excessive drinking. The observed pattern mirrors earlier studies of the impact of age and ethnicity on drinking behavior.Women of any racial/ethnic group have a higher probability of being a non-drinker than men of any racial group. This increases and persists through all age groups. These gender differences in probabilities are more prominent when examining the likelihood of engaging in excessive drinking. The probability of a men engaging in drinking is almost one and a half that of women for each ethnic group in the early ages and about twice that of women by age 65. While Fig. The existing literature has used education as a proxy for socioeconomic status. Studies have primarily aimed at examining the impact of educational attainment on the risk of alcohol dependence –28. The We collected data from 8 am to midnight because of the availability of research assistants. Patients arrive between midnight and 8 am may have different drinking patterns. Patients were approached for screening while they were intoxicated, but they could be approached in their stay later if sober.The study relies on self-reported ethnicity and racial classifications and drinking. Self-report for race and ethnic is an advantage over assigned-ethnicity by health-care personnel. We didn’t assess acculturation, and this may influence drinking as well as other behaviors. While it is likely that drinking behavior is under-reported, the anonymous and automated nature of the survey is intended to minimize under-reporting. CASI has been shown to increase detection of alcohol consumption and at risk drinking, as compared to the medical screening exam, in both English and Spanish interviews .Two groups, Native Americans and Blacks, are included in non-Hispanic Other category, as they do not comprise a large proportion of the patient population for the hospital included in this study. However, this does not influence the results for the races included in this study. Other studies have reported difference in age and drinking behavior among Blacks compare other races/ethnic groups.  ExistingThe results of this study confirm some alcohol consumption trends among ethnic minorities observed in literature , 16. It


Poor communication is a source of risk. This can be particularly significant in areas of high clinical acuity such as intensive care. Ward rounds are points where large amounts of information must be communicated in a time-limited environment with many competing interests. This has the potential to reduce effective communication and risk patient safety. Checklists have been used in many industries to improve communication and mitigate risk. We describe the introduction of a ward round safety checklist ‘DEFAULT’ on a paediatric intensive care unit.A non-blinded, pre- and post-intervention observational study was undertaken in a 12-bedded Level 3 tertiary PICU between July 2009 and December 2011.P <0.0001). The ward round checklist was also associated with an increase in the proportion of invasively ventilated patients with target tidal volumes of <8 ml/kg, which increased from 35 of 71 patients at 08.00 representing a proportion of 0.49 (95% CI 0.38 to 0.60) to 23 of 38 . This represented a trend towards an increased proportion of cases in the target range .Ward round stakeholders subjectively liked the checklist and felt it improved communication. Introduction of the ward round checklist was associated with an increase in median days between accidental extubations from 14 (range 2 to 86) to 150 (56 to 365) (Mann–Whitney The introduction of a ward round safety checklist was associated with improved communication and patient safety. Communication failures are very common causes of errors and harm in medicine . IntensiThe aviation industry recognised the utility of checklists as defence against the limitation in human memory and attention as far back as 1930 –8]. Pae. Pae8]. Ward round checklists are not in widespread use. One ‘FAST HUG’ checklist has been described for use in adult intensive care. This checklist was designed for the individual bedside nurse to confirm adherence to evidence-based practice rather than as a team exercise . ImproveOne study provides support for the use of a ward round checklist on an adult ICU with increased attention to the issues that the team felt needed to be discussed for every patient every day . Team buWithin our unit, we identified ward round bedside communication as specific risk. We felt that ward rounds should be the key decision-making events with the whole team contributing to, and agreeing, a plan for the next 12 hours. We were concerned that information may be being miscommunicated, misunderstood or simply not heard. Any of these failings would reduce ‘situation awareness’ and reduce consistency of the mental model of the patients that are communicated across handovers to ensure delivery of high levels of longitudinal care . SpecifiOur aim was to improve the effectiveness of information sharing on ward rounds in our paediatric intensive care unit (PICU).A prospective, non-blinded, pre- and post-intervention observational study was undertaken in a 12-bedded Level 3 tertiary PICU between July 2009 and December 2011.The study was discussed with the Bloomsbury (London) Research Ethics Committee who confirmed that the need for ethical approval was waived.The risk action group designed a mnemonic aimed to cover important aspects of patients’ care that were necessary to discuss at each bedside interaction.In preparation for introduction of the checklist, all stakeholders in the process including consultant intensivists and senior nurses were invited to comment or amend the proposal.The DEFAULT mnemonic was developed for use to ensure that the following were discussed: D-Do Not Attempt Resuscitation status, E-Endotracheal tube fixation reviewed as secure and cuff inflated appropriately, F-Fluid management - agreement of type, allowance and overall balance target within next shift, A-Analgesia (and sedation) plan agreed and weaned if possible, U-Ulcer prophylaxis , L-Lines  sufficient or to be removed if possible and T-Tidal volume less than 8 ml/kg Table .As implementation was to be led by the consultants and senior nursing staff, agreement from these groups in particular and commitment to a daily change in practice was necessary. Subsequent to this consultation phase, strategies for dissemination of information regarding the checklist to junior doctors and the nursing team have included discussion at the unit meeting, emails and printed stickers to act as visual prompts.From 1 July 2009 the ward round checklist was introduced on morning rounds. Continuity on daily rounds from a senior fellow ensured rigorous adherence to the change in practice and reinforced the role of the checklist.After each bedside discussion of the patient the team ran through the ‘DEFAULT’ checklist. Initially this was led by the duty consultant intensivist. This was done aloud, to all members of the round and issues that had been missed or were not clear to all members of the team were discussed as prompted by the checklist.Six outcome measures were assessed:1) The proportion of ward round bedspace visits in which the DEFAULT checklist was observed to be performed.2) The number of ‘issues’ identified during the checklist .3) The length of time (seconds) between the start of the DEFAULT checklist until its completion.Measures 1 to 3 were assessed on 10 consecutive weekdays after implementation.4) Qualitative staff satisfaction and comments. Staff satisfaction was assessed by an ‘anonymised’ questionnaire provided to all medical and nursing staff. A total of 24 questionnaires were distributed to all nursing and junior medical staff members on a day shift two months post the introduction of the DEFAULT mnemonic.5) The frequency of episodes of accidental extubation. Because of the relatively low incidence of these events, comparison of accidental extubations rates is made between the one-year period prior to implementation of DEFAULT and two years afterward.6) The proportion of patients with inspiratory tidal volumes estimated on the Servo-i or or Evita-4 ventilators <8 mls/kg. Inspiratory tidal volume is recorded on all patients at least at hourly intervals on computerised records . Cases less than 10 kg body weight were excluded from this analyses as the potential error in measured tidal volume was considered to be too great  as were Tidal volume data was collected for the 8.00 (pre-ward round) and 12.00 (post-ward round) for one month prior to, and again immediately after, the introduction of DEFAULT. Required changes would be made by medical or bedside nursing staff. This analysis was repeated at month 6 and month 9 after implementation.The first four parameters are potentially vulnerable to bias and hence we planned to assess the impact of DEFAULT prospectively from 1 September 2009 (two months after implementation) to reduce the risk of describing a honeymoon effect or of a variable degree of staff experience of the intervention in the early phase. Accidental extubation rates and inspired tidal volumes were routinely collected on the unit thought to be less prone to bias. Hence impact of DEFAULT was assessed immediately by reviewing changes in these routine data.Non-parametric data are presented as medians and interquartile ranges and groups are compared with the Mann–Whitney test. Categorical data are presented as proportions with 95% confidence intervals of proportion and compared with the significance of the difference between two independent proportions (z-ratio). Statistical analyses were performed on SPSS 20 for Mac .Very early during the initial pilot period of two months it was decided the checklist should be led by the bedside nurse rather than the consultant conducting the round. This gave the bedside nurse a platform for communication and empowered him/her to lead at least one element of the communication episode.When audited over two weeks at the end of the two-month introduction period, 100%, of 103  96 to 100%) observed ward round bed space interactions employed DEFAULT, the median time for completion was 27 (interquartile range (IQR) 12 to 105) seconds and there were a median of 1.4 (IQR 0 to 5) ‘issues’ per bed. Subsequent re-audits at 12 and 24 months have confirmed 100% use of DEFAULT on ward rounds.aides-memoires and the DEFAULT acronym is now printed at the top of their daily fluid charts and onto the back of their clipboards. This was mostly for the benefit of newer or junior staff who may forget what the letters stand for. A summary of comments collected from the multidisciplinary team two months after the introduction of default is shown in Table Of the 24 questionnaires distributed, 12 were returned. Subjectively, feedback from nurses was that they ‘loved it’ as it improved the feeling of involvement in the ward round process and provided a platform to air issues. Comments included that the mnemonic helped improve memory recall and allowed for main or key points of care to be addressed on the ward round, facilitating effective planning. They reported that the DEFAULT checklist indirectly gave structure to staff for discussion of key points of care helped provide guidance particularly for more junior bedside nurses. Nursing staff subsequently developed their own The doctors felt it was a useful tool that usually brought up something to be discussed further. They also appreciated that asking the bedside nurse to ‘DEFAULT’ facilitated in providing structure to the ward round and helped ‘frame’ each patient interaction.P <0.0001) .Prior to the introduction of DEFAULT 35 of 71 invasively ventilated patients meeting inclusion criteria during a calendar month on PICU had a tidal volume <8 ml/kg at 08.00; this represents a proportion of 0.49 (95% CI 0.38 to 0.60). This was not significantly different at 12.00, when 29 of 67 patients had a tidal volume <8 ml/kg, . Following the introduction of DEFAULT, 23/38  invasively ventilated patients, had tidal volumes <8 ml/kg at 8.00, and 25/43 patients at 12.00, . This represented a trend towards an increased proportion of cases in the target range  and at nine months at 8.00: 19/25, , at 12.00, 18/22  (P <0.0002).At six and nine months after DEFAULT the proportion of cases in the target range were significantly greater than baseline Figure   and automated to some degree. A further flaw is that several components of acronym have not been assessed. Either because some parameters on the DEFAULT list represent very rare events , or those for which no gold standard care is defined . We could not devise an effective way of assessing these parameters not least because many of our patients leave intensive care and are repatriated to their local hospitals or host wards and are under the care of different teams with limited intensive care follow-up. While it is tempting to try to assess the numbers of days of patients spend with invasive lines (L-lines out) and to assess if this might have fallen following DEFAULT, defining when a line was or was not appropriate for a case-mix adjusted population was outside the scope of this work. Comparing central line-associated infection rates and ventilator-associated pneumonia rates before and after use of the ward round checklists was considered. However, rates for these are low on our unit after the introduction of specific care bundles so as make this comparison uninformative. Intensive care bed days are not comparable due to the multiple confounding variables such as seasonal variability in emergency referral. Therefore statistical proof of efficacy is challenging. Hence we have used what data are available but also considered subjective experiences of the altered processes.The strongest suggestion of DEFAULT improving safety comes from the comparison of accidental extubations before and after introduction of the checklist. While there was no other change in practice with respect to tube fixation on the intensive care unit during this period, accidental extubation rates are now (from 1 April 2011) reported to UK National Health Service commissioners. In theory, foreknowledge of this change may have altered in reporting practice. Regardless of the cause, we observed a clear reduction in the number of accidental extubations.Prior to introduction of DEFAULT there was no difference in the proportion of children ventilated ≤8 ml/kg between the 8.00 or pre-ward round tidal volumes and the 12.00 or post-ward round tidal volumes. On comparison of tidal volumes at these times after the DEFAULT checklist introduction period, there was no increase in the proportion of ventilated patients with tidal volumes in the target range. Three months later, there was an increase in the proportion of patients with tidal volumes in the target range after ward round use of DEFAULT. More importantly, there was an improvement in the overall proportion of patients who were ventilated with tidal volumes in the target range before and after the ward round. This suggests that ‘DEFAULT’ influenced daily thought processes and such that safe target ranges for ventilation are an overt goal of our care for all staff.aides-memoires by the nursing team for the nursing team has exemplified the commitment to continue use of this checklist at every patient’s bedside.We believe that ownership of a locally devised checklist has facilitated its introduction into this particular area and has ensured a change in culture in bedside communication. All members of the multidisciplinary team had been consulted prior to introduction of the DEFAULT checklist and were invested in its ongoing use. The development of With time, the authors have also become aware of the danger of the checklist being recited as a mantra, such that each part of the checklist is recited unconsciously. This has the consequence that there is little thought for the importance or significance of each part of the checklist and a rehearsed DEFAULT is communicated without incorporating the ward round decisions. This has been particularly noticeable in the younger members of staff who have focused on DEFAULT as the point at which they are expected to contribute in the ward round process. The authors hope that vigilance to this and education will help overcome this.Introduction of a ward round checklist, the acronym DEFAULT, has been popular with all members of the multidisciplinary team. It is well liked by the nursing team who has seen it provide a platform for them to speak and contribute to discussions in the large multidisciplinary ward rounds, overcoming perceived hierarchies of communication. The DEFAULT checklist has facilitated effective communication thereby reducing the risk of lost information at danger points during discussions regarding patient care. Its introduction has been associated with an increase in the proportion of paediatric patients ventilated with tidal volumes in the target range and a fall in the accidental extubation rate. In a paediatric intensive care setting use of a ward round checklist used systematically for every patient can reduce risk and improve patient care.● Effective communication during large multidisciplinary ward rounds is both crucial and difficult● A simple spoken checklist may improve ward round communication● Measures of patient safety including accidental extubation rates may be improved by simple structured communications about the control measures● The effectiveness of a checklist is likely to depend on active, unrehearsed participation by the teamNICU: Neonatal intensive care unit; PICU: Paediatric intensive care unit; WHO: World Health Organization.The authors declare that they have no competing interests.MP conceived of the study and designed the first draft of the checklist. This was revised with the RAG (see below). MP and SS planned the study and intervention. RAG members ensured implementation of the checklist. The SS and MP collected the data, MP analysed the data and both SS and MP prepared the manuscript. All authors read and approved the final manuscript.


Public health approaches have frequently conceptualised alcohol consumption as an individualbehaviour resulting from rational choice. We argue that drinking alcohol needs to be understood asan embodied social practice embedded in gendered social relationships and environments. We draw ondata from 14 focus groups with pre-existing groups of friends and work colleagues in which men andwomen in mid-life discussed their drinking behaviour. Analysis demonstrated that drinking alcoholmarked a transitory time and space that altered both women's and men's subjectiveembodied experience of everyday gendered roles and responsibilities. The participants positionedthemselves as experienced drinkers who, through accumulated knowledge of their own physical bodies,could achieve enjoyable bodily sensations by reaching a desired level of intoxication (being in thezone). These mid-life adults, particularly women, discussed knowing when they were approaching theirlimit and needed to stop drinking. Experiential and gendered embodied knowledge was more importantin regulating consumption than health promotion advice. These findings foreground the relational andgendered nature of drinking and reinforce the need to critically interrogate the concept of alcoholconsumption as a simple health behaviour. Broader theorising around notions of gendered embodimentmay be helpful for more sophisticated conceptualisations of health practices. Alcohol consumption and excessive drinking have received considerable research and public healthattention. Much of this work has conceptualised alcohol consumption as an individual behaviourresulting from rational choice, although public health approaches based on such assumptions arerelatively ineffective and assume that people will automatically amend their drinking in line with recommendations. Thissocial cognition approach has been heavily criticised for its lack of success in predicting orchanging behaviour  study aimed to explore experiences and understandingsof alcohol consumption in mid-life adults , excluding agroup of non-drinkers (FG7) recruited to provide a different perspective on the cultural context ofalcohol. Details of the groups are provided in Table Thematic analysis , astaking away ‘the aches and pains from the day's work’ (Craig FG1), andproviding that ‘nice sense of relaxation’ (Anne FG12). Alcohol consumption also markeda space away from domesticity and childcare for many women; for example Anne (FG12) framed drinkingas ‘a declaration of adulthood’ and Madeleine (FG15) as ‘the end of Mummyday’.Below Michael explains how the immediate embodied sensation of drinking a chilled glass of wineat the end of the day evokes a strong, positive emotional response:Michael: Wine's a good comforter – you know? If you've had a hard day atwork or something. I used to work quite, I won't say stressful but it was relativelystressful at one time, you know? And you used to come in and get a glass of wine just tae[to], you know?Grace: Oh yes, yes, I've had that.Michael: The cold hit at the back of the throat and you think, ‘Oh, that's my bestpal’. [laughter] (FG5)Hugh provided a vivid illustration of the embodied enjoyment of anticipating going to the pub anddrinking with his mates, and constructed drinking in traditional embodied masculinity terms,involving working hard, then having the reward of drinking at the pub:bursting to get out with your mates … You know most of the time, youknow you've got at least a 35-hour working week, maybe more, you know. And, week in, weekout, month in, month out. And you have to have the discipline to get through all that, whatever itis you're doing, grind most of the time … it is like a reward.(FG2)Hugh: You know, the thing is that, going to the pub feels to me like how I used to feel when Iwas 10 and I wanted to go out to play. It's that feeling of, ‘Right, I can cope withschool, I can cope with doing all the boring stuff, blah de blah de blah’, but you'rejust Some women also discussed alcohol enabling an escape from the grind of mundane work, but in thedifferent context of unpaid domestic work or combining domestic and paid work, reinforcingtraditional notions of femininity involving the domestic realm:Hannah: We always have wine with our meal because, you know, I like to set the table and sit downand, you know, ‘coz it's the only chance you get to sit down and have a, you know, anhour sort of niceness, then, before you've got to load the dishwasher, do the ironing, youknow, and so on and so forth. (FG8)In contrast, some participants said they did not drink alcohol to relax or escape, but to bingedrink and get drunk, which Ruth described as ‘a release valve’:Ruth: It's not really about relaxation for me, as such –Lynn: Yeah, I'm the same –Ruth: It's, like, about sociable, party –Lynn: I think, yeah, I think – I drink to get drunk. I think, unless I'm withpeople who aren't like that, and I would have a glass of wine not thinking – no, but Ithink I do, I do think I'm definitely a binge drinker … I don't think I couldever just be a moderate drinker. It's – you binge. You don't do it again for 3months. You binge. And it's just like that, you know.Ruth: It's like a kind of, like, release valve, like a kind of pressure valve, letting offsteam. (FG12)Here Ruth and Lynn describe a particular embodied engagement with their social world, wherefeelings of pressure built over time were released through binge drinking. The pressure valvemetaphor implies catastrophe if release is not achieved, representing drinking as both necessary andimportant and intimately tied to experiential, embodied contexts.et al. Drinking alcohol marked a transitory time and space that altered participants' subjectiveembodied experience to differentiate it from normal, everyday embodied experience  and the social contexts of being in mid-life (such as theresponsibilities of paid work and childcare) were perceived to limit excessive drinking.Participants found it difficult to fully disentangle the effects of ageing from social constraints,as Vicky described in relation to her body not ‘handling it as much now’:Vicky: The headaches last for longer and they're probably a bit more intense. You find, aswell, that you can't lie in bed all day the day after – you've got things to dothat you didn't have to do before – so you're kind of dragging yourself around.You're just punished for it a lot more. I think that really is a physicality of just gettingolder. So that means that you're less likely to binge. (FG6)Ageing bodies and social responsibilities were the primary reasons given for reducing alcoholconsumption. Decisions to moderate alcohol consumption were also influenced (to a lesser extent) bydriving the following day and weight concerns Audrey: It is like a small poison. I mean, that sounds ridiculous, but if it hits me at the wrongtime of day and, probably the wrong time of the month as well, and maybe even when I've gotother things on my mind – all these things combined, then it tastes like it is something thatmy body is etal. , arbitrary (Madeleine FG15) and a bit abstract (Elizabeth FG9). Thus,when limiting their consumption participants did not count units These positive feelings were described consistently as loss of inhibitions, exaggerated responsesto everything, becoming ‘an enhanced person – 10 per cent more charismatic, 10 percent more exciting, 10 per cent more funny’ . Both men and women described thisstate of enjoyment as being in the zone or that perfect level:all night but not get drunk. Get to that level of– that perfect level, you know, and stay there … in the zone, that's what itis.Bill: I'd love to drink Facilitator: Yeah. So is the zone, is that kind of feeling it a little bit then? Is that–Bill: [Overtalking] Uh huh, that's when you've managed to untie yourtongue enough and your brain seems to be working faster, and everything you say is reallyfascinating to other people [laughs] – and that happens to me all thetime! But it's for about 10 minutes or something [laughter]. Andthereafter it's all downhill. But there is that wee point where you think, I'm reallyenjoying myself. [Others agree]. And then there's the point where you get– the next day you're probably thinking, ‘And that's when I should havestopped’.Eleanor: I know.Facilitator: And is that alcohol or is that people, or is it both?Bill: I think it's just both. It's the reduction of inhibitions so thatyou're feeling more confident and cheerful perhaps. It's the social context as well.(FG3)Here the desirable feeling arises from the interplay between the physiological effects of alcoholand the social context. A key part of achieving this perfect level was sharing this with people whowere ideally getting in the zone or on the same wavelength (Eric FG10). The social bonding over thiscalibrated consumption could mean that being the only sober person was ‘horrible’,‘just terrible’ and socially isolating.This desired embodied state was also influenced by participants' moods, frame of mind,environment, time of day, the stage of women's hormonal cycle, what alcohol was beingconsumed and how much food had been eaten. Alongside achieving this enjoyable state, theparticipants talked about reaching a tipping point or a point of no return , when they realised they had consumed too much alcohol and were feeling less pleasantsensations. Women were much more likely to describe acting on this knowing sensation by stoppingdrinking:Mandy: You just start to get a sensation that, maybe, I really don't know, maybe thingsstart to slow down a tiny bit, or maybe you start to realise your own behaviour is, like, maybeyou're, you know, you spill something, or you, like, make a mistake when you'respeaking, like you say the wrong word, or something like that, and you think, ‘That'snot normal for me’; I'm at this, you know, I've sort of gone beyond the stageof, you know, what I'm happy with. But it's quite, it's very hard to articulatethe actual physical sensation of it, I think. (FG10)knowthere's been quite a lot of nights out where I've just gotten to the point whereI'm like, ‘If I have one more drink, I'm really not going to be happy.It's just gonna push past that point, and I just know that I don't wantanymore’, and I'll just stop … And it must be, through many years of experienceof me [laughs] going past that point – and I think it's hard toverbalise the feeling that it is. I mean, it's not necessarily that I feel sick or I feeldizzy – although, they would be obviously strong signs. It's, there might be a pointof being full – of just being full and, I don't know, maybe happy. I don'tknow, I'm just like, ‘No, that's it. That's enough’. It'sdefinitely subconscious, I think. (FG11)Tara: I feel like I've developed an internal kind of gate, which I know I don'twant to go through – and I don't really know what it is, I just Tara's embodied feeling of knowing when to stop consuming alcohol developed through experience and thus now operated at a ‘subconscious’ level, implyingthat bodily experiences become so well-rehearsed that they no longer require conscious interventionor scrutiny. Some women also linked getting to the point that they have had too much with‘thinking about the next day. Your time's too precious’ (Isobel FG8). While thewomen were willing to engage with questions around how they knew when they had drunk enough, manymen noted that they just know. For example, Paul (FG6) talked about how ‘Something tells meI've had enough … My brain, I'm just trained, I just know when I've hadenough’ Graham (FG2) described it as ‘just an internal thing you just know’,while Ewan (FG2) stated that ‘instinct is experience coalesced’.The corporeal feelings of going past one's limit were described in various physical andembodied ways (and appeared easier for participants to articulate than describing approaching thatlimit). For example, participants talked about not being able to communicate, stumbling, slurring,having double vision, an upset stomach, numb gums; feeling nauseous, queasy, fuzzy, blurry, tired;keeling to the side, bumping into people and becoming too loud. They also described it as when‘the liquid won't go down their throat’ anymore, feeling bloated, and gettingto a point where they no longer liked the taste of alcohol. In three groups, participants discussedblackouts ; for Finn (FG13), it was ‘passing out in the club, done thatonce’ while for Rach (FG5) blackouts occurred ‘all the time’:Rach: I get blackouts wae [with] wine all the time – get blackouts, justdon't remember. [laughs] … So now I don't drink wine when I goout. I very, very rarely, don't I? Very, very rarely.Grace: No, you're on the vodka maybe more …Facilitator: So you can know where you are a bit more?Rach: Aye, because I know that once I go on that wine, I just don't remember. And I do,literally, take blackouts. I just don't remember – get up in the morning and all mylights is on, my telly's on, the fire's on. (FG5)Gavin and Mark discussed drinking to a point that they were not able to remember what happenedand Mark described having ‘that blackout at the end of the night’, implying these werea relatively regular (and normative) experience:Gavin: See my problem is I don't know, I just wake up the next day and go, ‘Right,well, I don't remember, from this point on, so I must've but’ – sothat's essentially my problem. But then yeah.Mark: You can probably tell we know each other quite well, but we've discussed thisbefore, it generally tends to be more when we're drinking whisky that you have that blackoutat the end of the night. [Others agree] How did I get home, sort of thing. (FG14)Both male and female participants discussed vomiting after excessive alcohol consumption, asillustrated by Susan below. In the next extract Callum explains how he would preplan what he atebefore a ‘fairly big night out’ in anticipation of being sick from excessivedrinking:glass then somethinghappens,Susan: I can have a bottle of wine and I really, I'm OK, I've obviously beendrinking but I'm OK. If I have a bottle and a Cath: It's that glass that did it! Not the bottle, it's the glass.am physically sickand I can't have any more. That's that. (FG4)Susan: I turn my head to the side and it's such a queasy feeling that I am actually,I'm sick, so I know that that's me, I'm absolutely finished. [Othersagree] And it does make me feel really nauseous or else I always, if I knew I was going out for afairly big night out, have soup. This sounds really, really grim, like it sounds terrible, but whatI'm thinking is, ‘What if I get so drunk that I'm sick, or even sick in mysleep. If I'm being sick liquid, I'll survive’. [Laughter]. But Ithink if I have a big meal, I'm far more likely to be sick, and also if I'm sick andit's just soup at least it's liquid coming out, if it's horrible big, you know,meat or whatever, then it's going to be fatal. And you shouldn't be thinking likethat, but [overtalk] that's always in there. (FG13)Callum: Subconsciously as well, I would Lynn and Ruth (FG12) discussed making themselves vomit so they could keep drinking during a nightout. Ruth was reluctant to discuss this topic, while Lynn appealed to their friend Anne not to‘judge’ them, illustrating their awareness of the gendered morality that is attachedto drinking  was frequently the first moment when participants realised thatthey had passed that limit. These social and physical perturbations act as sobering moments; theyprovide time out for a more objective assessment of physical state. Jeff (FG6) commented that‘it doesn't really hit me till I get out in the air’, while Jody (FG5) noted‘I just feel perfectly fine and then I'll go to stand up, or go to go into the kitchenor something’. Group 12 described these moments as follows:Erin: Yeah, it's the going to the toilet thing, and realising that it's[alcohol] having an effect. ‘Coz I think – it's more likeyou're either talking or you're just like, busy, and then you're – goingto the toilet's the first time you actually get to think how the night's going andthen, ‘how many drinks have I had’. [Group laughter].Ruth: I hadn't actually thought about it like that but it probably is.Erin: It's the first time you're kind of like – the lights are different andyou're like oh!Lynn: The music isn't in your ears (FG12)Thus the embodied, subjective experience of intoxication involves physical sensations in thebody, but their interpretation depends upon the context, environment, space and place in whichpeople are located. Alcohol facilitates togetherness and sociability, and drinking with others inthe same space enables shared embodied experiences with everyone aiming for an ideal level ofintoxication. Knowing when to stop and heeding the physical signs that are hard to articulate waslinked to age, gender and experience. Women were more willing to state that particular physicalsensations led them to stop drinking, quite suddenly at times. Men may present themselves asdrinking heavily without a great deal of consideration, given that this behaviour is itself part ofhegemonic masculinity. In contrast, women may take more notice of bodily signs and sensations.Femininity has traditionally been linked to an awareness of health and the body, thus women may bemore conscious of physical changes while drinking, perhaps finding it easier to describe feelings ofintoxication and bodily sensations than men. Further, women may monitor such changes and ceasedrinking when they occur because hegemonic femininity requires women to remain in control (ensuringrespectability). However for both women and men, their own experiential and embodied knowledge wasmore important in regulating consumption during a drinking episode than health promotion advice.This research demonstrates that drinking is an embodied social practice that is both gendered andrelated to age and life stage. For these adults in mid-life, drinking with others was about markingout temporary spaces from everyday life in which they could alter their way of being in the world.This was frequently gendered; a shift from domestic work and childcare (often in addition to paidwork) for women, and from paid work for men. Furthermore, by mid-life, participants were able todraw on a history of drinking over at least a decade or two that enabled them to position themselvesas ‘experienced’ drinkers who knew their own physical bodies, how to achieve a desiredlevel of intoxication and how to sustain this level by knowing when they had passed the point of noreturn and needed to stop drinking. Embodied feelings or sensations of intoxication, and decisionsabout when to stop or moderate their drinking, were articulated in more detail by women thanmen.et al.  can act assobering moments providing a space to (re)assess one's physical state and decide to stop orslow down drinking, and may be key points for intervention strategies to focus on. Future researchmight usefully focus on alterations in environmental contexts and the cues that may facilitate thisprocess.et al. The lived meaning of embodied drinking practices cannot be divorced from gender. Women'sdrinking was more strongly associated with their emotional and relational lives and men'swith their external work lives, highlighting gendered styles of engagement with alcohol Ettorre. As gendOur exploratory findings need to be considered cautiously. We employed friendship discussiongroups to investigate both subjective embodied experience and co-constructed accounts of socialisingand drinking together. This may have encouraged discussion of embodied experiences and heightenedthe level of similarity of the topics and ideas discussed but it may also have limited thedisclosure of more personal, private or sensitive material on individual embodied experience. Futureresearch could beneficially explore the use of individual interviews or ethnographic approaches togain further insights.Embodied, gendered experiences are central to drinking practices and are important inconceptualising health behaviour as beyond the individual. We cannot fully comprehend drinking andalcohol consumption practices without the consideration of bodies and their social and culturallocation in terms of age, gender and life stage. Health promotion needs to move beyond this neglectof the body and engage with drinking as a gendered, embodied activity. Bodies are intertwined withself and culture and inextricably link the material and the discursive (Gill, Henwood, and McLean