Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials

OBJECTIVE

To identify the optimal dose and modality of exercise for treating major depressive disorder, compared with psychotherapy, antidepressants, and control conditions.

DESIGN

Systematic review and network meta-analysis.

METHODS

Screening, data extraction, coding, and risk of bias assessment were performed independently and in duplicate. Bayesian arm based, multilevel network meta-analyses were performed for the primary analyses. Quality of the evidence for each arm was graded using the confidence in network meta-analysis (CINeMA) online tool.

DATA SOURCES

Cochrane Library, Medline, Embase, SPORTDiscus, and PsycINFO databases.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Any randomised trial with exercise arms for participants meeting clinical cut-offs for major depression.

RESULTS

218 unique studies with a total of 495 arms and 14 170 participants were included. Compared with active controls (eg, usual care, placebo tablet), moderate reductions in depression were found for walking or jogging (n=1210, κ=51, Hedges' g -0.62, 95% credible interval -0.80 to -0.45), yoga (n=1047, κ=33, g -0.55, -0.73 to -0.36), strength training (n=643, κ=22, g -0.49, -0.69 to -0.29), mixed aerobic exercises (n=1286, κ=51, g -0.43, -0.61 to -0.24), and tai chi or qigong (n=343, κ=12, g -0.42, -0.65 to -0.21). The effects of exercise were proportional to the intensity prescribed. Strength training and yoga appeared to be the most acceptable modalities. Results appeared robust to publication bias, but only one study met the Cochrane criteria for low risk of bias. As a result, confidence in accordance with CINeMA was low for walking or jogging and very low for other treatments.

CONCLUSIONS

Exercise is an effective treatment for depression, with walking or jogging, yoga, and strength training more effective than other exercises, particularly when intense. Yoga and strength training were well tolerated compared with other treatments. Exercise appeared equally effective for people with and without comorbidities and with different baseline levels of depression. To mitigate expectancy effects, future studies could aim to blind participants and staff. These forms of exercise could be considered alongside psychotherapy and antidepressants as core treatments for depression.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018118040.

Expanding mental health services in low- and middle-income countries: A task-shifting framework for delivery of comprehensive, collaborative, and community-based care

This paper proposes a framework for comprehensive, collaborative, and community-based care (C4) for accessible mental health services in low-resource settings. Because mental health conditions have many causes, this framework includes social, public health, wellness and clinical services. It accommodates integration of stand-alone mental health programs with health and non-health community-based services. It addresses gaps in previous models including lack of community-based psychotherapeutic and social services, difficulty in addressing comorbidity of mental and physical conditions, and how workers interact with respect to referral and coordination of care. The framework is based on task-shifting of services to non-specialized workers. While the framework draws on the World Health Organization's Mental Health Gap Action Program and other global mental health models, there are important differences. The C4 Framework delineates types of workers based on their skills. Separate workers focus on: basic psychoeducation and information sharing; community-level, evidence-based psychotherapeutic counseling; and primary medical care and more advanced, specialized mental health services for more severe or complex cases. This paper is intended for individuals, organizations and governments interested in implementing mental health services. The primary aim is to provide a framework for the provision of widely accessible mental health care and services.

Stable iPSC-derived NKX2-1+ lung bud tip progenitor organoids give rise to airway and alveolar cell types

Bud tip progenitors (BTPs) in the developing lung give rise to all epithelial cell types found in the airways and alveoli. This work aimed to develop an iPSC organoid model enriched with NKX2-1+ BTP-like cells. Building on previous studies, we optimized a directed differentiation paradigm to generate spheroids with more robust NKX2-1 expression. Spheroids were expanded into organoids that possessed NKX2-1+/CPM+ BTP-like cells, which increased in number over time. Single cell RNA-sequencing analysis revealed a high degree of transcriptional similarity between induced BTPs (iBTPs) and in vivo BTPs. Using FACS, iBTPs were purified and expanded as induced bud tip progenitor organoids (iBTOs), which maintained an enriched population of bud tip progenitors. When iBTOs were directed to differentiate into airway or alveolar cell types using well-established methods, they gave rise to organoids composed of organized airway or alveolar epithelium, respectively. Collectively, iBTOs are transcriptionally and functionally similar to in vivo BTPs, providing an important model for studying human lung development and differentiation.

Temperature-Dependent Carrier Extraction and the Effects of Excitons on Emission and Photovoltaic Performance in Cs0.05FA0.79MA0.16Pb(I0.83Br0.17)3 Solar Cells

The photovoltaic parameters of triple cation perovskite [Cs_0.05FA_0.79MA_0.16Pb(I_0.83Br_0.17)₃] solar cells are investigated focusing on the electro-optical properties and differences in performance at low and high temperatures. The signature of a parasitic barrier to carrier extraction is observed at low temperatures, which results in a loss of performance at T < 200 K. Intensity-dependent measurements indicate extraction across this parasitic interface is limited by a combination of the exciton binding energy and thermionic emission. However, the photovoltaic performance of the device is recovered at low intensity─where the photocarrier generation rate threshold is lower than the thermionic extraction rate. Loss of solar cell performance is also observed to be strongly correlated to an increase in photoluminescence intensity, indicating inhibited carrier extraction results in strong radiative recombination and that these systems do not appear to be limited by significant thermally activated non-radiative processes. Evidence of limited carrier extraction due to excitonic effects is also observed with a strong anti-correlation in photoluminescence and carrier extraction observed at lower temperatures.

A multimodal iPSC platform for cystic fibrosis drug testing

Cystic fibrosis is a monogenic lung disease caused by dysfunction of the cystic fibrosis transmembrane conductance regulator anion channel, resulting in significant morbidity and mortality. The progress in elucidating the role of CFTR using established animal and cell-based models led to the recent discovery of effective modulators for most individuals with CF. However, a subset of individuals with CF do not respond to these modulators and there is an urgent need to develop novel therapeutic strategies. In this study, we generate a panel of airway epithelial cells using induced pluripotent stem cells from individuals with common or rare CFTR variants representative of three distinct classes of CFTR dysfunction. To measure CFTR function we adapt two established in vitro assays for use in induced pluripotent stem cell-derived airway cells. In both a 3-D spheroid assay using forskolin-induced swelling as well as planar cultures composed of polarized mucociliary airway epithelial cells, we detect genotype-specific differences in CFTR baseline function and response to CFTR modulators. These results demonstrate the potential of the human induced pluripotent stem cell platform as a research tool to study CF and in particular accelerate therapeutic development for CF caused by rare variants.

Factors Associated with Self-Reported Dysphagia in Older Adults Receiving Meal Support

OBJECTIVES

Dysphagia is common in older adults. However, there are no current estimates of dysphagia in community-dwelling older adults those receiving meal support. It is unknown whether dysphagia is associated with other measures of physical function (activities of daily living [ADL] ability or nutrition status). The study purposes were to determine the prevalence of self-reported dysphagia and to identify factors associated with self-reported dysphagia in community-dwelling older adults receiving meal support.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

476 community-dwelling older adults (78.5±0.51 years) across five Elder Nutrition Program meal services in Wisconsin participated in the study.

MEASUREMENTS

Data were collected through administration of validated ADL and nutrition questionnaires (nutritional status, functional status with ADLs, chewing ability, dental conditions, and prior diagnoses of dysphagia, pneumonia, and dementia). For self-reported dysphagia, the validated 10-item eating assessment tool (EAT-10) was used.

RESULTS

The prevalence of self-reported dysphagia (EAT-10 score of ≥ 3) was 20.4%. Multivariate logistic regression results indicated that poor nutritional status (OR=3.1, p=0.04), difficulty chewing (OR=2.2, p=0.03), prior dysphagia diagnosis (OR=34.8, p<0.001), prior pneumonia diagnosis (OR=2.1, p=0.04), and meal service site (OR=2.68, p=0.02) were associated with self-reported dysphagia.

CONCLUSION

Approximately one in five community-dwelling older adults receiving meal support had self-reported dysphagia. Increased risk for poor nutrition, reduced chewing ability, prior dysphagia and pneumonia diagnosis, and meal service site were identified as factors associated with dysphagia on the EAT-10. Results highlight the need for further studies across more sites to identify dysphagia risk indicators in community-dwelling older adults receiving meal support state-wide.

"Between a Rock and a Hard Place": A Case Report of Stone Fragment Impaction Causing a Retained Ureteroscope Requiring Open Surgical Intervention

Background: Ureteroscopy is frequently used for small renal and ureteral calculi. Rarely cases have been reported of retained ureteroscopes as a complication. With the limited number of cases, it is important to add these to the literature to mitigate the future risk from this complication that can lead to significant morbidity. We present our unique experience with a retained ureteroscope requiring open surgical intervention. Case Presentation: Our case is a 65-year-old female undergoing ureteroscopy for a 2 cm right ureteropelvic junction obstructing stone. After laser lithotripsy, there was significant buildup of stone debris distally along the ureteroscope. Conservative measures failed to remove the ureteroscope, so an open surgical approach was taken. The ureteroscope was removed, and a ureteral reimplant was performed. Postoperative CT shows residual hydronephrosis, but there is no obstruction seen on renal Lasix scan. Conclusions: This is a rare, but real, complication that urologists must be aware of. Preventive measures with pre-stenting early intraoperative stenting, using a ureteral access sheath, or using a single-use flexible ureteroscope could be considered especially when treating larger stones endoscopically.

Generation of mesenchyme free intestinal organoids from human induced pluripotent stem cells

Efficient generation of human induced pluripotent stem cell (hiPSC)-derived human intestinal organoids (HIOs) would facilitate the development of in vitro models for a variety of diseases that affect the gastrointestinal tract, such as inflammatory bowel disease or Cystic Fibrosis. Here, we report a directed differentiation protocol for the generation of mesenchyme-free HIOs that can be primed towards more colonic or proximal intestinal lineages in serum-free defined conditions. Using a CDX2eGFP iPSC knock-in reporter line to track the emergence of hindgut progenitors, we follow the kinetics of CDX2 expression throughout directed differentiation, enabling the purification of intestinal progenitors and robust generation of mesenchyme-free organoids expressing characteristic markers of small intestinal or colonic epithelium. We employ HIOs generated in this way to measure CFTR function using cystic fibrosis patient-derived iPSC lines before and after correction of the CFTR mutation, demonstrating their future potential for disease modeling and therapeutic screening applications.

Images - Adenomatoid tumor of testis, concerning for malignancy after ultrasound

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Assessing cell-specific effects of genetic variations using tRNA microarrays

Background

By definition, effect of synonymous single-nucleotide variants (SNVs) on protein folding and function are neutral, as they alter the codon and not the encoded amino acid. Recent examples indicate tissue-specific and transfer RNA (tRNA)-dependent effects of some genetic variations arguing against neutrality of synonymous SNVs for protein biogenesis.

Results

We performed systematic analysis of tRNA abunandance across in various models used in cystic fibrosis (CF) research and drug development, including Fischer rat thyroid (FRT) cells, patient-derived primary human bronchial epithelia (HBE) from lung biopsies, primary human nasal epithelia (HNE) from nasal curettage, intestinal organoids, and airway progenitor-directed differentiation of human induced pluripotent stem cells (iPSCs). These were compared to an immortalized CF bronchial cell model (CFBE41o⁻) and two widely used laboratory cell lines, HeLa and HEK293. We discovered that specific synonymous SNVs exhibited differential effects which correlated with variable concentrations of cognate tRNAs.

Conclusions

Our results highlight ways in which the presence of synonymous SNVs may alter local kinetics of mRNA translation; and thus, impact protein biogenesis and function. This effect is likely to influence results from mechansistic analysis and/or drug screeining efforts, and establishes importance of cereful model system selection based on genetic variation profile.

Electronic supplementary material

The online version of this article (10.1186/s12864-019-5864-1) contains supplementary material, which is available to authorized users.

CFTR modulator theratyping: Current status, gaps and future directions

BACKGROUND

New drugs that improve the function of the cystic fibrosis transmembrane conductance regulator (CFTR) protein with discreet disease-causing variants have been successfully developed for cystic fibrosis (CF) patients. Preclinical model systems have played a critical role in this process, and have the potential to inform researchers and CF healthcare providers regarding the nature of defects in rare CFTR variants, and to potentially support use of modulator therapies in new populations.

METHODS

The Cystic Fibrosis Foundation (CFF) assembled a workshop of international experts to discuss the use of preclinical model systems to examine the nature of CF-causing variants in CFTR and the role of in vitro CFTR modulator testing to inform in vivo modulator use. The theme of the workshop was centered on CFTR theratyping, a term that encompasses the use of CFTR modulators to define defects in CFTR in vitro, with application to both common and rare CFTR variants.

RESULTS

Several preclinical model systems were identified in various stages of maturity, ranging from the expression of CFTR variant cDNA in stable cell lines to examination of cells derived from CF patients, including the gastrointestinal tract, the respiratory tree, and the blood. Common themes included the ongoing need for standardization, validation, and defining the predictive capacity of data derived from model systems to estimate clinical outcomes from modulator-treated CF patients.

CONCLUSIONS

CFTR modulator theratyping is a novel and rapidly evolving field that has the potential to identify rare CFTR variants that are responsive to approved drugs or drugs in development.

Improving access to urologists through an electronic consultation service

INTRODUCTION

Access to specialist services is limited by wait times and geographic availability. Champlain Building Access to Specialist Advice (BASE) has been implemented in our service region to facilitate access to specialists by primary care providers (PCPs). Through a secure web-based system, PCPs are able to send eConsults instead of requesting a formal in-office consultation.

METHODS

Urology eConsults completed through the Champlain BASE service from March 2013 to January 2015 were analyzed. Each consult was characterized in regard to the type of question asked by the referring physician and the clinical content of the referral. Using the mandatory close-out surveys, we analyzed rates of referral avoidance, physician satisfaction, and overall impact on patient care.

RESULTS

Of 190 eConsultations, 70% were completed in less than 10 minutes. The most common clinical questions related to the interpretation of imaging reports (16%) and tests to choose for investigating a condition (15%). The most common diagnoses were hematuria (13%) and renal mass (8%). In 35% of cases, referral to a urologist had originally been contemplated and was avoided. In 8% of cases, a PCP did not believe a consultation was initially needed, but a referral was ultimately initiated after the eConsultation.

CONCLUSIONS

Our study shows that although certain clinical presentations still require a formal in-person urological consultation, eConsultations can potentially reduce unnecessary clinic visits while identifying patients who may benefit from early urological consultation. Through both these mechanisms, we may improve timely access to urologists.

Brief work-integrated learning opportunities and first-year university students’ perceptions of employability and academic performance

Universities are attempting to respond to recent changes in the employment sector in order to ensure graduates are job ready. One approach for preparing students for the evolving employment sector is to expose them to work-integrated learning experiences during their undergraduate degree. Traditionally, work-integrated learning experiences have been offered toward the end of students’ degrees, but there might be value in offering such opportunities as students’ transition into university. The aim of this study was to explore the outcomes of brief work-integrated learning experiences on first-year university students. A series of paired samples t-tests showed significant differences in students’ ( N = 28, Mage = 18.89 years) perceptions of employability and academic performance following exposure to 10-hours of job shadowing. The outcomes from the study suggest that students might benefit from work-integrated learning experiences in their foundation year of university. Implications for educators, universities, and the employment sector are highlighted.

A Clinical Procedures Course for Medical Students

INTRODUCTION

Doctors perform many clinical procedures throughout their careers. It is important for students to learn these procedures in a nonthreatening environment. This clinical procedures course introduces students to several basic diagnostic and therapeutic procedures, both invasive and noninvasive. These include managing pediatric and adult airways, starting intravenous lines, inserting arterial and central lines, inserting Foley catheters and nasogastric tubes, and performing lumbar punctures and paracentesis.

METHODS

Small-group teaching is used to achieve these objectives; over the course of 4 weeks, the medical students meet once a week for 4 hours. Each meeting includes teaching and demonstrations of the procedures by faculty instructors and residents. This is followed by practice of the procedures on mannequin simulators and partial task trainers by the students. Feedback is then given to the students by the instructors.

RESULTS

Based on conversations during the feedback sessions, the students feel that the materials used in the course are helpful in learning these clinical procedures.

DISCUSSION

The medical students feel that the course familiarizes them with clinical procedures they may be asked to perform on patients during their clinical rotations and postgraduate training.

Personality Characteristics of Volunteers for Thanatological Research

In an investigation of volunteers for thanatological research, two hundred and thirty-seven college students were presented with the option of completing the Do-It-Yourself-Death Certificate (DIYDC) as a component of a test battery which included an omnibus personality inventory and measures of dissimulation, locus of control, anxiety and Machiavellianism. A total of seventy-five males and ninety-seven females completed the DIYDC. Completers demonstrated a tendency toward scientific interest in death, rather than morbid curiosity about it. There was no differential rate of completion as a function of gender, anxiety, dissimulation, locus of control or Machiavellianism. It was concluded that student volunteers for thanatological research constitute a reasonably representative cross section of student volunteers for general psychological research and that the usefulness of the DIYDC in death workshop settings may be reliably extended to large-sample survey research applications.

Values in Presidential Inaugural Addresses: A Test of Rokeach's Two-Factor Theory of Political Ideology

Values expressed in the inaugural addresses of the presidents of the United States were hypothesized to reflect an underlying factor structure characterized by historical value citations of “Freedom” and “Equality,” identified by Rokeach in 1973 as relevant to major political ideologies. A positive emphasis on both values yields a socialistic perspective, while rejection of both values generates fascism. Capitalism endorses “freedom” but rejects “equality,” while an emphasis on “equality” to the exclusion of “freedom” reflects Communism. Blind raters (with interrater reliabilities of .88 to .92) content analyzed the 50 inaugural addresses of 40 presidents, from Washington through Reagan, with reference to eight values (economy, equality, freedom, justice, morality, peace, power, and religion) identified as historically consistent themes in inaugural addresses. Factor analysis yielded two basic dimensions clearly identifiable as “Freedom” and “Equality,” lending substantial support to Rokeach's findings.

Faith and Locus of Control

A total of four dimensions emerged from a factor analytic study of faith. They were titled Faith in God, Faith in People, Faith in Self, and Faith in Technology. Comparisons of religious and secular groups and of liberal and conservative religious groups strongly supported the construct validity of the Faith in God subscale. A moderately low correlation obtained between the Faith in Self subscale and internal locus of control suggested conceptual similarity. Inspection of the item content on the two scales indicates that the internal subscale assesses one's perception that an individual can affect what happens to him, whereas items on the Faith in Self subscale concern more the perception that the individual will control his life in a positive direction.

Inadvertent transmission of polycystic kidney disease in kidney transplantation

Patient: Male, 55

Final Diagnosis: Polycystic transformation of transplant kidney

Symptoms: Hematuia

Medication: Tacrolimus • Mycophenoalte Moefitil • Prednisone

Clinical Procedure: Graft nephrectomy

Specialty: Nephrology

An open-label, single-arm, phase 2 trial of the Polo-like kinase inhibitor volasertib (BI 6727) in patients with locally advanced or metastatic urothelial cancer

BACKGROUND

Polo-like kinases (Plks) control multiple steps during the cell cycle, and Plk1 is overexpressed in urothelial cancer (UC). Volasertib (BI 6727), a Plk inhibitor, has demonstrated antitumor activity in several malignancies, including UC. In this phase 2 trial, the authors investigated volasertib as a second-line treatment in advanced/metastatic UC.

METHODS

Patients who progressed within 2 years of 1 prior chemotherapy regimen received 300 mg volasertib on day 1 every 3 weeks. The dose was escalated to 350 mg in cycle 2 if volasertib was tolerated in cycle 1. The primary endpoint was tumor response, which was assessed every 6 weeks; secondary endpoints were progression-free survival, overall survival, duration of response, safety, and pharmacokinetics.

RESULTS

Fifty patients were enrolled, and the median patient age was 68.5 years (range, 52-83 years). All patients had received prior platinum, 94% of patients had relapsed ≤2 years after prior therapy, 36% had liver metastases, and 54% had lung metastases. The median number of treatment cycles was 2 (range, 1-27 treatment cycles), and 23 patients were dose escalated at cycle 2. Seven patients (14%) had a partial response, 13 (26%) had stable disease, and 30 (60%) progressed within 6 weeks. The median response duration was 41 weeks (range, 29.1-77.3 weeks). The median progression-free survival was 1.4 months, and the median overall survival was 8.5 months. The most frequent grade 3 and 4 adverse events were neutropenia (28%), thrombocytopenia (20%), and anemia (16%). No cumulative toxicity was observed.

CONCLUSIONS

Volasertib as second-line treatment for advanced/metastatic UC had an acceptable safety profile but demonstrated insufficient antitumor activity for further evaluation as a monotherapy.

A comprehensive evaluation of the performance of the test strip technology for OneTouch Verio glucose meter systems

BACKGROUND

OneTouch® Verio™ test strips (LifeScan Inc., Milpitas, CA) are designed to minimize error when used in blood glucose monitoring systems. These strips have a specialized architecture and incorporate a sophisticated waveform and proprietary algorithm.

MATERIALS AND METHODS

Performance of OneTouch Verio test strips was assessed in the laboratory in the presence of a wide range of patient, environmental, and pharmacologic factors. A clinical evaluation was conducted in which 296 patients and healthcare professionals (HCPs) performed glucose testing using OneTouch Verio test strips and OneTouch VerioIQ meters.

RESULTS

In the laboratory study, OneTouch Verio test strip results achieved a high level of performance over a wide range of hematocrit (19-61%), temperature (5-45(°)C), humidity (10-90% relative humidity), and altitude (0-3,048 m) conditions. Performance was not affected by 22 of 23 chemical compounds. In the clinical study, 100% (31/31) of lay-user test results were within ±10 mg/dL of reference values for blood glucose <75 mg/dL. At blood glucose ≥75 mg/dL, 99.2% (243/245) were within ±15% of reference values. A feature of the VerioIQ meter, PatternAlert(™) Technology, was correctly used and positively evaluated by >98% of lay users.

CONCLUSIONS

OneTouch Verio test strips are accurate and precise over a wide range of patient, environmental, and pharmacologic conditions. In addition, lay-users were able to successfully use the OneTouch VerioIQ PatternAlert Technology without HCP training.

Development of an Evidence biochip array kit for the multiplex screening of more than 20 anthelmintic drugs

Anthelmintic drugs are used in clinical and veterinary practice for the treatment of infections caused by parasitic worms. Their extensive use in food-producing animals can cause the presence of residues in food. For consumer protection it is necessary to monitor the levels of anthelmintic residues to ensure that they remain within the legally permitted maximum acceptable concentrations. For this purpose, the use of multiplex screening methods is advantageous. Biochip array technology allows the simultaneous determination of multiple analytes from a single sample at a single point in time. This study reports the development of an Evidence biochip array for the multiplex screening of anthelmintic drugs. Simultaneous competitive chemiluminescent immunoassays are employed. The solid support and vessel is the biochip, which contains an array of discrete test sites. The assays were applied to the semiautomated bench-top analyser Evidence Investigator. The aminobenzimidazoles assay detected aminomebendazole, albendazole 2-aminosulphone and aminoflubendazole, the avermectins assay detected emamectin benzoate, eprinomectin, abamectin, ivermectin and doramectin, the benzimidazoles assay detected albendazole sulphone, albendazole, albendazole sulphoxide, oxibendazole, oxfendazole and flubendazole, the thiabendazole assay detected cambendazole, thiabendazole and 5-hydroxythiabendazole and the triclabendazole assay detected ketotriclabendazole, triclabendazole and triclabendazole sulphoxide. The limits of detection ranged from 0.3 ppb (aminobenzimidazoles) to 2.0 ppb (levamisole) in milk and from 0.15 ppb (aminobenzimidazoles) to 6.5 ppb (levamisole) in tissue. The average recovery range was 71-135 %. This multianalytical approach on a biochip platform is applicable to the screening of more than 20 anthelmintic drugs in different food matrices, leading to consolidation of tests and enhancement of the test result output.

Perfectionistic profiles among elite athletes and differences in their motivational orientations

Although there is an emerging body of research that has examined perfectionistic clusters in the general population, few studies have explored such profiles in athlete samples. The purposes of this research were to explore perfectionistic profiles within a sample of elite athletes and the differences between them on key motivational variables. A sample of 423 elite athletes (179 males, 244 females) aged between 14 and 66 years (M = 25.64; SD = 8.57) from a variety of team (e.g., rowing, hockey, baseball, rugby) and individual sports (e.g., cycling, athletics, triathlon, gymnastics) completed a multisection questionnaire including measures of sport perfectionism, motivation regulation, achievement goals, and fear of failure. Cluster analyses revealed the existence of three perfectionism profiles, namely, nonperfectionists, maladaptive perfectionists, and adaptive perfectionists. Subsequent analyses generally supported the robustness of these perfectionism profiles in terms of differential motivational orientations (achievement goals, fear of failure, and motivation regulation) in hypothesized directions. Overall, the differences in motivational orientations between the three clusters supported a categorical conceptualization of perfectionism.

Associations between medical student log data and clerkship learning outcomes

BACKGROUND

Largely due to regulatory requirements, medical students increasingly document patient encounters in logs. Prior studies demonstrated value in achieving course objectives but not regarding objective learning outcomes.

PURPOSE

The purpose of this article is to assess the associations between students' log data and clerkship outcomes.

METHODS

We assessed ambulatory, internal medicine-pediatrics clerkship logs. Students recorded patients' diagnoses, preceptor's teaching content and performing histories and physicals (H&P). We examined associations between log data and National Board of Medical Examiners Subject Exams (NBME), Objective Structured Clinical Exams (OSCE), and clinical evaluations.

RESULTS

All 272 students completed logs (M diagnoses = 146.5, SD = 24.9). In univariate analysis number of diagnoses, preceptors' teaching patient management and performing H&P independently correlated with OSCE scores (r = .13-.24, p < .05). NBME scores correlated with diagnoses, performing H&P independently (r = .13-.18, p < .05). Teaching patient management, diagnoses, performing H&P independently were associated with clinical evaluations (all ps < .05). Regressions demonstrated that performing physicals independently was associated with NBME and OSCE scores (p < .05, R (2) = .03 and .05, respectively). Teaching disease management and pediatric diagnoses were associated with clinical evaluations (p < .05) in medicine and pediatrics, respectively.

CONCLUSIONS

Aspects of teaching, increased clinical involvement, and student autonomy were associated with clerkship performance.

Arsenic trioxide enhances the cytotoxic effect of thalidomide in a KG-1a human acute mylogenous leukemia cell line

Studies have shown that thalidomide exerts modest activity as a single agent in the therapy of acute myeloid leukemia (AML). The present investigation was conducted to test the hypothesis that the cytotoxic effect of thalidomide is enhanced when properly combined with other chemotherapeutic agents. The human AML cell line KG-1a was used in this study. Cells were cultured for 48 h in the presence or absence of thalidomide, arsenic trioxide and a combination of the two substances. Results obtained indicate that thalidomide at concentrations of 1, 2 and 5 mg/l produced a dose-dependent cytotoxic effect and at 5 mg/ml resulted in late apoptosis in 49.39% of the total cell population (as compared to 5.35% in the control cells). When the cells were incubated with arsenic trioxide alone (4 µM), late apoptosis was detected in 16.97% of the total cell population. However, when cells were incubated with a combination of thalidomide (5 mg/l) and arsenic trioxide (4 µM), late apoptosis was noted to be 80.6% in the total cell population. This percentage of late apoptosis was statistically significant from that observed when cells were incubated with thalidomide alone. These findings clearly indicate that arsenic trioxide enhances the cytotoxic effects of thalidomide.

Target-specific, histology-independent, randomized discontinuation study of lapatinib in patients with HER2-amplified solid tumors

3541

Background: The current paradigm of histology-specific drug development may not be optimal in the era of targeted therapeutics. We sought to explore the activity of lapatinib, an oral tyrosine kinase inhibitor of HER2, with a trial design focused on the target rather than on tumor-type. Methods: Patients (pts) with HER2-amplified treatment-refractory metastatic gastro- esophageal (G/E), bladder (B), ovarian (O), or uterine (U) tumors were enrolled into a double-blinded randomized discontinuation study of lapatinib 1500 mg PO daily (malignancies selected based on reported frequencies of HER2 amplification). The planned sample size was 250 HER2+ pts, with the goal of then randomizing 100 pts with SD at week (wk) 12 to either lapatinib or placebo until progressive disease (PD). Pts who responded at wk 12 (CR or PR) continued on lapatinib; those who progressed were discontinued from study. Primary objectives were response rate at 12 wks and percentage of pts who remain progression free at 24 wks. Secondary objectives were duration of response, progression free survival (PFS) after randomization, and determination of the incidence of HER2 amplification in multiple tumor types. Futility analyses were preplanned to ensure feasibility of screening and of randomization (i.e. a sufficient rate of non- progression at 12 wks). Results: A total of 145 pts were screened (G/E=47, B=35, O=58, U=5); 42 were HER2-amplified (G/E=16, B=13, O=13, U=0) and 32 (G/E=13, B=9, O=10) were enrolled. At wk 12, 1 (3%) patient had a CR, 10 (31%) had SD, 19 (59%) had PD, and 2 (6%) were unknown. Median time to progression during open-label lapatinib was 78 days, 95% CI (42, 92). Only 7 pts with SD underwent randomization. Two pts with esophageal cancer remain on study; one (CR at wk 12) remains a CR at wk 60 and the other (SD at wk 12) remains with SD at wk 36. Low response rate coupled with slow screening and enrollment led to early study closure. Conclusions: Basing trial eligibility on a target, versus histologic classification, is challenging. While HER2 amplifications appear to be prevalent in select non-breast tumors, lapatinib monotherapy in refractory disease is associated with a low level of objective responses.

[Table: see text]

Feedback circuit among INK4 tumor suppressors constrains human glioblastoma development

We have developed a nonheuristic genome topography scan (GTS) algorithm to characterize the patterns of genomic alterations in human glioblastoma (GBM), identifying frequent p18(INK4C) and p16(INK4A) codeletion. Functional reconstitution of p18(INK4C) in GBM cells null for both p16(INK4A) and p18(INK4C) resulted in impaired cell-cycle progression and tumorigenic potential. Conversely, RNAi-mediated depletion of p18(INK4C) in p16(INK4A)-deficient primary astrocytes or established GBM cells enhanced tumorigenicity in vitro and in vivo. Furthermore, acute suppression of p16(INK4A) in primary astrocytes induced a concomitant increase in p18(INK4C). Together, these findings uncover a feedback regulatory circuit in the astrocytic lineage and demonstrate a bona fide tumor suppressor role for p18(INK4C) in human GBM wherein it functions cooperatively with other INK4 family members to constrain inappropriate proliferation.

Barriers to improvement of mental health services in low-income and middle-income countries

Despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle-income countries. We reviewed barriers to mental health service development through a qualitative survey of international mental health experts and leaders. Barriers include the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralisation of mental health services; challenges to implementation of mental health care in primary-care settings; the low numbers and few types of workers who are trained and supervised in mental health care; and the frequent scarcity of public-health perspectives in mental health leadership. Many of the barriers to progress in improvement of mental health services can be overcome by generation of political will for the organisation of accessible and humane mental health care. Advocates for people with mental disorders will need to clarify and collaborate on their messages. Resistance to decentralisation of resources must be overcome, especially in many mental health professionals and hospital workers. Mental health investments in primary care are important but are unlikely to be sustained unless they are preceded or accompanied by the development of community mental health services, to allow for training, supervision, and continuous support for primary care workers. Mobilisation and recognition of non-formal resources in the community must be stepped up. Community members without formal professional training and people who have mental disorders and their family members, need to partake in advocacy and service delivery. Population-wide progress in access to humane mental health care will depend on substantially more attention to politics, leadership, planning, advocacy, and participation.