ENETS Consensus Guidelines for Standard of Care in Neuroendocrine Tumours: Biochemical Markers

Biomarkers have been the mainstay in the diagnosis and follow-up of patients with neuroendocrine tumors (NETs) over the last few decades. In the beginning, secretory products from a variety of subtypes of NETs were regarded as biomarkers to follow during diagnosis and treatment: serotonin for small intestinal (SI) NETs, and gastrin and insulin for pancreatic NETs. However, it became evident that a large number of NETs were so-called nonfunctioning tumors without secreting substances that caused hormone-related symptoms. Therefore, it was necessary to develop so-called “general tumor markers.” The most important ones so far have been chromogranin A and neuron-specific enolase (NSE). Chromogranin A is the most important general biomarker for most NETs with a sensitivity and specificity somewhere between 60 and 90%. NSE has been a relevant biomarker for patients with high-grade tumors, particularly lung and gastrointestinal tract tumors. Serotonin and the breakdown product urinary 5-hydroxyindoleacetic acid (U-5-HIAA) is still an important marker for diagnosing and follow-up of SI NETs. Recently, 5-HIAA in plasma has been analyzed by high-performance liquid chromatography and fluorometric detection and has shown good agreement with U-5-HIAA analysis. In the future, we will see new tests including circulating tumor cells, circulating DNA and mRNA. Recently, a NET test has been developed analyzing gene transcripts in circulating blood. Preliminary data indicate high sensitivity and specificity for NETs. However, its precise role has to be validated in prospective randomized controlled trials which are ongoing right now.

Outcomes of implementing the women's health assessment tool and clinical decision support toolkit

AIM

To evaluate outcomes after implementing the women's health assessment tool (WHAT) and clinical decision support toolkit during annual well-women visits.

METHODS

An observational project involved women aged 45-64 years attending one of three medical sites in Washington (WA, USA). Responses to the WHAT questionnaire and patients' health resource utilization prepost toolkit implementation were analyzed.

RESULTS

A total of 110 women completed the WHAT questionnaire. Majority of women were postmenopausal (77.3%) and experienced depressive mood (63.6%), hot flashes (61.8%) or anxiety (60.9%) in the last 3 months. There was a 72.2% increase in the number of diagnoses made during the annual visit versus the previous 12 months.

CONCLUSION

The WHAT/clinical decision support toolkit helped identify conditions relevant to mid-life women.

An Innovative Interactive Modeling Tool to Analyze Scenario-Based Physician Workforce Supply and Demand

Effective physician workforce management requires that the various organizations comprising the House of Medicine be able to assess their current and future workforce supply. This information has direct relevance to funding of graduate medical education. We describe a dynamic modeling tool that examines how individual factors and practice variables can be used to measure and forecast the supply and demand for existing and new physician services. The system we describe, while built to analyze the pathologist workforce, is sufficiently broad and robust for use in any medical specialty. Our design provides a computer-based software model populated with data from surveys and best estimates by specialty experts about current and new activities in the scope of practice. The model describes the steps needed and data required for analysis of supply and demand. Our modeling tool allows educators and policy makers, in addition to physician specialty organizations, to assess how various factors may affect demand (and supply) of current and emerging services. Examples of factors evaluated include types of professional services (3 categories with 16 subcategories), service locations, elements related to the Patient Protection and Affordable Care Act, new technologies, aging population, and changing roles in capitated, value-based, and team-based systems of care. The model also helps identify where physicians in a given specialty will likely need to assume new roles, develop new expertise, and become more efficient in practice to accommodate new value-based payment models.

DEEP BIOSPHERE. Exploring deep microbial life in coal-bearing sediment down to ~2.5 km below the ocean floor

Microbial life inhabits deeply buried marine sediments, but the extent of this vast ecosystem remains poorly constrained. Here we provide evidence for the existence of microbial communities in ~40° to 60°C sediment associated with lignite coal beds at ~1.5 to 2.5 km below the seafloor in the Pacific Ocean off Japan. Microbial methanogenesis was indicated by the isotopic compositions of methane and carbon dioxide, biomarkers, cultivation data, and gas compositions. Concentrations of indigenous microbial cells below 1.5 km ranged from <10 to ~10(4) cells cm(-3). Peak concentrations occurred in lignite layers, where communities differed markedly from shallower subseafloor communities and instead resembled organotrophic communities in forest soils. This suggests that terrigenous sediments retain indigenous community members tens of millions of years after burial in the seabed.

Wide cleft between theory and practice: medical students' perception of their education in patient and medication safety

In medicine today, future doctors are expected to ensure patient safety. Yet medical students often feel uncertain if they can meet these high expectations. This study aims to quantify the perceptions of medical students regarding the actual quality of their education in the fields of patient safety and, in particular, medication safety. A questionnaire was designed and distributed to about 100 upper-level medical students. The students had to respond to 12 questions regarding the following categories: 1) familiarity with patient safety and/or medication safety; 2) personal experience in high-risk clinical situations; and 3) perceived relevance of knowledge in the area of patient and medication Safety for clinical practice. Of the respondents 42.1% and 36.8% had delved into the topic patient safety and medication safety, respectively. In clinical practice 88.2% of respondents had experienced a high-risk situation for patients. Regarding patient safety and medication safety, respectively, 82.9% and 85.3% of the respondents found these topics to be particularly relevant to their clinical practice. This study has shown that there is a measurable discrepancy between the students' perceived quality of their medical education and their feelings that they are well prepared to cope with severe clinical challenges.

Unifying framework for relaxations of the causal assumptions in Bell's theorem

Bell's theorem shows that quantum mechanical correlations can violate the constraints that the causal structure of certain experiments impose on any classical explanation. It is thus natural to ask to which degree the causal assumptions-e.g., locality or measurement independence-have to be relaxed in order to allow for a classical description of such experiments. Here we develop a conceptual and computational framework for treating this problem. We employ the language of Bayesian networks to systematically construct alternative causal structures and bound the degree of relaxation using quantitative measures that originate from the mathematical theory of causality. The main technical insight is that the resulting problems can often be expressed as computationally tractable linear programs. We demonstrate the versatility of the framework by applying it to a variety of scenarios, ranging from relaxations of the measurement independence, locality, and bilocality assumptions, to a novel causal interpretation of Clauser-Horne-Shimony-Holt inequality violations.

Pulmonary neuroendocrine (carcinoid) tumors: European Neuroendocrine Tumor Society expert consensus and recommendations for best practice for typical and atypical pulmonary carcinoids

BACKGROUND

Pulmonary carcinoids (PCs) are rare tumors. As there is a paucity of randomized studies, this expert consensus document represents an initiative by the European Neuroendocrine Tumor Society to provide guidance on their management.

PATIENTS AND METHODS

Bibliographical searches were carried out in PubMed for the terms 'pulmonary neuroendocrine tumors', 'bronchial neuroendocrine tumors', 'bronchial carcinoid tumors', 'pulmonary carcinoid', 'pulmonary typical/atypical carcinoid', and 'pulmonary carcinoid and diagnosis/treatment/epidemiology/prognosis'. A systematic review of the relevant literature was carried out, followed by expert review.

RESULTS

PCs are well-differentiated neuroendocrine tumors and include low- and intermediate-grade malignant tumors, i.e. typical (TC) and atypical carcinoid (AC), respectively. Contrast CT scan is the diagnostic gold standard for PCs, but pathology examination is mandatory for their correct classification. Somatostatin receptor imaging may visualize nearly 80% of the primary tumors and is most sensitive for metastatic disease. Plasma chromogranin A can be increased in PCs. Surgery is the treatment of choice for PCs with the aim of removing the tumor and preserving as much lung tissue as possible. Resection of metastases should be considered whenever possible with curative intent. Somatostatin analogs are the first-line treatment of carcinoid syndrome and may be considered as first-line systemic antiproliferative treatment in unresectable PCs, particularly of low-grade TC and AC. Locoregional or radiotargeted therapies should be considered for metastatic disease. Systemic chemotherapy is used for progressive PCs, although cytotoxic regimens have demonstrated limited effects with etoposide and platinum combination the most commonly used, however, temozolomide has shown most clinical benefit.

CONCLUSIONS

PCs are complex tumors which require a multidisciplinary approach and long-term follow-up.

Automated prediction of risk for problem opioid use in a primary care setting

Identification of patients at increased risk for problem opioid use is recommended by chronic opioid therapy (COT) guidelines, but clinical assessment of risks often does not occur on a timely basis. This research assessed whether structured electronic health record (EHR) data could accurately predict subsequent problem opioid use. This research was conducted among 2,752 chronic noncancer pain patients initiating COT (≥70 days' supply of an opioid in a calendar quarter) during 2008 to 2010. Patients were followed through the end of 2012 or until disenrollment from the health plan, whichever was earlier. Baseline risk indicators were derived from structured EHR data for a 2-year period prior to COT initiation. Problem opioid use after COT initiation was assessed by reviewing clinician-documented problem opioid use in EHR clinical notes identified using natural language processing techniques followed by computer-assisted manual review of natural language processing-positive clinical notes. Multivariate analyses in learning and validation samples assessed prediction of subsequent problem opioid use. The area under the receiver operating characteristic curve (c-statistic) for problem opioid use was .739 (95% confidence interval = .688, .790) in the validation sample. A measure of problem opioid use derived from a simple weighted count of risk indicators was found to be comparably predictive of the natural language processing measure of problem opioid use, with 60% sensitivity and 72% specificity for a weighted count of ≥4 risk indicators.

PERSPECTIVE

An automated surveillance method utilizing baseline risk indicators from structured EHR data was moderately accurate in identifying COT patients who had subsequent problem opioid use.

Increased Preclass Preparation Underlies Student Outcome Improvement in the Flipped Classroom

Active-learning environments such as those found in a flipped classroom are known to increase student performance, although how these gains are realized over the course of a semester is less well understood. In an upper-level lecture course designed primarily for biochemistry majors, we examine how students attain improved learning outcomes, as measured by exam scores, when the course is converted to a more active flipped format. The context is a physical chemistry course catering to life science majors in which approximately half of the lecture material is placed online and in-class problem-solving activities are increased, while total class time is reduced. We find that exam performance significantly improves by nearly 12% in the flipped-format course, due in part to students interacting with course material in a more timely and accurate manner. We also find that the positive effects of the flipped class are most pronounced for students with lower grade point averages and for female students.

Matrix-product operators and states: NP-hardness and undecidability

Tensor network states constitute an important variational set of quantum states for numerical studies of strongly correlated systems in condensed-matter physics, as well as in mathematical physics. This is specifically true for finitely correlated states or matrix-product operators, designed to capture mixed states of one-dimensional quantum systems. It is a well-known open problem to find an efficient algorithm that decides whether a given matrix-product operator actually represents a physical state that in particular has no negative eigenvalues. We address and answer this question by showing that the problem is provably undecidable in the thermodynamic limit and that the bounded version of the problem is NP-hard (nondeterministic-polynomial-time hard) in the system size. Furthermore, we discuss numerous connections between tensor network methods and (seemingly) different concepts treated before in the literature, such as hidden Markov models and tensor trains.

Laboratory capability and surveillance testing for Middle East respiratory syndrome coronavirus infection in the WHO European Region, June 2013

Since September 2012, over 90 cases of respiratory disease caused by a novel coronavirus, now named Middle East respiratory syndrome coronavirus (MERSCoV), have been reported in the Middle East and Europe. To ascertain the capabilities and testing experience of national reference laboratories across the World Health Organization (WHO) European Region to detect this virus, the European Centre for Disease Prevention and Control (ECDC) and the WHO Regional Office for Europe conducted a joint survey in November 2012 and a follow-up survey in June 2013. In 2013, 29 of 52 responding WHO European Region countries and 24 of 31 countries of the European Union/European Economic Area (EU/EEA) had laboratory capabilities to detect and confirm MERS-CoV cases, compared with 22 of 46 and 18 of 30 countries, respectively, in 2012. By June 2013, more than 2,300 patients had been tested in 23 countries in the WHO European Region with nine laboratory-confirmed MERS-CoV cases. These data indicate that the Region has developed significant capability to detect this emerging virus in accordance with WHO and ECDC guidance. However, not all countries had developed capabilities, and the needs to do so should be addressed. This includes enhancing collaborations between countries to ensure diagnostic capabilities for surveillance of MERS-CoV infections across the European Region.

Current concepts in the diagnosis and management of type 1 gastric neuroendocrine neoplasms

The vast majority of gastrin-related gastrointestinal neuroendocrine neoplasms (GI-NENs) develop in the context of chronic atrophic gastritis (type 1), a condition closely related to autoimmune thyroid diseases. These neoplasms are defined as gastric NENs type 1 (GNEN1) and have recently been shown to constitute the commonest GI-NENs in a prospective study. GNEN1s are usually multiple and follow a relative indolent course, raising questions regarding the extent that such patients should be investigated and the appropriate therapeutic interventions needed. Recently, a number of consensus statements and guidelines have been published from various societies dealing with the diagnosis and management of GI-NENs. Endocrinologists are among the many different medical specialties involved in GNEN1s diagnosis and management. However, despite recent advances, few randomized trials are available, and thus existing evidence remains relatively weak compared to other malignancies. The purpose of this review is to provide recent evidence along with currently employed modalities addressing the diagnosis, management, long-term follow-up and potential comorbidities of GNEN1s.

Experimental comparison of efficient tomography schemes for a six-qubit state

Quantum state tomography suffers from the measurement effort increasing exponentially with the number of qubits. Here, we demonstrate permutationally invariant tomography for which, contrary to conventional tomography, all resources scale polynomially with the number of qubits both in terms of the measurement effort as well as the computational power needed to process and store the recorded data. We demonstrate the benefits of combining permutationally invariant tomography with compressed sensing by studying the influence of the pump power on the noise present in a six-qubit symmetric Dicke state, a case where full tomography is possible only for very high pump powers.

Darstellung und Eigenschaften von β-Alkoxypropionsäureestern des Cholesterins

Es werden die Darstellung und die Eigenschaften von β-Alkoxypropionsäure-Cholesterinestern beschrieben und mit denen der entsprechenden Fettsäuren verglichen. Die Schmelzpunkte nehmen mit einer steigenden Zahl von Ätherfunktionen ab. Alle untersuchten Verbindungen durchlaufen die cholesterinische Phase nur beim Abkühlen. Smektische Phasen wurden nicht beobachtet.

Untersuchungen zur Biosynthese der Nicotinsäure bei Mycobacterium tuberculosis

14C-markierte C3-Verbindungen. wie Glycerin, Glycerinaldehyd, Glycerinsäure und Pyruvat werden vorwiegend in den Pyridinring der von Mycobacterium tuberculosis Stamm BCG gebildeten Nicotinsäure eingebaut. Entsprechende Abbauversuche ergeben, daß Glycerin bevorzugt in die C-Atome 4, 5 und 6 der Nicotinsäure inkorporiert wird. Danach erfolgt in diesem Organismus die Biosynthese der Nicotinsäure aus Asparaginsäure und einem C3-Körper wie Glycerin.

3-Hydroxymethylpyridin, ein neues Stoffwechselprodukt der Mycobakterien

Aus dem Kulturfiltrat von Mycobacterium bovis Stamm BCG wird neben Nicotinsäure eine weitere Bromcyan-positive Substanz isoliert und als 3-Hydroxymethylpyridin identifiziert. Dieses Pyridin-Derivat läßt sich auch als Ausscheidungsprodukt anderer Mycobakterien-Arten nachweisen. 3-Hydroxymethylpyridin ist eng mit dem Stoffwechsel der Nicotinsäure verbunden. Angebotene Nicotinsäure wird von den BCG-Bakterien aufgenommen und zu 3-Hydroxymethylpyridin umgewandelt.

Zum Einbau von Trigonellin-[14CT3] in Ricinin

Durch Biosynthese-Untersuchungen mit Trigonellin-[14CH3] an Keimlingen von Ricinus communis wird gezeigt, daß die N-Methylgruppe des Trigonellins abgespalten wird und über den C1-Pool gleichwertig in beide Methylgruppen des Ricinins gelangt. Somit ist ein intakter Trigonellineinbau auszuschließen.

In weiteren Versuchen wird Trigonellin-[14CT3] mit einem bekannten T/14C-Verhältnis an Ricinuskeimlinge verabreicht. Die spezifische T-Einbaurate beträgt nur etwa 30% der 14C-Inkorporation. Sowohl im Ricinin als auch in den beiden Methylgruppen ist das T/14C-Verhältnis auf ein Drittel gegenüber dem Wert des applizierten Trigonellins-[14CT3] reduziert. Dieser Tritiumverlust spricht für eine oxydative Demethylierung des Triginellins und gegen eine echte Transmethylierung.

Self-perceived stigmatization in female patients with anorexia nervosa--results from an explorative retrospective pilot study of adolescents

BACKGROUND

The stigma of mental illness has been identified as an important barrier to treatment and recovery. Previous research reported the stigmatization of individuals with eating disorders by both health professionals and the general public. The aim of this pilot study was to empirically assess the previous stigmatization and discrimination experiences of young female patients with anorexia nervosa (AN) using a retrospective explorative approach.

METHODS

An in-house questionnaire that was developed to survey experiences of stigmatization was mailed to 75 former adolescent patients with AN. The mean time of assessment after discharge was 5.6 ± 1.2 years. The patients were asked to respond anonymously. The response rate was approximately 48% (n = 36).

RESULTS

Feelings that society held negative stereotypes of individuals with AN, concrete experiences of stigmatization and discrimination, and rejection by peers were reported. A remarkable degree of self-stigmatization, as indexed by high rates of agreement to stigmatizing statements, was detected. Approximately one third of the participants reported delayed initiation of treatment due to fear of stigmatization and discrimination.

CONCLUSION

Stigmatization plays a decisive role in young patients with AN and impacts their motivation to seek professional help and engage in treatment. Clinicians should be aware of the stigmatization related to eating disorders and its burden for affected patients.