Training Surgical Residents for Ultrasound-Guided Assessment and Management of Unstable Patients

OBJECTIVE

Proficiency in the use of ultrasound is presently not an ACGME required core competency for accredited surgical training. There should be a basic unified ultrasound curriculum for surgical trainees. We developed a multimodal ultrasound-training program to ensure baseline proficiency and readiness for clinical performance without impacting trainee duty hours.

DESIGN

We developed and implemented a multimodal curriculum for ultrasound education and its use as a supplement to clinical evaluation of unstable patients.

SETTING

A single-center study was completed in a hospital setting.

PARTICIPANTS

Post-graduate year-1 surgical residents at our institution were invited to participate in a multimodal perioperative course.

RESULTS

51 residents attended the course over the three sessions. The vignette exam as a whole demonstrated a Cronbach's alpha of 0.819 indicating good internal reliability of the entire test. There was significant improvement in their knowledge in clinical vignettes (55% ± 12.4 on pre-test vs. 83% ± 13.2% on post-test, p<0.001).

CONCLUSION

It is feasible to incorporate a focused ultrasound curriculum to assess clinically unstable patients. The multimodal nature of the course aid in the development of preclinical proficiency and decreased the orientation phase of ultrasound use.

Experimental Observation of Proton Bunch Modulation in a Plasma at Varying Plasma Densities

We give direct experimental evidence for the observation of the full transverse self-modulation of a long, relativistic proton bunch propagating through a dense plasma. The bunch exits the plasma with a periodic density modulation resulting from radial wakefield effects. We show that the modulation is seeded by a relativistic ionization front created using an intense laser pulse copropagating with the proton bunch. The modulation extends over the length of the proton bunch following the seed point. By varying the plasma density over one order of magnitude, we show that the modulation frequency scales with the expected dependence on the plasma density, i.e., it is equal to the plasma frequency, as expected from theory.

Experimental Observation of Plasma Wakefield Growth Driven by the Seeded Self-Modulation of a Proton Bunch

We measure the effects of transverse wakefields driven by a relativistic proton bunch in plasma with densities of 2.1×10^{14} and 7.7×10^{14}  electrons/cm^{3}. We show that these wakefields periodically defocus the proton bunch itself, consistently with the development of the seeded self-modulation process. We show that the defocusing increases both along the bunch and along the plasma by using time resolved and time-integrated measurements of the proton bunch transverse distribution. We evaluate the transverse wakefield amplitudes and show that they exceed their seed value (<15  MV/m) and reach over 300  MV/m. All these results confirm the development of the seeded self-modulation process, a necessary condition for external injection of low energy and acceleration of electrons to multi-GeV energy levels.

Differential susceptibility to tetracycline, oxytetracycline and doxycycline of the calf pathogens Mannheimia haemolytica and Pasteurella multocida in three growth media

For clinical isolates of bovine Mannheimia haemolytica and Pasteurella multocida, this study reports minimum inhibitory concentration (MIC) differences for tetracycline, oxytetracycline and doxycycline between cation-adjusted Mueller-Hinton broth (CAMHB), foetal bovine serum (FBS) and Roswell Park Memorial Institute (RPMI) medium. MICs were determined according to CLSI standards and additionally using five overlapping sets of twofold dilutions. Matrix effect: (a) free drug MICs and minimum bactericidal concentrations (MBC) for all drugs were significantly higher in FBS than in CAMHB for both pathogens (p < 0.001); (b) MICs and MBCs were higher for CAMHB and FBS compared to RPMI for P. multocida only. Net growth rate for P. multocida in CAMHB was significantly slower than in FBS and higher than in RPMI, correlating to MIC and MBC ranking. Drug effect: doxycycline MICs and MBCs were significantly lower (p < 0.001) in both CAMHB and FBS than tetracycline and oxytetracycline for both pathogens. Only for M. haemolytica were oxytetracycline MIC and MBC significantly lower than tetracycline, precluding the use of tetracycline to predict oxytetracycline susceptibility in this species. Determining potencies of tetracyclines in a physiological medium, such as FBS, is proposed, when the objective is correlation with pharmacokinetic data for dosage determination.

Abstract A29: The CUTO panel of patient-derived NSCLC cell lines reveals unique molecular characteristics and responses to targeted therapies

Cell lines generated from human tumors have been an invaluable tool in dissecting the underlying molecular mechanisms of cancer biology and for cancer drug development. The large library of original human lung cancer cell lines established by Minna and Gazdar, though instrumental in investigating various aspect of lung cancer biology, lacks examples of some of the diverse mutations responsible for this cancer. The CUTO (Colorado University Thoracic Oncology) cell line series, initiated in 2011, had the goal of curating a new panel of cells derived from NSCLC patients with distinct oncogenic drivers. By generating multiple, unique cell lines representing each oncogene driver subset, we believe that these lines would allow study of interpatient variability that underlie differential patient responses and duration of response to targeted therapies. The current CUTO panel consist of 33 cell lines with either 1) gene rearrangements in ALK, RET, ROS1 or NTRK1; 2) activating mutations in the ERBB gene family including exon 20 insertions in EGFR and ERBB2 (HER2) as well as rare mutations in EGFR; and 3) inactivation of the NF1 gene either as a concurrent mutation with other oncogenic alterations or as the sole driver mutation. For cells harboring gene rearrangements we have amassed four EML4-ALK lines, two KIF5B-RET cell lines, five ROS1 fusion lines (3 CD74-ROS1, 1 SDC4-ROS1, and 1 TPM3-ROS1), and one MPRIP-NTRK1 cell line. Our ERBB mutant lines include one cell line with HER2 exon 20 insertion, three lines with different exon 20 insertions in EGFR, and two EGFR mutant cell lines with compound mutations. We present our characterization of these cell lines in terms of their proliferation profiles and molecular signaling pathways in the presence of targeted inhibition. The derivation and characterization of these cell lines have facilitated the study of cell signaling in oncogene-driven cancer, have helped identify new resistance mechanisms, and have facilitated drug development for rare oncogenes such as NTRK1 gene fusions and EGFR exon 20 insertions. We expect that this growing library of cell lines will continue to further our understanding of oncogenic-driven tumor biology and provide mechanistic insight towards the development of novel therapeutics and drug combinations.

Citation Format: Anh Tuan Le, Adriana Estrada-Bernal, Laura Schubert, Andrea Doak, Nan Chen, Kurtis Davies, Aria Vaishnavi, Mary Jackson, Vignesh Narayana, Kimi Kondo, John Mitchell, Michael Weyant, Tom Purcell, Paul Bunn, Ross Camidge, Janet Freeman-Daly, Robert Doebele. The CUTO panel of patient-derived NSCLC cell lines reveals unique molecular characteristics and responses to targeted therapies [abstract]. In: Proceedings of the Fifth AACR-IASLC International Joint Conference: Lung Cancer Translational Science from the Bench to the Clinic; Jan 8-11, 2018; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(17_Suppl):Abstract nr A29.

Acceleration of electrons in the plasma wakefield of a proton bunch

High-energy particle accelerators have been crucial in providing a deeper understanding of fundamental particles and the forces that govern their interactions. To increase the energy of the particles or to reduce the size of the accelerator, new acceleration schemes need to be developed. Plasma wakefield acceleration^1–5, in which the electrons in a plasma are excited, leading to strong electric fields (so called ‘wakefields’), is one such promising acceleration technique. Experiments have shown that an intense laser pulse^6–9 or electron bunch^10,11 traversing a plasma can drive electric fields of tens of gigavolts per metre and above—well beyond those achieved in conventional radio-frequency accelerators (about 0.1 gigavolt per metre). However, the low stored energy of laser pulses and electron bunches means that multiple acceleration stages are needed to reach very high particle energies^5,12. The use of proton bunches is compelling because they have the potential to drive wakefields and to accelerate electrons to high energy in a single acceleration stage¹³. Long, thin proton bunches can be used because they undergo a process called self-modulation^14–16, a particle–plasma interaction that splits the bunch longitudinally into a series of high-density microbunches, which then act resonantly to create large wakefields. The Advanced Wakefield (AWAKE) experiment at CERN^17–19 uses high-intensity proton bunches—in which each proton has an energy of 400 gigaelectronvolts, resulting in a total bunch energy of 19 kilojoules—to drive a wakefield in a ten-metre-long plasma. Electron bunches are then injected into this wakefield. Here we present measurements of electrons accelerated up to two gigaelectronvolts at the AWAKE experiment, in a demonstration of proton-driven plasma wakefield acceleration. Measurements were conducted under various plasma conditions and the acceleration was found to be consistent and reliable. The potential for this scheme to produce very high-energy electron bunches in a single accelerating stage²⁰ means that our results are an important step towards the development of future high-energy particle accelerators^21,22.

Electron acceleration to very high energies is achieved in a single step by injecting electrons into a ‘wake’ of charge created in a 10-metre-long plasma by speeding long proton bunches.

Surgical Management of Pulmonary Mycobacterial Disease

There is renewed interest in the use of adjuvant surgical resection in the treatment of pulmonary mycobacterial disease. For pulmonary Mycobacterium tuberculosis, the emergence of significant drug resistance has led clinicians to reconsider surgery in select cases, where a clear benefit in bacterial conversion and cure has been noted. Less data exist for the use of anatomic resection in the setting of pulmonary nontuberculous mycobacterial disease, although multiple reports have supported the use of surgery in select cases. Resection is generally well tolerated, and may often be performed through a minimally invasive approach. While medical treatment clearly remains the mainstay of therapy, more research is needed regarding the use of adjuvant resection in this patient population.

Reduction of enthalpy relaxation in gelatine films by addition of polyols

The aim of this study was to evaluate the effect of plasticisers with different molecular weights (glycerol and sorbitol) on the structural relaxation kinetics of bovine gelatine films stored under the glass transition temperature (Tg). Plasticisers were tested at weight fractions of 0.0, 0.06 and 0.10. Films conditioned in environments under ∼44% relative humidity gave moisture contents (w/w) in the range 0.14-0.18. The enthalpy relaxation (ΔH) was determined using differential scanning calorimetry (DSC). Samples used had Tg values in the range 24-49 °C. After removing the thermal history (30 °C above Tg, 15 min), samples were isothermally stored at 10 °C below Tg for between 2 and 80 h. The addition of plasticisers induced a significant reduction in the rate of structural relaxation. The linearisation of ΔH by plotting against the logarithm of ageing time showed a reduction in the slope of samples plasticised with both polyols. The reduction in relaxation kinetics may be related to the ability of polyols to act as enhancers of molecular packing, as recently reported using positron spectroscopy (PALS). However, a direct correlation between the relaxation kinetics and the plasticiser's molecular weight could not be established, suggesting that this phenomenon may be governed by complex molecular gelatin-plasticiser-water interactions.

Experimental demonstration of multi-Gbps multi sub-bands FBMC transmission in mm-wave radio over a fiber system

The filter bank multicarrier (FBMC) modulation format is considered as a potential candidate for future wireless 5G due to its feature of high suppression for out-of-band emissions, which allows combining multiple sub-bands with very narrow band-gaps, and hence increases the overall wireless transmission capacity. In this paper, we experimentally demonstrate the generation of multi sub-bands FBMC signals at millimeter-wave (mm-wave) for radio-over-fiber (RoF) systems. The designed multi sub-bands FBMC system consists of 5 sub-bands of 800 MHz with inter sub-band gaps of 781.25 kHz. The composite 5 sub-bands FBMC signal is generated with no band-gap between dc to the first sub-band to preserve the bandwidth of the system. Each FBMC sub-band consists of 1024 sub-carriers and is modulated with uncorrelated data sequences. The aggregate FBMC signal is carried optically by externally modulating a free running laser and is converted to millimeter waves (mm-waves) by photomixing with another free running laser at a frequency offset of 53 GHz. At the receiver, the received electrical mm-wave signal is down-converted to an intermediate frequency (IF) and then post-processed using digital signal processing (DSP) techniques. With the use of the simple recursive least square (RLS) equalizer in the DSP receiver, the achieved aggregate data rate is 8 Gbps and 12 Gbps for 16 quadrature amplitude modulation (QAM), and 64 QAM, respectively with a total bandwidth of 4.2 GHz. The system performance is evaluated by measuring error vector magnitude (EVM) and bit error rate (BER) calculations.

Kin discrimination via odour in the cooperatively breeding banded mongoose

Kin discrimination is often beneficial for group-living animals as it aids in inbreeding avoidance and providing nepotistic help. In mammals, the use of olfactory cues in kin discrimination is widespread and may occur through learning the scents of individuals that are likely to be relatives, or by assessing genetic relatedness directly through assessing odour similarity (phenotype matching). We use scent presentations to investigate these possibilities in a wild population of the banded mongoose Mungos mungo, a cooperative breeder in which inbreeding risk is high and females breed communally, disrupting behavioural cues to kinship. We find that adults show heightened behavioural responses to unfamiliar (extra-group) scents than to familiar (within-group) scents. Interestingly, we found that responses to familiar odours, but not unfamiliar odours, varied with relatedness. This suggests that banded mongooses are either able to use an effective behavioural rule to identify likely relatives from within their group, or that phenotype matching is used in the context of within-group kin recognition but not extra-group kin recognition. In other cooperative breeders, familiarity is used within the group and phenotype matching may be used to identify unfamiliar kin. However, for the banded mongoose this pattern may be reversed, most likely due to their unusual breeding system which disrupts within-group behavioural cues to kinship.

Sleep and quality of life of patients with glycogen storage disease on standard and modified uncooked cornstarch

BACKGROUND

Glycemic control in hepatic glycogen storage diseases (GSDs) relies on specific nutritional recommendations, including strict avoidance of a fasting period. Uncooked cornstarch (UCCS) is an important therapeutic component. A new modified UCCS, Glycosade™, was created with the objective of prolonging euglycemia. We aimed to determine the length of euglycemia on Glycosade™ using a continuous glucose monitor (CGM) and to evaluate whether longer euglycemia and thus less nighttime interruptions would improve sleep and quality of life (QoL) after the introduction of the modified cornstarch.

METHODS

We conducted a prospective cohort study to assess quality and quantity of sleep and quality of life (QoL) in patients with GSDs on standard UCCS and after the introduction of Glycosade™. Sleep and QoL evaluation was done for patients using validated questionnaires, a standardized sleep diary and actigraphy. Length of fast and glucose variability were determined with CGM.

RESULTS

Nine adults with GSD Ia took part in the study. Glycosade™ introduction was done under close supervision during a hospital admission. Comparison of sleep in 9 patients showed sleep disturbances on standard UCCS that were improved with Glycosade™. QoL was normal both pre and post Glycosade™. The CGM confirmed maintenance of a longer fasting period with Glycosade™ at home.

CONCLUSION

Glycosade™ represents an alternative option for GSD patients. We showed possible benefits in terms of sleep quality. We also confirmed the longer length of fast on Glycosade™.

SYNOPSIS

A new modified form of uncooked starch for patients with glycogen storage disease represents an alternative option as it showed a longer length of fast and improvements in sleep quality.