Initial Immune Response in Escherichia coli, Staphylococcus aureus, and Candida albicans Bacteremia

Sepsis remains a leading cause of mortality worldwide and is characterized by sustained inflammatory responses, reflected as changes in the expression profile of cytokines with time. The aim of the present study was to investigate the dynamic changes in complete blood count, serum chemistry, procalcitonin (PCT), tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6) in Escherichia coli, Staphylococcus aureus, and Candida albicans bacteremia. Study subjects were 32 healthy male Landrace-Large White pigs, aged 10-15 weeks and of average weight 19 ± 2 kg. Bacteremia was induced by continuous intravenous infusion of microbial suspensions during a period of 8 h. E. coli and S. aureus bacteremia were associated with a significant gradual decrease in white blood cells and platelets, respectively (p = 0.002 and p = 0.004), while candidemia was characterized by a significant gradual decrease in lymphocytes (p = 0.009). Serum PCT levels were either undetectable or very low, with no significant changes with time in all groups. E. coli bacteremia elicited a strong pro-inflammatory response, characterized by a significant increase in TNF-α expression from the onset of bacteremia (p = 0.042). C. albicans exhibited a different profile with an early, moderate increase in TNF-α followed by a subsequent marked increase in IL-6 levels (p = 0.03). The differential regulation of inflammatory and hematological responses depending on the pathogenic agent can reveal differences in the underlying inflammatory mechanisms, which may assist in the ongoing quest for the identification of a panel of circulating biomarkers during bacteremia.

Effect of Triiodothyronine Administration on the Kidney During Haemorrhagic Shock and Resuscitation

Objective

Apoptosis, measured via caspase activity, can be used to assess renal tissue damage in haemorrhagic shock. We investigated whether Triiodothyronine could attenuate apoptosis and protect against haemorrhagic shock-induced renal injury.

Methods

Haemorrhagic shock was induced in swine until the mean arterial pressure (MAP) was 35–40 mmHg for 40 minutes. Animals were randomly assigned to a control group (n=5), Group-F (Fluid resuscitation, n=6), and Group-T3 (Fluid plus Triiodothyronine, n=6). The swine were resuscitated for 1 hour aiming to MAP restoration (±10% from baseline) and were followed up for another 360 minutes. Haemodynamic parameters, fluids, acid-base status, plasma urea nitrogen, creatinine levels and caspase activity in the kidney were measured.

Results

Haemodynamic parameters did not differ significantly amongst the three groups. Group-T3 required less normal saline (Group-T3: 1083±204 mL versus F: 2500±547 mL, p=0.001) and hydroxyethyl starch (Group-T3: 558±102 mL versus F: 916±204 mL, p=0.004) during resuscitation. Additionally, Group-T3 swine experienced less acidosis following haemorrhage/resuscitation with a pH of 7.39 versus a pH of 7.26 in Group-F (p=0.004) at 360 minutes. Urea remained within normal limits in all groups, but creatinine levels were elevated at 6 hours in Group-F as compared to Group-T3 (p=0.019). Apoptosis, assessed by renal caspase-3 activity, was increased in Group-T3 (132±174 pmol minute⁻¹ g⁻¹) and reduced in Group-F (32±18 pmol minute⁻¹ g⁻¹) as compared to the control group, but without statistical significance (p=0.245 between Group-T3 and Group-F).

Conclusion

Administration of Triiodothyronine in a swine model of haemorrhagic shock seems to interfere with renal cell apoptosis. The exact mechanism needs to be further investigated in future research.

Does the Inion OTPSTM absorbable plating system induce higher foreign-body reaction than titanium implants? An experimental randomized comparative study in rabbits

Hardware removal after complete fracture healing is a laborious and traumatic procedure that bears the risks of refracture, infection, and soft tissue damage. Absorbable materials for fracture fixation have the advantage of eliminating the need for removal; however, they may stimulate a considerable inflammatory response. For that reason, we compared in a prospective randomized experimental animal model study the incidence of foreign-body reactions between Inion OTPS^TM absorbable plate implants, consisting of carbon trimethylene, L-polylactic acid, and D, L-polylactic acid, and conventional titanium plates. Seventy rabbits were equally divided into two groups. Titanium (Group A) or absorbable (Group B) plates and screws were implanted in the femoral shaft of the rabbits. Wound reaction and laboratory tests including white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) values were measured and compared at different time points. Radiographs and histological analysis of tissue samples from all animals were also used to identify potential foreign-body reactions. WBC showed normal values in both groups. In Group A, ESR levels were higher at all time points but CRP values were normalized at 3 weeks postoperatively. In Group B, ESR and CRP levels reached a peak at 3 weeks and were above normal values throughout the whole experiment (p < 0.001). Radiologic examination revealed periosteal thickening and surrounding sclerosis in 23 out of 35 animals of Group B (66%). All Group A animals had normal radiographic findings. Histopathology showed a typical non-specific foreign-body reaction in all animals in Group B (100%) but none in Group A. However, only four of them (11.8%) developed non-infected wound complications and showed significantly elevated CRP and ESR values (p = 0.054). Although Inion OTPS^TM Biodegradable Plating System stimulates a foreign-body reaction, only a small but not negligible percentage of almost 12% may lead to wound problems. However, this difference compared to titanium plates was of borderline not statistically significant. Future studies should focus on the development of absorbable implants with improved biocompatibility aiming to further decrease the potential of foreign-body reaction and eliminate the need for additional reoperative procedures.

Assessment of Post-Resuscitation Intestinal Injury and Timing of Bacterial Translocation in Swine Anaesthetized With Propofol-Based Total Intravenous Anaesthesia

Introduction and objectives Bacterial translocation (BT) is the passage of viable bacteria or endotoxins from the gastrointestinal lumen to extra-luminal tissues and is usually observed after intestinal ischaemia-reperfusion injury. The aim of this study was to investigate post-resuscitation BT after cardiac arrest and resuscitation in a swine anaesthetized with propofol-based total intravenous anaesthesia. Materials and methods Eighteen female Landrace/Large White piglets were randomly divided into control (CON), cardiac arrest (CA) and cardiac arrest-cardiopulmonary resuscitation (CA-CPR) groups. In the CON group, the animals were only monitored for two hours. In the CA group, the animals were not resuscitated and underwent necropsy immediately after cardiac arrest. In the CA-CPR group, the animals were resuscitated until the return of spontaneous circulation (ROSC) and were monitored for two hours. The animals of the CON and CA-CPR groups underwent necropsy 24 hours later. Bacterial translocation was assessed by blood and tissue cultures and endotoxin measurement in the portal and systemic circulation. Malondialdehyde content calculation and histological analysis of the intestine were performed in order to estimate ischemia and reperfusion (I/R) tissue damage. Results  Malondialdehyde content, an indicator of oxidative stress, was significantly higher in the CA-CPR group compared to the CA in homogenized ileum (p=0.016). Malondialdehyde content in homogenized colon revealed significantly higher levels in the CA-CPR group compared to the CON (p=0.004) and the CA group (p=0.016). We found significantly higher levels of portal endotoxin in the CA-CPR group compared to the CON (p=0.026) and the CA group (p=0.026). The number of positive mesenteric lymph nodes cultures for E. coli was greater in the CA-CPR group, followed by the CA and CON groups, although the difference was not significant (67%, 33%, and 33%, respectively; p=0.407). Conclusions Malondialdehyde content and portal endotoxin levels do not increase during the cardiac arrest interval, but only after CPR and ROSC. Although the number of positive MLNs cultures was greater in the CA-CPR animals, no statistically significant differences were observed between the three groups due to the short monitoring period.

ABC of Surgical Teaching: Time to Consider a Global Blueprint for Holistic Education

BACKGROUND

Educating and equipping students and trainees into clinicians capable of meeting healthcare demands and service provision needs is essential. Unprecedented events like COVID-19 pandemic, highlight urgent need for reformation of training to ensure high quality education is maintained. To this end, we describe an innovative and globally adaptable blueprint for establishing a surgical curriculum, aiming to optimize preparation of future surgeons.

METHODS

We used a structured protocol to synthesize evidence from previous systematic reviews focused on surgical education alongside a series of focused original educational studies. This approach allowed incorporation of prospectively applied novel ideas into the existing landscape of published evidence. All material used for this proof of concept derives from the outputs of a dedicated research network for surgical education (eMERG).

RESULTS

We propose the foundation blueprint framework called "Omnigon iG4" as a globally applicable model. It allows adaptation to individual local educational environments for designing, appraising and/or refining surgical curricula. We also describe the "Omnigon iG4 Hexagon Pragmatic Model," a novel perspective model which assesses the performance of our blueprint in a multi-layer fashion. This "Hexagon" model is the first to introduce pragmatic outcomes in curricula performance assessment.

CONCLUSIONS

This proof of concept, "Omnigon iG4," proposes an adaptable version of a curriculum blueprint. The framework allows educators to establish a surgical curriculum with the ability to map out competencies, permitting full control over their intended learning outcomes. This can form the basis for developing globally adaptable multifaceted Simulation-Based learning (SBL) courses or even surgical curricula for undergraduates.

A student initiative to improve exposure in research - Dual benefit?

Purpose

Despite the recent implementation of research-focused activities into undergraduate education, there is still a universal lack of offered exposure experienced by medical students. We organised an undergraduate research conference to explore students' views on research and evaluate the impact of the conference on participants' and organisers’ research skills and non-technical skills respectively.

Methods

The conference was a student-led initiative which took place at a London medical school. Feedback from delegates was collected before and after the conference and aimed to evaluate previous experience and views in research, subjective assessment of relevant skills and the overall quality of the conference. Subjective change in organisers’ non-technical skill performance was also evaluated using an online questionnaire following the conference.

Results

Forty-four students attended the conference, out of which only 3 (7.7%) have published in an international peer-reviewed journal. Finding a project supervisor was reported by most delegates as the biggest barrier in becoming involved in research. Delegates' study design (p = 0.041) and oral/poster presentation skills (p = 0.041) showed a statistically significant subjective improvement. A clear benefit in organisers’ subjective improvement in non-technical skill performance has been demonstrated. The conference was evaluated highly.

Conclusion

There is need to address the barriers that medical and dental students face in the path to get involved in research. Our conference framework has demonstrated benefit to both delegates and organisers in improving their research skills and non-technical skills respectively. The conference, being highly appraised, lays the ground for such initiatives to be integrated in undergraduate medical and dental curricula.

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Less than 10% of students have published in peer-reviewed journals.

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Finding a project supervisor was reported as the biggest barrier in becoming involved in research.

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A student-led research conference can improve organisers' non-technical skills.

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A student-led research conference can improve delegates research and presentation skills.

HDAC1/2 Inhibitor Romidepsin Suppresses DEN-Induced Hepatocellular Carcinogenesis in Mice

Background

Hepatocellular carcinoma (HCC) is a frequently diagnosed cancer and a leading cause of cancer-related death worldwide. Its rapid progression, combined with the limited treatment options at late stages, imposes the need for early detection and aggressive intervention. Based on the knowledge that hepatocarcinogenesis is significantly influenced by histone acetylation, we directed our search for novel HCC therapeutics among histone deacetylation inhibitors (HDACi). The aim of the present study was to investigate the effect of HDAC1/2 inhibitor Romidepsin in the well-established mouse model of diethylnitrosamine (DEN)-induced HCC.

Materials and Methods

C56BL/6 mice were treated with Romidepsin at the critical point of 10 months after DEN challenge and their livers were examined 2 months later using histopathology and morphometry. Protein levels were assessed in serum using ELISA and in liver tissues using Western blot and immunohistochemistry (in-situ detection). Gene expression was quantified using real-time PCR.

Results

Romidepsin suppressed cancer progression. This effect was associated with decreased proliferation and increased apoptosis of cancer cells. The cell cycle regulator CK2a, the anti-inflammatory molecule PPAR-γ, and the tumor suppressors PTEN and CYLD were upregulated in treated HCC. By contrast, the expression of PI3K, NF-κB p65 and c-Jun was reduced. In line with this result, the levels of two major apoptosis regulators, ie, BAD and the multifunctional protein c-Met, were lower in the blood serum of treated mice compared to the untreated mice with HCC.

Conclusion

These findings suggest that Romidepsin, a drug currently used in the treatment of lymphoma, could also be considered in the management of early-stage HCC.

ATSC transplantation contributes to liver regeneration following paracetamol-induced acute liver injury through differentiation into hepatic-like cells

INTRODUCTION

Drug-induced liver injury (DILI) is a leading cause of acute liver injury (ALI). Acetaminophen (also termed paracetamol), can often be found in drugs that may be abused (i.e., prescription for pain relief). Animal experiments have shown that mesenchymal stem cell transplantation can ameliorate or even reverse hepatic injury.

MATERIAL AND METHODS

ALI was induced in Wistar rats using paracetamol. ATSCs were transplanted via the intravenous, portal vein, or intrahepatic route directly onto the liver parenchyma. Histological evaluation was conducted to assess drug-induced injury following transplantation. Fluorescence in situ hybridization (FISH) was used to verify the location of stem cells on the liver parenchyma. The effect of those cells on liver regeneration was tested by immunohistochemistry for hepatic growth factor (HGF). In addition, reverse transcription-quantitative PCR (qRT-PCR) was used to assess hepatic growth factor (HGF), hepatic nuclear factor 4α (HNF4α), cytochrome P450 1A2 (CYP1A2) and α-fetoprotein (AFP) mRNA expression.

RESULTS

Immunohistochemical staining for HGF was stronger in the transplanted groups than that in the control group (P<0.001). HNF4α and HGF mRNA levels were increased on day 7 following transplantation (P<0.001 and P=0.009, respectively). CYP1A2 mRNA levels were also increased (P=0.013) in the intravenous groups, while AFP levels were higher in the intrahepatic groups (P=0.006). ATSC transplantation attenuates ALI injury and promotes liver regeneration. Furthermore, expression of specific hepatic enzymes points to ATSC hepatic differentiation.

CONCLUSION

The study showed the positive effects of transplanted adipose tissue stem cells (ATSCs) on liver regeneration (LG) through hepatotrophic factors. Furthermore, increased expression of hepatic specific proteins was recorded in ATSC transplanted groups that indicate stem cells differentiation into hepatic cells.

Team performance training for medical students: Low vs high fidelity simulation

Objectives

The aim of this study is to evaluate a simulation-based team performance course for medical students and compare its low- and high-fidelity components.

Study design

This is a prospective crossover observational study. Groups participated in one low- and one high-fidelity session twice. Low-fidelity scenarios included management of an emergency case on a simulated-patient, whereas high-fidelity scenarios constituted of multiple-trauma cases where simulated-patients wore a hyper-realistic suit. Team performance was assessed objectively, using the TEAM™ tool, and subjectively using questionnaires. Questionnaires were also used to assess presence levels, stress levels and evaluate the course.

Results

Participants’ team performance was higher in the low-fidelity intervention as assessed by the TEAM™ tool. An overall mean increase in self-assessed confidence towards non-technical skills attitudes was noted after the course, however there was no difference in self-assessed performance between the two interventions. Both reported mean stress and presence levels were higher for the high-fidelity module. Evaluation scores for all individual items of the questionnaire were ≥4.60 in both NTS modules. Students have assessed the high-fidelity module higher (4.88 out of 5, SD = 0.29) compared to low-fidelity module (4.74 out of 5, SD = 0.67).

Conclusions

Both the low- and high-fidelity interventions demonstrated an improvement in team performance of the attending medical students. The high-fidelity intervention was more realistic, yet more stressful. Furthermore, it proved to be superior in harvesting leadership, teamwork and task management skills. Both modules were evaluated highly by the students, however, future research should address retention of the taught skills and adaptability of such interventions.

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The high-fidelity intervention was superior in harvesting leadership, teamwork and task management skills, yet more stressful.

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We set the group to develop a novel group of team-based OSCE performance.

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The next step is to adapt such taught skills to different specialties and implement initiatives in the medical school curricula.

Measurement of mean systemic filling pressure after severe hemorrhagic shock in swine anesthetized with propofol-based total intravenous anesthesia: implications for vasopressor-free resuscitation

Background

Mean systemic filling pressure (Pmsf) is a quantitative measurement of a patient’s volume status and represents the tone of the venous reservoir. The aim of this study was to estimate Pmsf after severe hemorrhagic shock and cardiac arrest in swine anesthetized with propofol-based total intravenous anesthesia, as well as to evaluate Pmsf’s association with vasopressor-free resuscitation.

Methods

Ten healthy Landrace/Large-White piglets aged 10–12 weeks with average weight 20±1 kg were used in this study. The protocol was divided into four distinct phases: stabilization, hemorrhagic, cardiac arrest, and resuscitation phases. We measured Pmsf at 5–7.5 seconds after the onset of cardiac arrest and then every 10 seconds until 1 minute postcardiac arrest. During resuscitation, lactated Ringers was infused at a rate that aimed for a mean right atrial pressure of ≤4 mm Hg. No vasopressors were used.

Results

The mean volume of blood removed was 860±20 ml (blood loss, ~61%) and the bleeding time was 43.2±2 minutes while all animals developed pulseless electrical activity. Mean Pmsf was 4.09±1.22 mm Hg, and no significant differences in Pmsf were found until 1 minute postcardiac arrest (4.20±0.22 mm Hg at 5–7.5 seconds and 3.72±0.23 mm Hg at 55– 57.5 seconds; P=0.102). All animals achieved return of spontaneous circulation (ROSC), with mean time to ROSC being 6.1±1.7 minutes and mean administered volume being 394±20 ml.

Conclusions

For the first time, Pmsf was estimated after severe hemorrhagic shock. In this study, Pmsf remained stable during the first minute post-arrest. All animals achieved ROSC with goal-directed fluid resuscitation and no vasopressors.

A prospective study integrating a curriculum of interventional radiology in undergraduate education: a tetra-core simulation model

Background

Interventional radiology (IR) is underrepresented in undergraduate medical curricula across Europe. By continuing to challenge the boundaries of IR, a rise in the demand for radiologists has been inevitable – a trend not met by a corresponding rise in the supply of radiologists. On tracing the roots of this shortage, lack of awareness of the specialty within medical trainees coupled with a global lack of IR teaching in undergraduate education seem to constitute major exacerbating factors. The purpose of this study was to identify gaps in the field of IR education and address these by implementing an international IR simulation-based course for undergraduates.

Results

Implementation of a multi-modality simulation-based course consisted of seven modules incorporating technical and non-technical skills, basic science and applied clinical science modules. Of all participants, 90.7% (N = 68) never had previous IR teaching experience and only 28% (N = 21) had a previous placement in an IR department. Following the course, confidence improvement was statistically significant both in IR skills (1/5, p < 0.01) and knowledge (1/5, p < 0.01)]. The majority (90.7%) said they would benefit with more exposure to IR. In terms of the students’ motivation for a career in IR, 32% (N = 24) reported that they would more likely consider a career in IR after completing the course.

Conclusion

Delivery of a tetra-core simulation course with the aim to address the gaps in undergraduate IR education has had a positive impact on students’ skills, confidence levels as well as motivation. We propose reviewing the curricula across medical schools in Europe to identify gaps and address any inadequacies; for this, we consider our simulation course an excellent starting point.

Retrospective qualitative study evaluating the application of IG4 curriculum: an adaptable concept for holistic surgical education

OBJECTIVES

Faced with a costly and demanding learning curve of surgical skills acquisition, the growing necessity for improved surgical curricula has now become irrefutable. We took this opportunity to formulate a teaching framework with the capacity to provide holistic surgical education at the undergraduate level.

SETTING

Data collection was conducted in all the relevant healthcare centres the participants worked in. Where this was not possible, interviews were held in quiet public places.

PARTICIPANTS

We performed an in-depth retrospective evaluation of a proposed curriculum, through semi-structured interviews with 10 participants. A targeted sampling technique was employed in order to identify senior academics with specialist knowledge in surgical education. Recruitment was ceased on reaching data saturation after which thematic data analysis was performed using NVivo 11.

RESULTS

Thematic analysis yielded a total of 4 main themes and 29 daughter nodes. Majority of study participants agreed that the current landscape of basic surgical education is deficient at multiple levels. While simulation cannot replace surgical skills acquisition taking place in operating rooms, it can be catalytic in the transition of students to postgraduate training. Our study concluded that a standardised format of surgical teaching is essential, and that the Integrated Generation 4 (IG4) framework provides an excellent starting point.

CONCLUSIONS

Through expert opinion, IG4 has been validated for its capacity to effectively accommodate learning in a safer and more efficacious environment. Moreover, we support that through dissemination of IG4, we can instil a sense of motivation to students as well as develop robust data sets, which will be amenable to data analysis through the application of more sophisticated methodologies.

Artificial Intelligence in Obstetrics and Gynaecology: Is This the Way Forward?

An increasing trend in funding towards artificial intelligence (AI) research in medicine has re-animated huge expectations for future applications. Obstetrics and gynaecology remain highly litigious specialities, accounting for a large proportion of indemnity payments due to poor outcomes. Several challenges have to be faced in order to improve current clinical practice in both obstetrics and gynaecology. For instance, a complete understanding of fetal physiology and establishing accurately predictive antepartum and intrapartum monitoring are yet to be achieved. In gynaecology, the complexity of molecular biology results in a lack of understanding of gynaecological cancer, which also contributes to poor outcomes. In this review, we aim to describe some important applications of AI in obstetrics and gynaecology. We also discuss whether AI can lead to a deeper understanding of pathophysiological concepts in obstetrics and gynaecology, allowing delineation of some grey zones, leading to improved healthcare provision. We conclude that AI can be used as a promising tool in obstetrics and gynaecology, as an approach to resolve several longstanding challenges; AI may also be a means to augment knowledge and assist clinicians in decision-making in a variety of areas in obstetrics and gynaecology.

Alarming endoscopic data in young and older asymptomatic people: Results of an open access, unlimited age colonoscopic screening for colorectal cancer

There is a lack of a national organized screening program for colorectal cancer in Greece, and asymptomatic detection is usually the result of individual decisions. The collection of epidemiologic endoscopic data from a population of interest would therefore provide valuable information for future treatment guidance, especially during periods of economic austerity. The current cross-sectional study included 380 asymptomatic, average risk individuals undergoing screening colonoscopy for the first time, during the period of one year in a tertiary public hospital in Athens. Descriptive and analytic epidemiologic data were analyzed. The prevalence of adenomas and advanced lesions were compared between the younger and older cohort, and a regression model was applied for risk evaluation. The mean age of participants was 63 years, and 53% were male. A significant proportion of patients presented with polyps (51.5%) and 25% of them had lesions in the proximal colon. The prevalence of adenomas and advanced adenomas was 29.5 and 11.8%, respectively. Similar high prevalence rates of lesions were identified in the cohort of individuals <50 years of age and the older cohort (>50 years of age). Regression models identified age, number and size of polyps as the major risk factors for the detection of adenomas. The increase of advanced lesions in the older and younger cohort requires confirmation by larger studies. Overall, the results of the present study indicate the requirement for a well-organized screening colonoscopy program starting from as early as 40 years of age. This program may confer an additional endoscopic burden with socioeconomic consequences in a country with limited health resources.

Correction to: Initial Immune Response in Escherichia coli, Staphylococcus aureus, and Candida albicans Bacteremia

The original version of this article contained mistakes, and the authors would like to correct them.

Apigenin Exerts Anti-inflammatory Effects in an Experimental Model of Acute Pancreatitis by Down-regulating TNF-α

BACKGROUND/AIM

This study investigated the anti-inflammatory effect of apigenin in an experimental model of acute pancreatitis. Inflammatory response was reflected by tissue expression of the cytokine TNF-α coupled with histological examination.

MATERIALS AND METHODS

Wistar rats were divided into three groups: Sham-group animals underwent laparotomy only, without any other interventions. Control-group animals underwent laparotomy and bilio-pancreatic duct ligation to induce pancreatitis without apigenin administration. Apigenin group animals were further treated with apigenin. Euthanasia was performed at 6, 12, 24, 48 and 72 h post-operatively.

RESULTS

Over-expression of TNF-α in relation to postoperative time was observed in the control group (p<0.001). In the apigenin group, under-expression of TNF-α in relation to postoperative time was observed (p<0.013). At 72 h, apigenin reduced pancreatic TNF-α expression and prevented pancreatic necrosis.

CONCLUSION

Apigenin slows progression and reduces severity of acute pancreatitis. Apigenin may serve as an adjunct to a more successful therapeutic strategy in acute pancreatitis.

Can ReGeneraTing Agents Improve Functional Recovery of Transected Peripheral Nerve through a Nerve Gap Bridged with an Artery Graft?

Background The purpose of this study was to use artery grafts filled with CACIPLIQ20 and see if they promote nerve regeneration.

Methods Sixty male Wistar rats were used. The rats were randomly divided into four experimental groups (n = 15): transected control group (negative control group [NCG]), sham-operated group (positive control group [SO]) artery graft group filled with saline (AG/NS), and CACIPLIQ20-treated group (AG/CACIPLIQ20). Fifteen rats were used as artery graft donors. In the SO group, the sciatic nerve was dissected from the surrounding tissues and left intact. In the NCG, AG/NS and AG/CACIPLIQ20) groups, a 10-mm gap was created in the left sciatic nerve. In the NCG group, the gap was not bridged with a graft. In the AG/NS group, the gap was bridged with a graft filled with saline. In the AG/CACIPLIQ20 group, the graft was filled with CACIPLIQ20. Walking track analysis was performed at 4, 8, 12, and 16 weeks after surgery. At 16 weeks postoperatively, the rats were sacrificed, nerve sections were harvested for histopathology analysis, and the weight ratio of the gastrocnemius muscle was measured.

Results There was no significant difference in myelin sheath thickness between the AG/NS and AG/CACIPLIQ20 groups. Muscle weight in the AG/CACIPLIQ20 group was higher but not statistically significant (p = 0.168) compared with the AG/NS group. Also, AG/CACIPLIQ20 mean was better than AG/NS mean, although there was no statistically significant difference (p = 0.605).

Conclusion There could be an indication that CACIPLIQ20 improves functional recovery of a transected peripheral nerve through a nerve gap bridged with an artery graft.

Regulation of breathing pattern by IL-10

Proinflammatory cytokines like interleukin-1β (IL-1β) affect the control of breathing. Our aim is to determine the effect of the anti-inflammatory cytokine IL-10 οn the control of breathing. IL-10 knockout mice (IL-10^-/-, n = 10) and wild-type mice (IL-10^+/+, n = 10) were exposed to the following test gases: hyperoxic hypercapnia 7% CO₂-93% O₂, normoxic hypercapnia 7% CO₂-21% O₂, hypoxic hypercapnia 7% CO₂-10% O₂, and hypoxic normocapnia 3% CO₂-10% O₂. The ventilatory function was assessed using whole body plethysmography. Recombinant mouse IL-10 (rIL-10; 10 μg/kg) was administered intraperitoneally to wild-type mice (n = 10) 30 min before the onset of gas challenge. IL-10 was administered in neonatal medullary slices (10-30 ng/ml, n = 8). We found that IL-10^-/- mice exhibited consistently increased frequency and reduced tidal volume compared with IL-10^+/+ mice during room air breathing and in all test gases (by 23.62 to 33.2%, P < 0.05 and -36.23 to -41.69%, P < 0.05, respectively). In all inspired gases, the minute ventilation of IL-10^-/- mice was lower than IL-10^+/+ (by -15.67 to -22.74%, P < 0.05). The rapid shallow breathing index was higher in IL-10^-/- mice compared with IL-10^+/+ mice in all inspired gases (by 50.25 to 57.5%, P < 0.05). The intraperitoneal injection of rIL-10 caused reduction of the respiratory rate and augmentation of the tidal volume in room air and also in all inspired gases (by -12.22 to -29.53 and 32.18 to 45.11%, P < 0.05, respectively). IL-10 administration in neonatal rat (n = 8) in vitro rhythmically active medullary slice preparations did not affect either rhythmicity or peak amplitude of hypoglossal nerve discharge. In conclusion, IL-10 may induce a slower and deeper pattern of breathing.

Lazaroid U-74389G in liver ischemia-reperfusion injury: A swine model

Reactive oxygen species have a key role in liver ischemia-reperfusion (I/R) injury. In the present study, the effect of the anti-oxidant compound lazaroid U-74389G in preventing liver I/R injury was investigated in a swine model. Ischemia was produced by portal vein occlusion. Two sets of experiments were performed, each with two groups (n=7 per group). In the first group, the potential protective effect of an intracaval injection of U-74389G after a 30-min ischemia, followed by a 60-min reperfusion period was assessed (biopsies at 0, 15, 30 and 90 min experimental time). In the second set, the effect of intracaval U-74389G injection after 30 min of ischemia, followed by a longer reperfusion period of 120 min was determined (biopsies at 0, 15, 30 and 150 min experimental time). Liver malondialdehyde, hepatocyte vacuolation-degeneration, venous congestion, inflammatory cell infiltration, sinus congestion-dilation and Chiu score of intestinal damage were determined at up to 150 min of reperfusion. In the second set of experiments, the Chiu score of intestinal damage was improved by the administration of U-74389G (3.17±0.40 vs. 4.33±0.21; P=0.030). However, in the two sets of experiments, the liver inflammatory reaction was more pronounced in the U-74389G groups (P=0.017 for the first set, P=0.021 for the second set). No significant effect of U-74389G on any other parameters was detected. In conclusion, intestinal damage due to portal venous congestion and reflow appears to be mitigated by the lazaroid U-74389G; however, intracaval administration of U-74389G does not appear to exert any protective effects against liver I/R-induced inflammation.

Advancing Medical Students' Non-technical Skills in a Group-Based Setting

Aim of the study: Introduction of non-technical skill (NTS) modules in undergraduate medical curricula is essential to prevent errors that occur due to inadequate communication and malfunctioning teams. We primarily aimed to observe medical students' NTS performance improvement in a group-based setting and compare it across participants of different countries of study. Secondarily, we aimed to assess students' views on such initiatives. Material and Methods: We designed a pilot module for assessing and improving a group's NTS performance. This was based on three main pillars: simulation-based learning, constructive feedback and objective assessment. Senior medical students from EU universities were invited to apply online. Delegates were divided according to their country of study and participated in two surgical scenarios. Groups had two attempts at each scenario and feedback was given in between. Performance was assessed using a modified version of the Individual Teamwork Observation and Feedback Tool (iTOFT). Participant feedback was collected at the end of the module. Results: Eighty delegates were recruited and finished the study. A mean increase performance of 0.81 out of 3 was noted between attempts in trauma-case scenarios and 0.88 out of 3 in ward round scenarios. Overall performance improvement was similar across all groups (p > 0.05). Feedback of delegates was encouragingly positive. Conclusions: The reported improvement and positive feedback received highlight that such an intervention can be implemented in medical school curricula of all countries. Our module design, along with the use of iTOFT, should act as the basis for future development of group-based learning and assessment in undergraduate medical education.

Are interventional radiology and allied specialities neglected in undergraduate medical education? A systematic review

OBJECTIVES

Minimally invasive interventional approaches are gaining wider acceptance with several specialities incorporating such principles. Awareness and understanding of interventional principles require efficacious education and training methodologies. We performed a systematic review to identify all available interventional speciality learning modules or training opportunities available for undergraduate medical students. We also propose a standardised framework for relevant modules.

METHODS

We searched PubMed and all Ovid databases with no language restriction for studies that report and evaluate interventional speciality educational modules or similar training initiatives. We followed a prospective protocol (PROSPERO registration: CRD42018110006). Internal and external validity of the included studies was assessed. Qualitative synthesis of data was performed to define performance improvement and/or motivation towards a career in an interventional speciality.

RESULTS

Out of 6081 records, 17 studies met the inclusion criteria, 15 of which were focused on interventional radiology. More than half of studies (9/17) were surveys where student knowledge and interest were reported as poor. 5 out of 6 studies which assessed the effect of educational interventions concluded to improved knowledge or performance. Most surveys concluded that early exposure can increase interest towards such specialities, improve knowledge and relevant motivation.

CONCLUSIONS

Few studies report teaching initiatives in interventional radiology and other interventional specialities, reflecting the poor relevant motivation and knowledge amongst medical students. Simple interventions e.g. introductory lectures and simulation sessions spark interest in students and also improve knowledge as proven in the case of interventional radiology. Standardisation of such efforts via a suggested framework, Strategy Development Framework for Interventional Radiology, can further optimise such outcomes.

Developing a novel framework for non-technical skills learning strategies for undergraduates: A systematic review

OBJECTIVES

There is substantial lack of guidance when it comes to the implementation of non-technical skills (NTS) in undergraduate medical education. This review aimed to identify and critically evaluate published literature on learning strategies for NTS in undergraduate medical education and to derive a training framework targeted towards standardizing future training interventions.

METHODS

A systematic review of the MEDLINE database was performed using a prospective protocol following PRISMA guidelines. Studies evaluating undergraduate medical students exposed to NTS interventions, which measured subjective or objective outcomes in selected attributes, were included.

RESULTS

Initial systematic search yielded a total of 5079 articles, out of which 68 fulfilled the inclusion criteria. A total of 24 NTS were identified, with communication skills being the most commonly reported skill evaluated (n = 37). A variety of educational tools were used (n = 32), noteworthy being the use of simulated patients. Great heterogeneity was also observed in measured outcomes and methods of assessment. A 'triad of outcomes' in NTS training was devised (knowledge, skill performance and attitude towards skills) and used for classification of all reported outcomes. Extracted data were used to design a non-technical skill training framework.

CONCLUSIONS

The existing literature describes a plethora of NTS interventions in undergraduate medical education, with varied outcomes and assessments. We hereby propose the 'NTS Training Framework', in an attempt to coordinate future research and catalyze the identification of an ideal NTS course structure to form tomorrow's physicians.

How Much Ischemia Can the Severely Steatotic Rat Liver Tolerate?

AIM

Steatotic liver is more susceptible to ischemia-reperfusion injury than is lean liver. Our aim was to investigate the ability of the severely steatotic rat liver to sustain ischemia.

MATERIALS AND METHODS

One hundred male Wistar rats aged 12-14 weeks were included. Fifty rats were given regular diet, while the rest were given a choline-free diet for 12-14 weeks to develop severe liver steatosis. Each group was divided into the following five subgroups: Sham-operated, and 5, 10, 15 and 20 minutes of continuous vascular inflow occlusion. Serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase levels were measured at 24 hours postoperatively and the animals were surveilled for 30 days.

RESULTS

Serum transaminase levels increased as the duration of ischemia increased in lean livers (p<0.0001), without a significant impact on animal survival. Similarly, serum transaminase levels increased as the duration of ischemia increased in severely steatotic livers (p<0.0001), reaching a plateau after 15 minutes of liver ischemia. Survival was significantly affected after the same cut-off point in rats with steatotic liver (p<0.0001). Serum transaminase levels were greater in severely rats with steatotic liver than in rats with lean liver, when they were adjusted for the duration of liver ischemia. Moreover, survival was reduced when serum transaminase levels surpassed the threshold of 2,000 IU/l (p<0.0001).

CONCLUSION

Severely steatotic rat liver can safely tolerate up to 10 minutes of continuous ischemia, with survival being affected after 15 minutes or more. On the other hand, lean rat liver can safely tolerate even 20 minutes of continuous ischemia.