An Embedded Curriculum to Teach Critical Incident Debriefing to Internal Medicine Residents

Background Internal medicine residents frequently experience distressing clinical events; critical event debriefing is one tool to help mitigate their effects. Objective To evaluate the effectiveness of a 1-hour workshop teaching residents a novel, efficient approach to leading a team debrief after emotionally charged clinical events. Methods An internal needs assessment identified time and confidence as debriefing barriers. In response, we created the STREAM (Structured, Timely, Reflection, tEAM-based) framework, a 15-minute structured approach to leading a debrief. Senior residents participated in a 1-hour workshop on the first day of an inpatient medicine rotation to learn the STREAM framework. To evaluate learning outcomes, participants completed the same survey immediately before and after the session, and at the end of their 4-week rotation. Senior residents at another site who did not complete the workshop also evaluated their comfort leading debriefs. Results Fifty out of 65 senior residents (77%) participated in the workshop. After the workshop, participants felt more prepared to lead debriefs, learned a structured format for debriefing, and felt they had enough time to lead debriefs. Thirty-four of 50 (68%) workshop participants and 20 of 41 (49%) comparison residents completed the end-of-rotation survey. Senior residents who participated in the workshop were more likely than nonparticipants to report feeling prepared to lead debriefs. Conclusions A brief workshop is an effective method for teaching a framework for leading a team debrief.

Hind feet position score: A novel trait to genetically reduce lameness incidence

Lameness is an important health and welfare issue that causes considerable economic losses in dairy herds. The objective of this study was to investigate whether the hind feet position score (HFPS) can be used as an auxiliary trait for genetic evaluation of lameness. The HFPS is evaluated by visual scoring of the position of both the hind-digits to the mid-line of the cow's body. The higher the heel height of the lateral claw, the higher is the HFPS, and the higher is the risk for development of lameness. In total, 3,478 records from 1,064 Fleckvieh cows from 35 farms were obtained between September 1, 2021, and March 5, 2022. Data collection was carried out by the regional milk recording organizations. Hind feet position was scored visually by trained personnel during routine milk performance testing in the milking parlor using a 3-class scoring system: score 1 = 0° to <17° indicating a balanced heel height of both the medial and the lateral claw; score 2 = angle of 17° to 24°; score 3 = angle of >24°. After all cows had been milked, locomotion scoring was performed for each animal using a 5-class scoring system with locomotion scores ranging between 1 (normal) and 5 (severely lame). Using HFPS, sensitivity and specificity were 69.5% and 66.8%, respectively, for detecting lameness defined by locomotion score ≥2. For genetic analyses, a bivariate linear animal model was fitted with fixed effects of herd, parity, lactation stage, and classifier, and random effects of animal and permanent environment. Heritabilities for HFPS and locomotion score were 0.07 and 0.10, respectively, and the genetic correlation between the 2 traits studied was 0.80. These results suggest that the HFPS could be used for genetic evaluations to reduce lameness incidence in dairy cattle.

Death Certification: An Interactive Teaching Session

INTRODUCTION

Documentation of the cause of death is important for local and national epidemiology as well as for research and public health funding allocation. Despite this, many physicians lack the skills necessary to accurately complete a death certificate.

METHODS

We created a 45-minute virtual workshop to improve skills in completing death certificates. Participants examined the role of death certificates in disease epidemiology and resource allocation for research and public health interventions, reviewed the components of a death certificate, and practiced correcting and filling out death certificates from actual patient cases. To assess the workshop, participants completed sample death certificates immediately before and after the workshop for two representative cases.

RESULTS

Thirty-six internal medicine residents (17 PGY 1s, 12 PGY 2s, and seven PGY 3s) completed the workshop. Prior to the workshop, 89% of the sample death certificates contained one or more errors, compared with 46% postworkshop. Major errors, such as incorrect categorization of a cause of death, decreased from 58% preworkshop to 17% postworkshop. Learners expressed discomfort after realizing they had made errors in completing previous death certificates and noted a desire for continuing education and reference materials on this topic.

DISCUSSION

Death certification is a key competency for physicians. Our virtual workshop improved participants' skills in completing death certificates. Although a significant number of errors remained after the workshop, most of these residual errors were minor and would not affect cause-of-death reporting. The durability of these improvements over time requires further study.

A Pt(IV)-conjugated brain penetrant macrocyclic peptide shows pre-clinical efficacy in glioblastoma

Glioblastoma (GBM) is the most aggressive primary malignant brain tumor, with a median survival of approximately 15 months. Treatment is limited by the blood-brain barrier (BBB) which restricts the passage of most drugs to the brain. We previously reported the design and synthesis of a BBB-penetrant macrocyclic cell-penetrating peptide conjugate (M13) covalently linked at the axial position of a Pt(IV) cisplatin prodrug. Here we show the Pt(IV)-M13 conjugate releases active cisplatin upon intracellular reduction and effects potent in vitro GBM cell killing. Pt(IV)-M13 significantly increased platinum uptake in an in vitro BBB spheroid model and intravenous administration of Pt(IV)-M13 in GBM tumor-bearing mice led to higher platinum levels in brain tissue and intratumorally compared with cisplatin. Pt(IV)-M13 administration was tolerated in naïve nude mice at higher dosage regimes than cisplatin and significantly extended survival above controls in a murine GBM xenograft model (median survival 33 days for Pt(IV)-M13 vs 24 days for Pt(IV) prodrug, 22.5 days for cisplatin and 22 days for control). Increased numbers of γH2AX nuclear foci, biomarkers of DNA damage, were observed in tumors of Pt(IV)-M13-treated mice, consistent with elevated platinum levels. The present work provides the first demonstration that systemic injection of a Pt(IV) complex conjugated to a brain-penetrant macrocyclic peptide can lead to increased platinum levels in the brain and extend survival in mouse GBM models, supporting further development of this approach and the utility of brain-penetrating macrocyclic peptide conjugates for delivering non-BBB penetrant drugs to the central nervous system.

Deliberate practices of speaking up and responding skills: the Speak-PREP e-learning module for healthcare professionals

Purpose

Speaking up and responding to others’ concerns promotes patient safety. We describe health professionals’ utilisation of these important skills.

Method

We developed an interactive e-learning module, Speak-PREP, to train healthcare professionals in speaking up and responding strategies. Participants completed interactive video-based exercises that engaged them with entering speaking up and responding statements, augmenting strategies from a list of prompting phrases and responding to a pushback. We report strategy utilisation.

Results

A total of 101 health professionals completed Speak-PREP training. Most frequently used speaking up strategies were: brainstorming to explore solutions (50%), showing consideration of others (45%) and encouraging others’ opinions through invitations (43%). Responding strategies included reflecting the concern expressed by colleagues, discussing next steps and expressing gratitude (70%, 67% and 50%, respectively). When prompted, participants augmented their statements with reframing concerns, asking questions to deepen understanding, using how or what to start questions and expressing curiosity (p<0.00001, p=0.003, p=0.0002 and p<0.0001, respectively). Pushbacks lead to increased use of reflecting the concern and decreasing consideration, curiosity, empathy, expressing gratitude and encouraging others’ opinions (p<0.05 for all).

Conclusions

The Speak-PREP module targeted deliberate practice in speaking up and responding skills. Future work should examine the application of these strategies in the clinical environment.

Baseline low ALT activity is associated with increased long-term mortality after COPD exacerbations

BACKGROUND

COPD exacerbations have negative impact on patients' survival. Several risk factors for grave outcomes of such exacerbations have been descried. Muscle dysfunction and mass loss were shown to impact negatively on prognosis and survival. Low activity of the enzyme ALT (Alanine amino-transferase) in the blood is a known indicator for sarcopenia and frailty, however, no previous studies addressed the association of low ALT amongst patients hospitalized due to COPD exacerbation and long-term survival.

METHODS

This is a historic prospective cohort study of patients hospitalized due to acute COPD exacerbation.

RESULTS

Included were 232 consecutive COPD exacerbation patients. The median time of follow-up was 34.9 months (IQR 23.13-41.73 months). During this period 104 (44.8%) patients died. All patients were grouped to quartiles according to blood ALT levels (after exclusion of cases considered to have hepatic tissue damage (ALT > 40 IU)). The risk of long-term mortality increased, in a statistically significant manner, amongst patients with low ALT values: the median survival of patients with ALT < 11 IU was 18.5 months only while the median survival for the rest of the study group was not reached. For ALT < 11 IU; 12-16 IU; 17-20 IU and > 21 IU the mortality rates were 69%; 40.9%; 36.3 and 25% respectively (p <  0.001 for comparison of lower quartile with upper three quartiles). The crude hazard ratio for mortality amongst patients with ALT levels lower than 11 IU was 2.37 (95% CI; 1.6-3.5). This increased risk of mortality remained significant after adjustment for age, weight, creatinine, albumin concentration and cardiovascular diseases (HR = 1.83; 95% CI 1.08-3.1, p <  0.05).

CONCLUSIONS

Low ALT values, a biomarker of sarcopenia and frailty, are associated with poor long-term survival amongst patients hospitalized due to COPD exacerbation.

Distress related to attenuated psychotic symptoms: Static and dynamic association with transition to psychosis, non-remission and transdiagnostic symptomatology in clinical high-risk patients in an international intervention trial

This study examined whether distress in relation to attenuated psychotic symptoms (DAPS) is associated with clinical outcomes in an ultra-high-risk (UHR) for psychosis sample. We also investigated whether DAPS is associated with cognitive style (attributional style and cognitive biases) and whether amount of psychosocial treatment provided is associated with reduction in DAPS. The study was a secondary analysis of the ‘Neurapro’ clinical trial of omega-3 fatty acids. 304 UHR patients were recruited across ten early intervention services. Data from baseline assessment, regular assessments over 12 months and medium term follow up (mean=3.4 years) were used for analysis. Findings indicated: a positive association between DAPS assessed over time and transition to psychosis; a significant positive association between baseline and longitudinal DAPS and transdiagnostic clinical and functional outcomes; a significant positive association between baseline and longitudinal DAPS and non-remission of UHR status. There was no relationship between severity of DAPS and cognitive style. A greater amount of psychosocial treatment (cognitive-behavioural case management) was associated with an increase in DAPS scores. The study indicates that UHR patients who are more distressed by their attenuated psychotic symptoms are more likely to have a poorer clinical trajectory transdiagnostically. Assessment of DAPS may therefore function as a useful marker of risk for a range of poor outcomes. The findings underline the value of repeated assessment of variables and incorporation of dynamic change into predictive modelling. More research is required into mechanisms driving distress associated with symptoms and the possible bidirectional relationship between symptom severity and associated distress.

Basic symptoms in young people at ultra-high risk of psychosis: Association with clinical characteristics and outcomes

There has been limited research into the predictive value of basic symptoms and their relationship with other psychopathology in patients identified using the 'ultra high risk' (UHR) for psychosis approach. The current study investigated whether basic symptoms, specifically cognitive disturbances (COGDIS), were associated with a greater risk of transition to psychotic disorder and persistent attenuated psychotic symptoms (APS) at medium term follow-up (mean = 3.4 years) in UHR patients, as well as with general psychopathology at baseline. The sample included 304 UHR participants (mean age = 19.12 years) involved in an international multicenter trial of omega-3 fatty acids. UHR individuals who also met the COGDIS criteria (basic symptoms risk criteria) did not have a greater risk of transition than those who met the UHR criteria alone. However, meeting COGDIS risk criteria was associated with a greater likelihood of meeting the UHR attenuated psychotic symptoms risk group (i.e., having persistent attenuated psychotic symptoms) at 12-month follow-up (odds ratio = 1.85; 95% CI = 1.03, 3.32). Greater severity of cognitive basic symptoms was also independently associated with more severe general psychopathology at study entry. The findings do not support the notion that combined risk identification approaches (UHR and basic symptoms) aid in the identification of individuals at greatest risk of psychosis, although this interpretation is limited by the modest transition to psychosis rate (13%) and the time of follow up. However, the findings indicate that basic symptoms may be a clinically useful marker of more severe general psychopathology in UHR groups and risk for persistent attenuated psychotic symptoms.

Dynamic prediction of transition to psychosis using joint modelling

Considerable research has been conducted seeking risk factors and constructing prediction models for transition to psychosis in individuals at ultra-high risk (UHR). Nearly all such research has only employed baseline predictors, i.e. data collected at the baseline time point, even though longitudinal data on relevant measures such as psychopathology have often been collected at various time points. Dynamic prediction, which is the updating of prediction at a post-baseline assessment using baseline and longitudinal data accumulated up to that assessment, has not been utilized in the UHR context. This study explored the use of dynamic prediction and determined if it could enhance the prediction of frank psychosis onset in UHR individuals. An emerging statistical methodology called joint modelling was used to implement the dynamic prediction. Data from the NEURAPRO study (n = 304 UHR individuals), an intervention study with transition to psychosis study as the primary outcome, were used to investigate dynamic predictors. Compared with the conventional approach of using only baseline predictors, dynamic prediction using joint modelling showed significantly better sensitivity, specificity and likelihood ratios. As dynamic prediction can provide an up-to-date prediction for each individual at each new assessment post entry, it can be a useful tool to help clinicians adjust their prognostic judgements based on the unfolding clinical symptomatology of the patients. This study has shown that a dynamic approach to psychosis prediction using joint modelling has the potential to aid clinicians in making decisions about the provision of timely and personalized treatment to patients concerned.

Robust Process Control for Rubber Injection Moulding with Use of Systematic Simulations and Improved Material Data

The heating phase is by far the most time-consuming part of rubber injection moulding. The determination of a suitable curing time is difficult despite extensive injection moulding trials, since in many cases the quality of a part, such as its degree of vulcanisation which is often visually detectable only where there is significant undercure (Figure 1a), cannot be assessed without closer examination (Figure 1b). Systematic injection moulding simulation with Varimos presents an effective solution because the Varimos methodology allows virtual detection of the impacts of process parameters and their interactions, as well as visualisation of e.g. impending undercure (Figure 1c). It therefore enables part, mould and process to be optimised automatically to the desired quality criteria. As a result, it is possible not only to save valuable machine time, which would otherwise be taken up for process development, but also to define the processing window more precisely and thus to improve the economic efficiency of the process while at the same time ensuring the necessary process stability. This was successfully investigated and demonstrated using a thick-walled test piece during the RubSim project at the Polymer Competence Center Leoben GmbH in collaboration with the Injection Moulding of Polymers Group of the University of Leoben and the industrial partners SKF Sealing Solutions Austria GmbH, Engel Austria GmbH, Simcon kunststofftechnische Software GmbH and Dr. Gierth Ingenieurgesellschaft mbH.

Metabolic control of type 1 diabetes in youth with autism spectrum disorder: A multicenter Diabetes-Patienten-Verlaufsdokumentation analysis based on 61 749 patients up to 20 years of age

BACKGROUND

A paucity of reports in the literature exists concerning the co-existence between autism spectrum disorder (ASD) and type 1 diabetes (T1D).

OBJECTIVE

To compare clinical characteristics, diabetes management and metabolic control in youth with T1D and ASD (T1D-ASD) with youth without ASD (T1D-non ASD).

METHODS

Using the German/Austrian diabetes patient follow-up registry, this study analyzed aggregated data from the last available year of observation for each patient with T1D, ages 1-20 with consistent data on insulin regimen and glycated hemoglobin (A1C), between January, 2005 and March, 2017.

RESULTS

From 61 749 patients, 150 (0.24%) were identified as T1D-ASD. Non-adjusted comparisons showed similar results for mean age at onset and duration of diabetes, but not for gender (male: T1D-ASD: 85.3%; T1D-non ASD: 52.8%; P < .001). Unadjusted comparisons showed no difference for severe hypoglycemia, diabetic ketoacidosis, insulin doses, insulin pump therapy, and body mass index. A statistical difference was observed for A1C (P-value .01) and in the number of blood glucose (SMBG) tests/day (median [interquartile range]: T1D-ASD 6.0 [4.4-7.0]; T1D-non ASD 5.0 [4.4-7.0]; P-value < .001). After adjusting for age, gender, duration of diabetes, and year of observation, only SMBG remained significant (P-value .003). T1D-ASD used psycho-stimulants (15.3% vs 2.2%; P-value < .001), antipsychotics (10.7% vs 0.6%; P-value < .001), and antidepressive medications (3.6% vs 0.7%; P-value < .001) more frequently.

CONCLUSION

Metabolic control was similar in the T1D-ASD group compared to T1D-non ASD despite their comorbidity. Awareness of ASD remains important in T1D treatment, as both conditions require long-term multi-disciplinary medical follow-up for optimal outcomes.

NEURAPRO: a multi-centre RCT of omega-3 polyunsaturated fatty acids versus placebo in young people at ultra-high risk of psychotic disorders-medium-term follow-up and clinical course

This study reports a medium-term follow-up of a randomised, double-blind, placebo-controlled trial of omega-3 polyunsaturated fatty acids (PUFA) in ultra-high risk for psychosis (UHR) patients. Primary outcomes of interest were transition to psychosis and symptomatic and functional outcome. A secondary aim was to investigate clinical predictors of medium-term outcome. Three hundred four UHR participants were recruited across 10 specialised early psychosis services in Australia, Asia, and Europe. The intervention consisted of 1.4 g/daily of omega-3 PUFA or placebo, plus up to 20 sessions of cognitive-behavioural case management (CBCM), over the 6-month study period, with participants receiving further CBCM sessions on basis of need between months 6-12. Mean time to follow-up was 3.4 (median = 3.3; SD = 0.9) years. There was a modest increase in transitions between 12-month and medium-term follow-up (11-13%) and substantial improvement in symptoms and functioning between baseline and follow-up, with no differences between the treatment groups. Most improvement had been achieved by end of the intervention. 55% of the sample received mental health treatment between end of intervention and follow-up. Omega-3 PUFA did not provide additional benefits to good quality psychosocial intervention over the medium term. Although most improvement had been achieved by end of intervention the substantial rates of post-intervention mental health service use indicate longer-term clinical need in UHR patients. The post-intervention phase treatment or the longer-term effect of CBCM, or a combination of the two, may have contributed to maintaining the gains achieved during the intervention phase and prevented significant deterioration after this time.

Lithium suppression of tau induces brain iron accumulation and neurodegeneration

Lithium is a first-line therapy for bipolar affective disorder. However, various adverse effects, including a Parkinson-like hand tremor, often limit its use. The understanding of the neurobiological basis of these side effects is still very limited. Nigral iron elevation is also a feature of Parkinsonian degeneration that may be related to soluble tau reduction. We found that magnetic resonance imaging T₂ relaxation time changes in subjects commenced on lithium therapy were consistent with iron elevation. In mice, lithium treatment lowers brain tau levels and increases nigral and cortical iron elevation that is closely associated with neurodegeneration, cognitive loss and parkinsonian features. In neuronal cultures lithium attenuates iron efflux by lowering tau protein that traffics amyloid precursor protein to facilitate iron efflux. Thus, tau- and amyloid protein precursor-knockout mice were protected against lithium-induced iron elevation and neurotoxicity. These findings challenge the appropriateness of lithium as a potential treatment for disorders where brain iron is elevated (for example, Alzheimer's disease), and may explain lithium-associated motor symptoms in susceptible patients.

Triple-stimuli responsive polymers with fine tuneable magnetic responses

The formation of multi-stimuli responsive polymers exhibiting magnetic, pH and light sensitivity is reported.

Halogen bonding in a multi-connected 1,2,2-triiodo-alkene involving geminal and/or vicinal iodines: a crystallographic and DFT study

Four halogen-bonded organizations of a 1,2,2-triiodo-alkene involving geminal and/or vicinal iodine atoms were studied both by X-ray diffraction and density functional theory (DFT).

CITED2-mediated human hematopoietic stem cell maintenance is critical for acute myeloid leukemia

As the transcriptional coactivator CITED2 (CBP/p300-interacting-transactivator-with-an ED-rich-tail 2) can be overexpressed in acute myeloid leukemia (AML) cells, we analyzed the consequences of high CITED2 expression in normal and AML cells. CITED2 overexpression in normal CD34(+) cells resulted in enhanced hematopoietic stem and progenitor cell (HSPC) output in vitro, as well as in better hematopoietic stem cell (HSC) engraftability in NSG (NOD.Cg-Prkdcscid Il2rgtm1Wjl/SzJ) mice. This was because of an enhanced quiescence and maintenance of CD34(+)CD38(-) HSCs, due in part to an increased expression of the cyclin-dependent kinase inhibitor CDKN1A. We demonstrated that PU.1 is a critical regulator of CITED2, as PU.1 repressed CITED2 expression in a DNA methyltransferase 3A/B (DNMT3A/B)-dependent manner in normal CD34(+) cells. CD34(+) cells from a subset of AML patients displayed higher expression levels of CITED2 as compared with normal CD34(+) HSPCs, and knockdown of CITED2 in AML CD34(+) cells led to a loss of long-term expansion, both in vitro and in vivo. The higher CITED2 expression resulted from reduced PU.1 activity and/or dysfunction of mutated DNMT3A/B. Collectively, our data demonstrate that increased CITED2 expression results in better HSC maintenance. In concert with low PU.1 levels, this could result in a perturbed myeloid differentiation program that contributes to leukemia maintenance.

Diagenesis and clay mineral formation at Gale Crater, Mars

The Mars Science Laboratory rover Curiosity found host rocks of basaltic composition and alteration assemblages containing clay minerals at Yellowknife Bay, Gale Crater. On the basis of the observed host rock and alteration minerals, we present results of equilibrium thermochemical modeling of the Sheepbed mudstones of Yellowknife Bay in order to constrain the formation conditions of its secondary mineral assemblage. Building on conclusions from sedimentary observations by the Mars Science Laboratory team, we assume diagenetic, in situ alteration. The modeling shows that the mineral assemblage formed by the reaction of a CO₂-poor and oxidizing, dilute aqueous solution (Gale Portage Water) in an open system with the Fe-rich basaltic-composition sedimentary rocks at 10-50°C and water/rock ratio (mass of rock reacted with the starting fluid) of 100-1000, pH of ∽7.5-12. Model alteration assemblages predominantly contain phyllosilicates (Fe-smectite, chlorite), the bulk composition of a mixture of which is close to that of saponite inferred from Chemistry and Mineralogy data and to that of saponite observed in the nakhlite Martian meteorites and terrestrial analogues. To match the observed clay mineral chemistry, inhomogeneous dissolution dominated by the amorphous phase and olivine is required. We therefore deduce a dissolving composition of approximately 70% amorphous material, with 20% olivine, and 10% whole rock component.

"Not so fast!" the complexity of attempting to decrease door-to-floor time for emergency department admissions

BACKGROUND

Successful quality improvement is fundamental to high-performing health care systems, but becomes increasingly difficult as systems become more complex. Previous attempts at the University of California, San Francisco (UCSF) Medical Center to reduce door-to-floor (D2F) time -the time required to move an ill patient through the emergency department (ED) to an appropriate inpatient bed-had not resulted in meaningful improvement. An analysis of why attempts at decreasing D2F times in the ED had failed, with attention to contextual factors, yields recommendations on how to decrease D2F time.

METHODS

A team of 11 internal medicine residents, in partnership with the Patient Flow Executive Steering Committee, performed a literature review, process mapping, and analysis of the admissions process. The team conducted interviews with medical center staff across disciplines, members of high-performing patient care units, and leaders of peer institutions who had undertaken similar efforts.

FINDINGS AND RECOMMENDATIONS

Each of the following three domains-(1) Improving Work Flow, (2) Changing Culture, and (3) Understanding Incentives-is independently an important source of resistance and opportunity. However, the improvement work and understanding of complexity science suggest that all three domains must be addressed simultaneously to effect meaningful change. Recommendations include eliminating redundant and frustrating processes; encouraging multidisciplinary collaboration; fostering trust between departments; providing feedback on individual performance; enhancing provider buy-in; and, ultimately, uniting staff behind a common goal.

CONCLUSION

By conceptualizing the hospital as a complex adaptive system, multiple interrelated groups can be encouraged to work together and accomplish a common goal.

Mineralogy of a mudstone at Yellowknife Bay, Gale crater, Mars

Sedimentary rocks at Yellowknife Bay (Gale crater) on Mars include mudstone sampled by the Curiosity rover. The samples, John Klein and Cumberland, contain detrital basaltic minerals, calcium sulfates, iron oxide or hydroxides, iron sulfides, amorphous material, and trioctahedral smectites. The John Klein smectite has basal spacing of ~10 angstroms, indicating little interlayer hydration. The Cumberland smectite has basal spacing at both ~13.2 and ~10 angstroms. The larger spacing suggests a partially chloritized interlayer or interlayer magnesium or calcium facilitating H2O retention. Basaltic minerals in the mudstone are similar to those in nearby eolian deposits. However, the mudstone has far less Fe-forsterite, possibly lost with formation of smectite plus magnetite. Late Noachian/Early Hesperian or younger age indicates that clay mineral formation on Mars extended beyond Noachian time.

Soil diversity and hydration as observed by ChemCam at Gale crater, Mars

The ChemCam instrument, which provides insight into martian soil chemistry at the submillimeter scale, identified two principal soil types along the Curiosity rover traverse: a fine-grained mafic type and a locally derived, coarse-grained felsic type. The mafic soil component is representative of widespread martian soils and is similar in composition to the martian dust. It possesses a ubiquitous hydrogen signature in ChemCam spectra, corresponding to the hydration of the amorphous phases found in the soil by the CheMin instrument. This hydration likely accounts for an important fraction of the global hydration of the surface seen by previous orbital measurements. ChemCam analyses did not reveal any significant exchange of water vapor between the regolith and the atmosphere. These observations provide constraints on the nature of the amorphous phases and their hydration.

Surgery of a cyanotic heart defect in an 11-year-old boy with thrombocytopenic thrombocytopathy and severe anemia due to a GATA-1 defect: hemostatic therapy

A child was admitted to our hospital for repair of a ventricular septal defect (VSD) characterized by a predominantly right-to-left shunt and a severe stenosis of the right ventricular outflow tract (Tetralogy of Fallot). Severe congenital anemia (hemoglobin 72 g/L), thrombocytopenia (42×G/L) and profound platelet dysfunction led a stem cell defect to be suspected. X-linked thrombocytopenia (GATA-1 mutation) was diagnosed. GATA-1 defect may complicate medical interventions due to excessive bleeding and partial or complete bone marrow failure. Maintaining a platelet count of 100 G/L and a maximal clot firmness (EXTEM-MCF) >50 mm allowed repair of the congenital heart defect without bleeding or hematological complications. Anemia and thrombocytopenia persisted after cardiac surgery, while the spontaneous bleeding tendency improved.

Structural and spectroscopic characterization of a series of potassium- and/or sodium-substituted β-tricalcium phosphate

In this paper, we report X-ray diffraction investigations as well as Raman and solid-state (31)P and (23)Na magic angle spinning nuclear magnetic resonance (NMR) characterization of three series of calcium orthophosphates. The general formulae of the studied compounds are Ca(10.5-x/2)M(x)(PO(4))(7), where M=K or Na and x=0, 0.25, 0.50, 0.75, 1.0; and Ca(10)K(x)Na(1-x)(PO(4))(7), where x=0, 0.25, 0.5, 0.75, 1.0. These calcium orthophosphates are found to be isostructural with β-tricalcium phosphate (β-TCP, Ca(3)(PO(4))(2)) with the substitution of some calcium sites by potassium and/or sodium cations. The unit cell parameters vary continuously with the level of substitution, a characteristic of these solid solutions. The Raman spectra show the different vibrational bands of the phosphate groups PO(4), while the NMR chemical shifts are sensitive to the non-equivalent phosphorus and sodium ions present in these substituted samples. As both Raman and NMR spectroscopies are local probes, they offer tools to distinguish between these different phosphorus and phosphate groups, according to their structural site and local environment, especially the type of cation substituent. A convenient decomposition of the Raman and NMR spectra into Gaussian-Lorentzian components leads us to propose an assignment of the main observed bands of these substituted β-TCPs.

Stage dependant effect of omega-3 fatty acids in emerging psychosis

Omega-3 fatty acid supplementation studies are inconclusive. We performed two intervention studies. The first study (Berger et al 2007) was a double blind, placebo-controlled randomized trial comparing 2 g Ethyl-eicosapentaenoic acid (EPA) versus placebo in addition to antipsychotic medication in 79 first episode psychosis patients. Mixed model analysis suggests that EPA augmented first episode psychosis patients respond quicker compared to placebo for time to response (p = 0.06). Post hoc analysis for cumulative response rates confirm a higher response rate at week 6 (42.9% versus 17.6% for all subjects, p = .036; 54,2% versus 17.2% for non-affective psychosis, p = .008) that was not significant anymore at week 12 (potential ceiling effect). In the second study (Amminger et al, 2010) using 840 mg EPA and 700 mg docosahexaenoic acid per day as sole treatment in 81 prodromal adolescents only 1 of 38 UHR adolescents (2.6%) in the EPA/DHA group compared to 8 of 38 (21.1%) prodromal adolescents in the placebo group met exit criteria for psychotic disorder (Chi-square Fisher's exact test =6.2, df = 1, p = 0.028; OR = 9.9). The change from baseline on the PANSS total symptom score (p = 0.006), and the GAF score (p = 0.025) were also significant between the treatment groups showing a clinically relevant advantage of EPA/DHA over placebo. Stage of illness may be more relevant for the use of the benign treatments such as omega-3 fatty acids in emerging psychosis and explain previous inconclusive findings. Research designs for future omega-3 fatty acid intervention trials and potential pitfalls will be discussed.

N-3 Fatty Acid Supplementation Influences Membrane Fatty Acids and Phospholipase A2 Activity in Patients at Risk to Develop Psychosis

Introduction

Decreased levels of polyunsaturated membrane fatty acids (PUFA) and increased activity of cytosolic phospholipase A2 (PLA2) enzymes (key regulating enzymes of membrane remodelling and PUFA availability) are supporting pillars of the “membrane phospholipids concept of schizophrenia”. Assuming that membrane PUFA profile and PLA2 activity are altered during the at risk phase of disorder and influenced by fatty acid supplementation, we investigated PUFA profiles and PLA2 activity simultaneously in ultra high-risk (UHR) subjects before and after (n-3) fatty acids supplementation.

Method

In 81 UHR patients (aged between 13 and 25 years) PUFA levels were assessed in erythrocyte membranes using gas chromatography, and cytosolic PLA2 activity was measured in blood serum using a fluorometric HPTLC-based assay. Measurements were performed before and after a 6 month interval of placebo-controlled supplementation with n-3 fatty acids.

Results

At baseline significant associations were found between (n-9) and (n-6)-PUFA levels and psychopathology (especially in negative symptoms) assessed by the PANSS according to PACE criteria. (n-3)-PUFA supplementation caused significant changes in (n-3)- and (n-6)-PUFA levels and a significant decrease of PLA2 activity.

Conclusion

Our results support associations between membrane biochemistry and psychopathology (especially negative symptoms) in people at risk to develop psychosis. Supplementation of n-3 PUFA increases PUFA availability at membrane level and modulates membrane repair and remodelling processes. Assuming that PLA2 activity reflects neuronal damage, PUFA supplementation might unfold neuroprotective effects.

Cellular compatibility of highly degradable bioactive ceramics for coating of metal implants

Resorbable ceramics can promote the bony integration of implants. Their rate of degradation should ideally be synchronized with bone regeneration. This study examined the effect of rapidly resorbable calcium phosphate ceramics 602020, GB14, 305020 on adherence, proliferation and morphology of human bone-derived cells (HBDC) in comparison to β-TCP. The in vitro cytotoxicity was determined by the microculture tetrazolium (MTT) assay. HBDC were grown on the materials for 3, 7, 11, 15 and 19 days and counted. Cell morphology, cell attachment, cell spreading and the cytoskeletal organization of HBDC cultivated on the substrates were investigated using laser scanning microscopy and environmental scanning electron microscopy. All substrates supported sufficient cellular growth for 19 days and showed no cytotoxicity. On each material an identical cell colonisation of well communicating, polygonal, vital cells with strong focal contacts was verified. HBDC showed numerous well defined stress fibres which give proof of well spread and strongly anchored cells. Porous surfaces encouraged the attachment and spreading of HBDC. Further investigations regarding long term biomaterial/cell interactions in vitro and in vivo are required to confirm the utility of the new biomaterials.

Hepatic arterial infusion in the treatment of liver metastases with PEG liposomes in combination with degradable starch microspheres (DSM) increases tumor 5-FU concentration. an animal study in CC-531 liver tumor-bearing rats

The regional application of cytostatics in liver metastases leads to increased concentrations in the tumor tissue. The effect of flow retardation by temporary occlusion and drug targeting with liposome encapsulation (PEG liposomes) on tumor 5-fluorouracil (5-FU) concentrations was investigated.

MATERIALS AND METHODS

Tumor-bearing rats were submitted to i.v. or intraarterial (i.a.) therapy with liposome-encapsulated or non-encapsulated 5-FU. The i.a. groups were additionally treated with or without Spherex® degradable starch microspheres (DSM). The tumor 5-FU concentrations were determined by high-performance liquid chromatography (HPLC) as area under the curve (AUC).

RESULTS

A comparison with i.v. in administered 5-FU yielded the following increases tumor concentrations: 5-FU-PEG liposomes i.v. 27-fold, 5-FU i.a. 19-fold, 5-FU i.a. + DSM 1760-fold, 5-FU-PEG liposomes i.a. 110-fold, 5-FU-PEG liposomes i.a. + DSM 7665-fold.

CONCLUSION

Liver intratumoral 5-FU concentration increases to >7,500 times that following i.v. administration by a combination of regional administration via the hepatic artery with temporary embolization by DSM and drug targeting by liposome-encapsulated 5-FU.

Improvement of biodistribution with PEGylated liposomes containing docetaxel with degradable starch microspheres for hepatic arterial infusion in the treatment of liver metastases: a study in CC-531 liver tumor-bearing WAG RIJ rats

AIM

To improve the drug concentration in liver metastases, docetaxel was encapsulated in polyethyleneglycol-liposomes and administered regionally with degradable starch microspheres (DSM).

MATERIALS AND METHODS

A rodent model of solitary metastasis (CC-531 adenocarcinoma) was studied. The animals were randomized into six groups and treated with 15 ng/kg docetaxel: I: intravenous (i.v.). II: PEG-liposomes i.v.; III: intraartial (i.a.) via the hepatica artery; IV: i.a.) + DSM; V: PEG-liposomes i.a.; and VI: PEG-liposomes i.a. + DSM. The docetaxel concentration in the serum, liver and liver tumor at defined times (5, 15, 30, 60,120 240 min and 24 h) was measured using HPLC.

RESULTS

The area under the concentration (AUC) versus time curves showed an 11-fold higher concentration in the tumor tissue when comparing the docetaxel-PEG-liposomes i.a. + DSM group to the i.v. group (p<0.01).

CONCLUSION

Compared to intravenous therapy, i.a. therapy with docetaxel-PEG-liposomes + DSM results in higher tumor tissue concentrations.

Volumetric analysis of osteoclastic bioresorption of calcium phosphate ceramics with different solubilities

Commonly, to determine osteoclastic resorption of biomaterials only the resorbed area is measured. The depth of the resorption pit, however, may also be important for the performance of a material. To generate such data we used two calcium phosphate ceramics (Ca(10) and Ca(2)). The solubility of the materials was determined according to DIN EN ISO 10993-14. They were scanned three-dimensionally using infinite focus microscopy and subsequently cultivated for 4 weeks in simulated body fluid without (control) or with human osteoclasts. After this cultivation period osteoclasts number was determined and surface changes were evaluated two- and three-dimensionally. Ca(10) and Ca(2) showed solubilities of 11.0+/-0.5 and 23.0+/-2.2 mgg(-1), respectively. Both materials induced a significant increase in osteoclast number. While Ca(10) did not show osteoclastic resorption, Ca(2) showed an increased pit area and pit volume due to osteoclastic action. This was caused by an increased average pit depth and an increased number of pits, while the average area of single pits did not change significantly. The deduced volumetric osteoclastic resorption rate (vORR) of Ca(2) (0.01-0.02 microm(3)microm(-2)day(-1)) was lower than the remodelling speed observed in vivo (0.08 microm(3)microm(-2)day(-1)), which is in line with the observation that implanted resorbable materials remain in the body longer than originally expected. Determination of volumetric indices of osteoclastic resorption might be valuable in obtaining additional information about cellular resorption of bone substitute materials. This may help facilitate the development of novel materials for bone substitution.