Undergraduate College Pathway Programs Designed to Attract and Matriculate Students from Underrepresented Groups into Medicine

OBJECTIVES

Undergraduate college pathway (or pipeline) programs support students' interests as they explore advanced degree and career pathways. Many programs aim to diversify the medical workforce by reducing barriers that may have otherwise prevented desired academic and career goals; however, variability in structure, expectations, benefits, and outcome data exist. This systematic review was conducted to identify and evaluate undergraduate college pathway programs designed to increase the diversity of medical school matriculants.

METHODS

We searched Ovid Medline, PsycInfo, Scopus, and the Education Resources Information Center for peer-reviewed, original research publications (1996-2019) describing US pathway/pipeline programs designed for undergraduate-level college students from underrepresented groups to apply and enter medical school. Data extraction included application processes, participant demographics, curricular components, social support systems, mentorship, funding, and program/participant outcomes. We reviewed the journal impact factor to inform us about where articles are being published.

RESULTS

Our full-text review included 137 articles; 25 articles met the inclusion criteria. All of the papers were descriptive, requiring an application, minimum grade point average, letters of recommendation, and personal statements. All of the programs aimed to diversify medicine, yet some could not request identification of race/ethnicity because of changes in affirmative action or legal restrictions when reporting demographics. Women represented the majority of enrollees. The program length varied; all reported having one or a combination of academic enrichment, research, field observation/experience, and mentorship. All of the programs included career development and various supplemental social supports. Only two programs provided comparison data; four reported no outcomes.

CONCLUSIONS

Pathway programs support the acquisition and enhancement of professional skills. Lacking longitudinal or comparison data leads to questions of the long-term impact on diversifying the medical workforce. This article highlights a need for rigorous data collection methods and transparent reporting of participant outcomes to inform programmatic efficacy.

Feasibility of individualised patient modelling for continuous vancomycin infusions in outpatient antimicrobial therapy, a retrospective study

BACKGROUND

The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter for dosing vancomycin continuous infusion in methicillin-resistant Staphylococcus aureus (MRSA) infection. Individualised pharmacokinetic-pharmacodynamic (PK/PD) calculation of AUC24 may better represent therapeutic dosing than current Therapeutic Drug Monitoring (TDM) practices, targeting a Steady State Concentration of 15-25 mg/L.

AIM

To compare real world TDM practice to theoretical, individualised, PK/PD target parameters utilising Bayesian predictions to steady state concentrations (Css) for outpatients on continuous vancomycin infusions.

METHOD

A retrospective single centre study was conducted at a tertiary hospital on adult patients, enrolled in an outpatient parenteral antimicrobial therapy (OPAT) program, receiving vancomycin infusions for MRSA infection. Retrospective Bayesian dosing was modelled to target PK/PD parameters and compared to real world data.

RESULTS

Fifteen patients were evaluated with 53% (8/15) achieved target CSS during hospitalisation, and 83% (13/15) as outpatient. Median Bayesian AUC/MIC was 613 mg.h/L with CSS 25 mg/L. Patients suffering an Acute Kidney Injury (33%) had higher AUC0-24/MIC values. Retrospective Bayesian modelling demonstrated on median 250 mg/24 h lower doses than that administered was required (R2 = 0.81) which achieved AUC24/MIC median 444.8 (range 405-460) mg.h/L and CSS 18.8 (range 16.8-20.4) mg/L.

CONCLUSION

Bayesian modelling could assist in obtaining more timely target parameters at lower doses for patients receiving continuous vancomycin infusion as part of an OPAT program, which may beget fewer adverse effects. Utilisation of personalised predictive modelling may optimise vancomycin prescribing, achieving earlier target concentrations as compared to empiric dosing regimens.

Audit of Sex and Gender Medicine Topics in Preclinical School of Medicine Curriculum

INTRODUCTION

The importance of the inclusion of sex and gender medicine (SGM) in medical education has been recognized formally by both the American Association of Medical Colleges and the Department of Health and Human Services since 1995. Yet, few medical schools, including the Medical College of Wisconsin, have a standard SGM curriculum. This work mapped the SGM health topics taught in the Medical College of Wisconsin preclinical curriculum.

METHODS

Seven medical students audited 16 basic science preclinical courses in 2020-2021. SGM characterizations, including epidemiology, diagnosis, presentation, treatment, prognosis, pharmacology, and disparity, were captured by an online survey tool. Comparisons were made to 38 high-yield topics presented in the textbook "How Sex and Gender Impact Clinical Practice: An Evidence-Based Guide to Patient Care."

RESULTS

Of the 604 preclinical sessions audited, 54% contained some SGM content. Epidemiology was the most common characterization (23% of total). Thirty-four of the 38 high-yield clinical SGM topics received mention in the basic science sessions. Breast cancer, stroke, osteoporosis, sex and gender considerations in therapeutic response, and systemic lupus erythematosus had the most frequent SGM-specific coverage (representation in at least 4 of the 16 preclinical courses).

CONCLUSIONS

Utilizing a medical student cohort to thoroughly audit courses was an effective way to document that Medical College of Wisconsin preclinical curriculum introduces many clinically relevant SGM topics. However, the audit also discovered varying levels of detail among the high-yield topics with concern that students may not be adequately prepared to treat all patients. These results establish the groundwork for a more formalized and integrated approach to include SGM in preclinical curriculum.

Automating Angle Measurements on Foot Radiographs in Young Children: Feasibility and Performance of a Convolutional Neural Network Model

Measurement of angles on foot radiographs is an important step in the evaluation of malalignment. The objective is to develop a CNN model to measure angles on radiographs, using radiologists' measurements as the reference standard. This IRB-approved retrospective study included 450 radiographs from 216 patients (< 3 years of age). Angles were automatically measured by means of image segmentation followed by angle calculation, according to Simon's approach for measuring pediatric foot angles. A multiclass U-Net model with a ResNet-34 backbone was used for segmentation. Two pediatric radiologists independently measured anteroposterior and lateral talocalcaneal and talo-1st metatarsal angles using the test dataset and recorded the time used for each study. Intraclass correlation coefficients (ICC) were used to compare angle and paired Wilcoxon signed-rank test to compare time between radiologists and the CNN model. There was high spatial overlap between manual and CNN-based automatic segmentations with dice coefficients ranging between 0.81 (lateral 1st metatarsal) and 0.94 (lateral calcaneus). Agreement was higher for angles on the lateral view when compared to the AP view, between radiologists (ICC: 0.93-0.95, 0.85-0.92, respectively) and between radiologists' mean and CNN calculated (ICC: 0.71-0.73, 0.41-0.52, respectively). Automated angle calculation was significantly faster when compared to radiologists' manual measurements (3 ± 2 vs 114 ± 24 s, respectively; P < 0.001). A CNN model can selectively segment immature ossification centers and automatically calculate angles with a high spatial overlap and moderate to substantial agreement when compared to manual methods, and 39 times faster.

Helping Residents Excel in Team-Based Care: An Interactive Case-Based Interprofessional Education Curriculum

INTRODUCTION

Communication and collaboration with an interprofessional team is vital for patient care, yet teaching these skills to resident physicians faces multiple challenges.

METHODS

We developed an interactive, case-based curriculum on interprofessional communication and collaboration and implemented it at a large Veterans Affairs hospital. A pre/post survey study design was used to evaluate the curriculum, with 31 residents completing both surveys (100% response rate).

RESULTS

After the curriculum, there was improvement in the residents' knowledge, comfort, and satisfaction in communicating and collaborating with the interprofessional team. Satisfaction scores with clinic also improved in all measures.

DISCUSSION/CONCLUSIONS

Overall, a curriculum aimed at teaching interprofessional communication and collaboration improved residents' comfort and satisfaction in this realm and may help them achieve competence in these challenging-to-teach skills.

Endurance training induced cellular electrophysiological remodeling in a small and a large animal athlete’s heart model

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Funding: It was supported by NKFIH grants (K-19992, K- 135464, GINOP-2.3.2-15-2016-00047).

Background

The positive impact of regular exercise on a healthy and fulfilling lifestyle. Therefore, active athletes are considered the healthiest members of our society. However, there is an increasing amount of evidence that long-term high-intensity sporting activity could also have adverse effects on the heart, such as impaired electrophysiological properties. Heavy long-term training can lead to structural and functional remodelling of the heart, which in turn, can evoke malignant cardiac arrhythmias.

Purpose

To develop animal models with a significant translational value of the human athlete’s heart and to investigate underlying malignant drivers of cardiac arrhythmias due to the long-term endurance training in in vitro studies.

Methods

24 dogs from both sexes and 26 male guinea pigs were randomly assigned to sedentary (’Sed’) and trained (’Tr’) groups (n = 12-12; n=13-13). The latter group underwent a long-term endurance interval-training program on the treadmill 5 days a week for 4 months. ECG recordings and echocardiography validated the characteristic of athlete’s heart. After heart removal, the degree of interstitial fibrosis was quantified and ventricular myocytes were enzymatically dissociated via retrograde perfusion. The transmembrane ionic currents were recorded using the whole-cell configuration of the patch-clamp technique. The action potentials were measured by the perforated patch-clamp technique. Immunocytochemistry measurements were performed to determine the density of transmembrane ion channels.

Results

Based on the ECG and ECHO results, the vigorous training program resulted in significant cardiac adaptation in both species. In addition, it caused mild ventricular fibrosis. The repolarization is reflected as the 90 percent of action potential duration (APD90). It was significantly lengthened in the left ventricular myocytes of ‘Tr’ dogs. (‘Tr’ vs. ‘Sed’ 472.8±29.6 ms; =29 vs. 369.3±31.4 ms; n=24, p=0.023) and there was no difference in the case of guinea pigs. The amplitude of the transient outward current (Ito), which is not expressed in the guinea pig heart, was significantly smaller in the ‘Tr’ dogs (‘Tr’ vs. ‘Sed’ 7.6±0.6 pA/pF, n=54 vs. 10.2±1.0 pA/pF, n=42, p&lt;0.05). Under the currently used protocols, no differences were detected in the magnitude of other ionic currents. The HCN4 gene expression was significantly higher in isolated myocytes in ’Tr’ dogs.

Conclusion

Increased ectopic activity is not rare among top athletes. Our results suggest an association between increased arrhythmia susceptibility and impaired repolarisation reserve related to down-regulation of Ito and prolonged APD90 and enhanced fibrotic changes. The overexpression of HCN4 gene in hypertrophic hearts, similar to heart failure, may evoke malignant ventricular arrhythmias. Further studies are warranted to clarify this hypothesis in more detail.

Cardiac remodeling accompanied by increased arrhythmia susceptibility in a dog model of chronic high-intensity endurance training

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by NKFIH grants (K-19992, K-135464) and GINOP-2.3.2-15-2016-00047.

Background

Despite the cardiovascular benefits of regular physical exercise, chronic high-level exercise can evoke malignant arrhythmias, including ventricular fibrillation and even sudden cardiac death, especially in young top athletes. In some cases the underlying mechanisms are unclear.

Objectives

The goal of this study was to assess mechanisms underlying cardiac structural-electrical changes and arrhythmia vulnerability by high-level vigorous exercise training in animal species that are electrophysiologically relevant to the human heart.

Methods

Beagle dogs were randomly assigned to matched sedentary (Sed) or intensive exercise-training (Ex) groups (n=12-12). Ex dogs underwent a 4-month-long intensive treadmill-running protocol (5 days a week, 6 hours a day at a speed of 14-21 km/h with an inclination from 5% to 12%). In vivo echocardiography and electrophysiological measurements were performed. Proarrhythmic sensitivity was tested and the autonomic alterations were examined. At study end, arrhythmia susceptibility was tested with high-frequency burst stimulation in open-chest anaesthetized dogs. This was followed by cardiac excision and cardiomyocyte isolation, formalin preservation for histology, snap-freezing in liquid nitrogen for molecular biology.

Results

The vigorous endurance training was resulted in increased left ventricular end-diastolic diameter, increased septal wall thickness and greater left ventricular mass index (Ex vs. Sed: 98±12 vs. 136±7 g/m2, p&lt;0.05). Some degree of enhanced fibrosis was observed. Endurance training decreased heart rate both in whole animal and in vitro dog experiments. ECG recordings presented enhanced heart rate variability parameters, prolonged PQ (Ex vs. Sed: 98.3±2.9 vs. 116.7±3.6 ms, p&lt;0.05), QRS (Ex vs. Sed : 60.5±2.4 vs 70.8±1.6 ms, p&lt;0.05), QTc (Ex vs. Sed: 213.6±2.8 vs. 237.1±3.4 ms, p&lt;0.05), Tp-Te (Ex vs. Sed: 27.9±2.5 vs.36.5±1.7 ms, p&lt;0.05) intervals associated with significantly enhanced QT interval variability (eg. Ex vs. Sed: QT-STV, 2.5±0.2 vs. 3.6±0.4 ms, p&lt;0.05), reflecting elevated level of repolarization dispersion. Ectopic activity was also enhanced in the exercised dog ventricle. Atropine treatment resulted in moderate heart rate increase in the Ex animals. Chronic endurance exercise elevated the proarrhythmic risk and consequent ventricular fibrillation in dogs subjected to burst electrical stimulation.

Conclusion

We developed a new animal model that shares similarities with the human endurance-trained athlete’s heart. The model represents increased arrhythmia susceptibility, an important clinical paradigm, and explores potential underlying mechanisms, including vagal enhancement, increased repolarization dispersion and enhanced fibrotic changes. Increased arrhythmia susceptibility is supported by the enhanced arrhythmia incidence in the exercised group. Similar changes may be present in young human top athletes, however further investigations are required.

Integrated twin-screw wet granulation, continuous vibrational fluid drying and milling: A fully continuous powder to granule line

Highly homogeneous low-dose (50 μg) tablets were produced incorporating perfectly free-flowing granules prepared by a fully integrated Continuous Manufacturing (CM) line. The adopted CM equipment consisted of a Twin-Screw Wet Granulator (TSWG), a Continuous Fluid Bed Dryer (CFBD) and a Continuous Sieving (CS) unit. Throughout the experiments a pre-blend of lactose-monohydrate and corn starch was gravimetrically dosed with 1 kg/h into the TSWG, where they were successfully granulated with the drug containing water-based PVPK30 solution. The wet mass was subsequently dried in the CFBD on a vibratory conveyor belt and finally sieved in the milling unit. Granule production efficiency was maximized by determining the minimal Liquid-to-Solid (L/S) ratio (0.11). Design of Experiments (DoE) were carried out in order to evaluate the influence of the drying process parameters of the CFBD on the Loss-on-Drying (LOD) results. The manufactured granules were compressed into tablets by an industrial tablet rotary press with excellent API homogeneity (RSD < 3%). Significant scale-up was realized with the CM line by increasing the throughput rate to 10 kg/h. The manufactured granules yielded very similar results to the previous small-scale granulation runs. API homogeneity was demonstrated (RSD < 2%) with Blend Uniformity Analysis (BUA). The efficiency of TSWG granulation was compared to High-Shear Granulation (HSG) with the same L/S ratio. The final results have demonstrated that both the liquid distribution and more importantly API homogeneity was better in case of the TSWG granulation (RSD 1.3% vs. 4.5%).

Sexual Harassment of Female Providers by Patients: a Qualitative Study

BACKGROUND

Sexual harassment of women is a pervasive problem. Prior studies found that sexual harassment of female providers by patients is common, but guidance on addressing this problem is limited.

OBJECTIVE

To understand the experiences of female providers with sexual harassment by patients with a focus on how practicing providers address these events.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

Twenty female, internal medicine providers, including resident physicians, staff physicians, and nurse practitioners at a large, urban, academic hospital in the USA.

APPROACH

Interviews were analyzed for themes.

KEY RESULTS

Two themes were explored: first, the experiences with sexual harassment and, second, the strategies to address sexual harassment. We coded four sub-themes regarding participant experiences: (1) their descriptions of the types of harassment, (2) the context of the event, (3) the impact of the harassment, and (4) their preparation to address the harassment. We coded seven sub-themes on strategies used by participants: (1) indirect strategies, (2) confrontation, (3) modifying the clinical encounter, (4) modifying self, (5) alerting others, (6) debrief, and (7) report.

CONCLUSION

Our qualitative study found that sexual harassment of female providers by patients is an ongoing problem, disruptive to the patient-provider relationship, and a possible threat to the well-being of both provider and patient. Formal training on how to address this problem was lacking, but all providers had developed or adapted strategies based on personal experiences or role modeling. Educating providers on strategies is an important next step to addressing this problem.

Association of Current Opioid Use With Serious Adverse Events Among Older Adult Survivors of Breast Cancer

IMPORTANCE

National efforts to improve safe opioid prescribing focus on preventing misuse, overdose, and opioid use disorder. This approach overlooks opportunities to better prevent other serious opioid-related harms in complex populations, such as older adult survivors of cancer. Little is known about the rates and risk factors for comprehensive opioid-related harms in this population.

OBJECTIVE

To determine rates of multiple opioid-related adverse drug events among older adults who survived breast cancer and estimate the risk of these events associated with opioid use in the year after completing cancer treatment.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used 2007 to 2016 Surveillance, Epidemiology and End Results-Medicare data from fee-for-service Medicare beneficiaries with first cancer diagnosis of stage 0 to III breast cancer at age 66 to 90 years from January 1, 2008, through December 31, 2015, who completed active breast cancer treatment. Data were analyzed from October 31, 2019, to June 10, 2020.

EXPOSURES

Repeated daily measure indicating possession of any prescription opioid supply in Medicare Part D prescription claims.

MAIN OUTCOMES AND MEASURES

Adjusted risk ratios (aRRs), estimated using modified Poisson generalized estimating equation models, for adverse drug events related to substance misuse (ie, diagnosed opioid abuse, dependence, or poisoning), other adverse drug events associated with opioid use (ie, gastrointestinal events, infections, falls and fractures, or cardiovascular events), and all-cause hospitalization associated with opioid supply the prior day, controlling for patient characteristics.

RESULTS

Among 38 310 women included in the study (mean [SD] age, 74.3 [6.3] years), there were 0.010 (95% CI, 0.008-0.011) adverse drug events related to substance misuse per 1000 person-days, 0.237 (95% CI, 0.229-0.245) other adverse drug events associated with opioid use per 1000 person-days, and 0.675 (95% CI, 0.662-0.689) all-cause hospitalizations per 1000 person-days. Opioid use was associated with increased risk of adverse drug events related to substance misuse (aRR, 14.62; 95% CI, 9.69-22.05; P < .001), other adverse drug events related to opioid use (aRR, 2.50; 95% CI, 2.11-2.96; P < .001), and all-cause hospitalization (aRR, 2.77; 95% CI, 2.55-3.02; P < .001). In a dose-response effect, individuals with high daily opioid doses had consistently higher risks of all study outcomes compared with individuals who had low opioid doses. Compared with days with no opioid exposure, the risk of any adverse drug event related to substance misuse was 3.4-fold higher for individuals with a current opioid supply ≥50 mg morphine equivalent dose per day (aRR, 3.40; 95% CI, 2.47-4.68; P < .001), while the risk was 2.3-fold higher for individuals with 1 to 49 mg morphine equivalent dose per day (aRR, 2.29; 95% CI, 1.89-2.77; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that among older adults who survived breast cancer, continued prescription opioid use in the year after completing active cancer treatment was associated with an immediate increased risk of a broad range of serious adverse drug events related to substance misuse and other adverse drug events associated with opioid use. Clinicians should consider the comprehensive risks of managing cancer pain with long-term opioid therapy.

Does Provider Gender Affect the Quality of Primary Care?

BACKGROUND

Women providers have a more patient-centered communication style than men, and some studies have found women primary care providers are more likely to meet quality performance measures.

OBJECTIVE

To explore gender differences in the quality of primary care process and outcome measures.

DESIGN

Retrospective analysis of primary care performance data from 1 year (2018-2019).

PARTICIPANTS

A total of 586 primary care providers (311 women and 275 men) who cared for 241,428 primary care patients at 96 primary care clinics at 8 Veterans Affairs (VA) medical centers.

MAIN MEASURES

Our primary outcome was a composite quality measure that averaged all thirty-four primary care performance measures that assessed performance in cancer screening, diabetes care, cardiovascular care, tobacco counseling, risky alcohol screening, immunizations, HIV testing, opiate care, and continuity. Our secondary outcomes were performance on each of the 34 measures.

KEY RESULTS

There was no difference in the average performance on our composite measure between men and women (75.8% vs. 76.6%, p = 0.17). Among the 34 primary care quality measures collected, there was no difference between male and female providers' performance. Using a more conservative cut-point, women were more likely to screen at-risk diabetic patients for hypoglycemia and document follow-up on risky alcohol behavior noted during patient check-in. These differences were clinically small and likely due to chance, given the multiple measures evaluated in this study.

CONCLUSIONS

We found little evidence of difference in the performance on primary care quality measures between male and female providers.

Single-Institution Experience of Synovial Sarcoma

OBJECTIVES

The purpose of this study was to investigate the patient population and outcomes of synovial sarcoma at a single institution.

METHODS

A retrospective review of the medical records of 28 patients with synovial sarcoma diagnosed from 1992 to 2017 was performed. Demographics, staging, disease location, treatment, and response to treatment were reviewed.

RESULTS

Individuals with larger tumors at the time of presentation had an increased risk of death. An additional factor associated with poor prognosis in synovial sarcoma was increasing patient age. The patient population had a higher rate of nonextremity disease and lower overall survival when compared with national averages.

CONCLUSIONS

Nonextremity disease and large size of tumor at presentation may have contributed to the disparity in institutional outcomes from the national averages. The advanced presentation of synovial sarcoma remains a significant challenge in improving patient survival.

Breast Cancer Chemoprevention: A Practical Guide for the Primary Care Provider

Several organizations, including the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the United States Preventive Services Task Force, recommend incorporation of breast cancer risk-based counseling and chemoprevention into routine well-woman care. However, primary care providers report both discomfort with and a lack of medical knowledge on this topic. In this review we present a practical, evidence-based guide for incorporating breast cancer risk assessment and chemoprevention into routine care. We advocate a stepwise approach consisting of: (1) risk assessment and communication, (2) selection of appropriate chemoprevention based on risk-benefit analysis, (3) shared decision-making regarding chemoprevention, and (4) management of chemoprevention side effects. We encourage providers to identify high-risk women and refer them to genetic counseling or a high-risk breast cancer clinic. For women who are not considered high risk, we suggest using the Gail model to estimate a woman's 5-year risk of invasive breast cancer. Usually, the benefits of chemoprevention outweigh the risks of chemoprevention once a woman's 5-year risk of invasive breast cancer reaches 3%. For these women there are several factors that need to be considered when selecting a chemoprevention agent, including patient preference, thrombotic history, menopausal status, absence or presence of a uterus, and bone mineral density. We advocate an evidence-based shared decision-making approach that reflects the woman's individual preferences when communicating risk and counseling about chemoprevention. After starting a chemoprevention agent, close follow-up is important as side effects of chemoprevention are common, including vasomotor symptoms and arthralgias. We also review evidence-based management of chemoprevention side effects.

Antibody-Mediated Rejection in a Multiple Lung Transplant Patient: A Case Report

Lung transplant is an effective way to treat many end-stage lung diseases. However, one of the main barriers of allograft organ transplant is still the immunologic rejection of transplanted tissue, which is a response of the HLA molecules. Rejection is a complex process involving both T-cell-mediated delayed-type hypersensitivity reactions and antibody-mediated hypersensitivity reactions to histocompatibility molecules on foreign grafts. We report the case of a 25-year-old female patient with cystic fibrosis who underwent 2 lung transplants because of her initial diagnosis and appearance of bronchiolitis obliterans syndrome after the first transplant. Only 13 months after the second transplant, despite the therapies applied, a new rejection occurred associated with high mean fluorescent intensity donor-specific antibody levels, which resulted later in the death of the patient. The present case draws attention to the importance of matching HLA molecules between donor and recipient in addition to immunosuppressive therapy.

Application of hydroxypropyl methylcellulose as a protective agent against magnesium stearate induced crystallization of amorphous itraconazole

Itraconazole is a fungicide drug which has low bioavailability due to its poor water solubility. Amorphous solid dispersion (ASD) is a tool that has the potential to greatly increase the dissolution rate and extent of compounds. In this work, the dissolution of tablets containing the ASD of itraconazole with either hydroxypropyl methylcellulose (HPMC) or vinylpyrrolidone-vinyl acetate copolymer (PVPVA) was compared in order to find a formulation which can prevent the drug from the precipitation caused by magnesium stearate. Formulations containing the PVPVA-based ASD with HPMC included in various forms could reach 90% dissolution in 2 h, while HPMC-based ASDs could release 100% of the drug. However, HPMC-based ASD had remarkably poor grindability and low bulk density, which limited its processability and applicability. The latter issue could be resolved by roller compacting the ASD, which significantly increases the bulk density and the flowability of the powder blends used for tableting. This roller compaction step might be a base for the industrial application of HPMC-based, electrospun ASDs.

Lethal disseminated dysembryoplastic neuroepithelial tumor following West Nile virus: Report of a very unusual combination

Dysembryoplastic neuroepithelial tumors (DNETs) are typically benign World Health Organization (WHO) grade I tumors of the cortical or deep gray matter with a favorable prognosis. We encountered a patient with DNET who has been evaluated and treated for West Nile encephalitis 7 months before presentation. Over the course of 2 years, the patient developed diffuse leptomeningeal carcinomatosis. As the disease burden increased, the patient eventually became quadriparetic. The patient elected for hospice care and expired shortly thereafter. Autopsy revealed DNET (WHO grade I) with extensive involvement of the cervical, thoracic, and lumbar spinal cord, bilateral cerebellar hemispheres, brainstem, the cortex of the right frontal and temporal lobes, and meningeal carcinomatosis of the brain and spinal cord. Mortality from DNET is rare, and as per our extensive literature search, there has been only 1 case reported of death attributed to seizures from this diagnosis. To the best of our knowledge, this is the only case of disseminated DNET with meningeal infiltration or carcinomatosis resulting in mortality.

Glioblastoma Presenting with Acute Middle Cerebral Artery Territory Infarct

Acute ischemic stroke caused by a malignant mass has been described in the literature in few case reports. We describe an unusual case of acute ischemic middle cerebral artery distribution infarction secondary to glioblastoma.

Application of ventricular tachyarrhythmia definitions of the updated Lambeth Conventions provides incompatibility with earlier results, masks antifibrillatory activity and reduces inter-observer agreement

The Lambeth Conventions (LC I), a landmark guidance document for arrhythmia research was updated and arrhythmia definitions were changed in the new Lambeth Conventions II (LC II). This study examined whether the arrhythmia definitions of LC I and LC II yield the same qualitative results and whether LC II improves inter-observer agreement. Two independent investigators performed blinded arrhythmia analysis of the electrocardiograms of isolated, Langendorff rat hearts subjected to regional ischemia and perfused with Class I antiarrhythmics with 3 or 5 mM K⁺ in the perfusate. Data obtained with arrhythmia definitions of LC I and LC II were compared within and between observers. Applying ventricular fibrillation (VF) definition of LC II significantly increased VF incidence and reduced VF onset time irrespective of treatment by detecting 'de novo' VF episodes not found by LC I. LC II reduced the number of ventricular tachycardia (VT) episodes and simultaneously increased the number of VF episodes as compared with the respective values obtained according to LC I. Using VF definition of LC II masked the significant antifibrillatory effects of flecainide and the high K⁺ concentration identified with the VF definition of LC I. When VF incidence was tested, a very strong inter-observer agreement was found according to LC I, whereas using VF definition of LC II reduced inter-observer agreement. It is concluded that LC II shifts some tachyarrhythmias from VT to VF class, and thus results obtained by arrhythmia definitions of LC I and LC II are not compatible; VF definition of LC II may change the conclusion of pharmacological, physiological and pathophysiological arrhythmia investigations and may reduce inter-observer agreement. Thus, VT and VF definitions of LC II should be amended in order to increase compatibility and inter-observer agreement.

Arterial tortuosity syndrome: An extremely rare disease presenting as a mimic of pulmonary sling

Pulmonary sling is the anatomic variant defined by the aberrant origin of the left pulmonary artery from the right pulmonary artery. This patient presented with a mimic of pulmonary sling as a result of an extremely rare condition, arterial tortuosity syndrome (ATS). The patient was first diagnosed with pulmonary sling on prenatal echocardiogram performed by cardiology. Computed tomography angiography of the chest obtained at birth to evaluate respiratory depression demonstrated ATS. The early detection of ATS has been demonstrated to improve patient outcome. This case provides an overview of the typical imaging features of ATS to aid radiologists in making this uncommon diagnosis.

Interspecies comparison of selected pollution biomarkers in dreissenid spp. inhabiting pristine and moderately polluted sites

Stress biomarkers, which can outline impacts of contaminants in aquatic biota at the biochemical level, are increasingly used as early warning tools in environmental monitoring. Reliable biomarker based assessment schemes, however, request appropriate knowledge of baseline levels of selected endpoints, and the potential influence of a range of natural influencing factors (both abiotic and biotic) as well. In this study, we examined the interspecies variability of various biomarkers (metallothioneins (MT), ethoxyresorufin-O-deethylase activity (EROD), lipid peroxidation (LPO), DNA strand breaks (DNA_sb), vitellogenin-like proteins (Vtg)) in Dreissena polymorpha and Dreissena bugensis inhabiting either pristine- or moderately impacted sites of Lake Balaton (Hungary). Levels of all biomarkers considered revealed low interspecies variability in the two dreissenid species at all sampling sites, with consistently higher (but statistically insignificant) values in Dreissena polymorpha. Levels of all biomarkers varied within the two investigated seasons, with significant influence of the reproduction cycle particularly on the levels of metallothioneins and vitellogenin-like proteins. Each biomarker considered was elevated by October, with significantly higher values in the mussels inhabiting harbours. Insignificant spatial and temporal variability in the general health indicators (condition index, total protein content) of dreissenids was observed, which, in parallel with evident rise in biomarker levels, apparently suggest that the anthropogenic impacts in harbours affect mussel fitness yet at sub organismal level. Our data might serve useful basis for future environmental monitoring surveys, especially in habitats where the progressive replacement of Dreissena polymorpha by Dreissena bugensis is taking place, as the interspecies variability in susceptibility to chemical stress of the two species is well comparable.

Investigation of Deteriorated Dissolution of Amorphous Itraconazole: Description of Incompatibility with Magnesium Stearate and Possible Solutions

Disadvantageous crystallization phenomenon of amorphous itraconazole (ITR) occurring in the course of dissolution process was investigated in this work. A perfectly amorphous form (solid dispersion) of the drug was generated by the electroblowing method (with vinylpyrrolidone-vinyl acetate copolymer), and the obtained fibers were formulated into tablets. Incomplete dissolution of the tablets was noticed under the circumstances of the standard dissolution test, after which a precipitated material could be filtered. The filtrate consisted of ITR and stearic acid since no magnesium content was detectable in it. In parallel with dissolution, ITR forms an insoluble associate, stabilized by hydrogen bonding, with stearic acid deriving from magnesium stearate. This is why dissolution curves do not have the plateaus at 100%. Two ways are viable to tackle this issue: change the lubricant (with sodium stearyl fumarate >95% dissolution can be accomplished) or alter the polymer in the solid dispersion to a type being able to form hydrogen bonds with ITR (e.g., hydroxypropyl methylcellulose). This work draws attention to one possible phenomenon that can lead to a deterioration of originally good dissolution of an amorphous solid dispersion.

Hyperventilation assists proarrhythmia development during delayed repolarization in clofilium-treated, anaesthetized, mechanically ventilated rabbits

Hyperventilation reduces partial pressure of CO₂ (PCO₂) in the blood, which results in hypokalaemia. Hypokalaemia helps the development of the life-threatening torsades de pointes type ventricular arrhythmia (TdP) evoked by repolarization delaying drugs. This implies that hyperventilation may assist the development of proarrhythmic events. Therefore, this study experimentally investigated the effect of hyperventilation on proarrhythmia development during delayed repolarization. Phenylephrine (an α₁-adrenoceptor agonist) and clofilium (as a representative repolarization delaying agent inhibiting the rapid component of the delayed rectifier potassium current, I_Kr) were administered intravenously to pentobarbital-anaesthetized, mechanically ventilated, open chest rabbits. ECG was recorded, and the onset times and incidences of the arrhythmias were determined. Serum K⁺, pH and PCO₂ were measured in arterial blood samples. Clofilium prolonged the rate corrected QT interval. TdP occurred in 15 animals (TdP+ group), and did not occur in 14 animals (TdP- group). We found a strong, positive, linear correlation between serum K⁺ and PCO₂. There was no relationship between the occurrence of TdP and the baseline K⁺ and PCO₂ values. However, a positive, linear correlation was found between the onset time of the first arrhythmias and the K⁺ and PCO₂ values. The regression lines describing the relationship between PCO₂ and onset time of first arrhythmias were parallel in the TdP+ and TdP- groups, but the same PCO₂ resulted in earlier arrhythmia onset in the TdP+ group than in the TdP- group. We conclude that hyperventilation and hypocapnia with the resultant hypokalaemia assist the multifactorial process of proarrhythmia development during delayed repolarization. This implies that PCO₂ and serum K⁺ should be controlled tightly during mechanical ventilation in experimental investigations and clinical settings when repolarization-delaying drugs are applied.

Seasonal and size-related variation of subcellular biomarkers in quagga mussels (Dreissena bugensis) inhabiting sites affected by moderate contamination with complex mixtures of pollutants

The size-related differences in subcellular biomarker responses were assessed in Dreissena bugensis mussels inhabiting harbours moderately affected by pollution with complex mixtures of heavy metals and polycyclic aromatic hydrocarbons (PAHs). Adult D. bugensis samples were collected from three harbours of Lake Balaton (Hungary) characterized by moderate shipping activity, and as reference site, from a highly protected remote area of the lake. Biomarkers of exposure (metallothioneins (MTs), ethoxyresorufin-o-deethylase (EROD)), oxidative stress (lipid peroxidation (LPO), DNA strand breaks (DNAsb)) and possible endocrine disruption (vitellogenin-like proteins (VTG)) were analysed in whole-tissue homogenates of differently sized groups of mussels in relation to environmental parameters and priority pollutants (heavy metals and polycyclic aromatic hydrocarbons). Integrated biomarker response (IBR) indices were calculated for biomarker responses gained through in situ measurements to signalize critical sites and to better distinguish natural tendencies from biological effects of contaminants. Biomarker responses showed close positive correlation in case of MT, EROD, LPO, and DNAsb and negative correlation with VTG levels with mussel shell length in autumn, when higher levels of biomarkers appeared, possibly due to natural lifecycle changes of animals.

Neonicotinoid insecticides inhibit cholinergic neurotransmission in a molluscan (Lymnaea stagnalis) nervous system

Neonicotinoids are highly potent and selective systemic insecticides, but their widespread use also has a growing impact on non-target animals and contaminates the environment, including surface waters. We tested the neonicotinoid insecticides commercially available in Hungary (acetamiprid, Mospilan; imidacloprid, Kohinor; thiamethoxam, Actara; clothianidin, Apacs; thiacloprid, Calypso) on cholinergic synapses that exist between the VD4 and RPeD1 neurons in the central nervous system of the pond snail Lymnaea stagnalis. In the concentration range used (0.01-1 mg/ml), neither chemical acted as an acetylcholine (ACh) agonist; instead, both displayed antagonist activity, inhibiting the cholinergic excitatory components of the VD4-RPeD1 connection. Thiacloprid (0.01 mg/ml) blocked almost 90% of excitatory postsynaptic potentials (EPSPs), while the less effective thiamethoxam (0.1 mg/ml) reduced the synaptic responses by about 15%. The ACh-evoked membrane responses of the RPeD1 neuron were similarly inhibited by the neonicotinoids, confirming that the same ACh receptor (AChR) target was involved. We conclude that neonicotinoids act on nicotinergic acetylcholine receptors (nAChRs) in the snail CNS. This has been established previously in the insect CNS; however, our data indicate differences in the background mechanism or the nAChR binding site in the snail. Here, we provide the first results concerning neonicotinoid-related toxic effects on the neuronal connections in the molluscan nervous system. Aquatic animals, including molluscs, are at direct risk while facing contaminated surface waters, and snails may provide a suitable model for further studies of the behavioral/neuronal consequences of intoxication by neonicotinoids.

Evaluation of multixenobiotic resistance in dreissenid mussels as a screening tool for toxicity in freshwater sediments

The multixenobiotic defense mechanism (MXR) in aquatic organisms was recognized as a first-line defense system, and its potential use as an early biomarker of exposure to environmental stress has raised attention in the last two decades. To evaluate the relevance of this biomarker in the freshwater mussel Dreissena polymorpha, we studied its responsiveness within laboratory exposures to contaminants sequestered in freshwater sediments affected by moderate anthropogenic impact. The effectiveness of this biomarker was assessed by comparing the MXR-transporter activities determined in bivalves first with toxicity scores recorded with the D. rerio embryo developmental assay. Both bioassays were applied in the sediment contact test format. As a second evaluation approach, MXR activities determined in exposed mussels were compared with sediment-contamination data integrated into toxic units on the basis of acute toxicity to Daphnia magna. In D. polymorpha subjected to acute exposure with moderately polluted sediments, we detected limited (22-33 %) but statistically significant induction of MXR activity. Mean MXR activities significantly correlated with TU values computed for test sediments. MXR activities in mussels showed strong positive correlation with the metal load of sediments and proved to be unrelated to the contamination with polycyclic aromatic compounds. MXR activity in laboratory-exposed mussels showed low variability within treatments and thus reliably reflected even low contaminant differences between the negative reference and moderately polluted harbor sediments. The strong correlation found in this study between the MXR-transporter activity in exposed mussels and environmentally realistic sediment contamination underscores the fairly good sensitivity of this biomarker in laboratory testing conditions to signal the bioavailability of sediment bound contaminants, and it may also anticipate even the incidence of toxicity to biota.

Pharmacological studies confirm neurotoxic metabolite(s) produced by the bloom-forming Cylindrospermopsis raciborskii in Hungary

A rapid cyanobacterial bloom of Cylindrospermopsis raciborskii (3.2 × 10(4) filaments/mL) was detected early November, 2012, in the Fancsika pond (East Hungary). The strong discoloration of water was accompanied by a substantial fish mortality (even dead cats were seen on the site), raising the possibility of some toxic metabolites in the water produced by the bloom-forming cyanobacteria (C. raciborskii). The potential neuronal targets of the toxic substances in the bloom sample were studied on identified neurons (RPas) in the central nervous system of Helix pomatia. The effects of the crude aqueous extracts of the Fancsika bloom sample (FBS) and the laboratory isolate of C. raciborskii from the pond (FLI) were compared with reference samples: C. raciborskii ACT 9505 (isolated in 1995 from Lake Balaton, Hungary), the cylindrospermopsin producer AQS, and the neurotoxin (anatoxin-a, homoanatoxin-a) producer Oscillatoria sp. (PCC 6506) strains. Electrophysiological tests showed that both FBS and FLI samples as well the ACT 9505 extracts modulate the acetylcholine receptors (AChRs) of the neurons, evoking ACh agonist effects, then inhibiting the ACh-evoked neuronal responses. Dose-response data suggested about the same range of toxicity of FBS and FLI samples (EC50  = 0.397 mg/mL and 0.917 mg/mL, respectively) and ACT 9505 extracts (EC50  = 0.734 mg/mL). The extract of the neurotoxin-producing PCC 6506 strain, however, proved to be the strongest inhibitor of the ACh responses on the same neurons (EC50  = 0.073 mg/mL). The presented results demonstrated an anatoxin-a-like cholinergic inhibitory effects of cyanobacterial extracts (both the environmental FBS sample, and the laboratory isolate, FLI) by some (yet unidentified) toxic components in the matrix of secondary metabolites. Previous pharmacological studies of cyanobacterial samples collected in other locations (Balaton, West Hungary) resulted in similar conclusions; therefore, we cannot exclude that this chemotype of C. raciborskii which produce anatoxin-a like neuroactive substances is more widely distributed in this region.

Robotic distal ureterectomy with psoas hitch and ureteroneocystostomy: Surgical technique and outcomes

Use of the da Vinci^® surgical robotic system has expanded to numerous upper and lower urinary tract procedures. We describe our surgical technique and perioperative outcome of robotic distal ureterectomy with psoas hitch and ureteroneocystostomy for distal ureteral pathologies. Eight patients with a median age of 69.5 years old underwent robotic distal ureterectomy with psoas hitch and ureteroneocystostomy between April 2009 and August 2014. The entirety of all cases was performed robotically by a single surgeon at a tertiary academic medical center. Median operative time was 285 min (range: 210-360 min), estimated blood loss was 50 mL (range: 50-75 mL) and median length of hospital stay was 2.5 days (range: 1-6 days). There was one post-operative complication, a readmission for dehydration (Clavien I). It suggests that robotic distal ureterectomy with psoas hitch and ureteroneocystostomy is a safe and effective minimally invasive alternative for patients with distal ureteral pathology.

Clinical practice guidelines on prostate cancer: a critical appraisal

PURPOSE

Clinical practice guidelines are increasingly being used by leading organizations to promote high quality evidence-based patient care. However, the methodological quality of clinical practice guidelines developed by different organizations varies considerably. We assessed published clinical practice guidelines on the treatment of localized prostate cancer to evaluate the rigor, applicability and transparency of their recommendations.

MATERIALS AND METHODS

We searched for English based clinical practice guidelines on treatment of localized prostate cancer from leading organizations in the 15-year period from 1999 to 2014. Clinical practice guidelines limited to early detection, screening, staging and/or diagnosis of prostate cancer were excluded from analysis. Four independent reviewers used the validated AGREE II instrument to assess the quality of clinical practice guidelines in 6 domains, including 1) scope and purpose, 2) stakeholder involvement, 3) rigor of development, 4) clarity of presentation, 5) applicability and 6) editorial independence.

RESULTS

A total of 13 clinical practice guidelines met inclusion criteria. Overall the highest median scores were in the AGREE II domains of clarity of presentation, editorial independence, and scope and purpose. The lowest median score was for applicability (28.1%). Although the median score of editorial independence was high (85.4%), variability was also substantial (IQR 12.5-100). NICE and AUA clinical practice guidelines consistently scored well in most domains.

CONCLUSIONS

Clinical practice guidelines from different organizations on treatment of localized prostate cancer are of variable quality and fall short of current standards in certain areas, especially in applicability and stakeholder involvement. Improvements in these key domains can enhance the impact and implementation of clinical practice guidelines.

Malnutrition and disability: unexplored opportunities for collaboration

There is increasing international interest in the links between malnutrition and disability: both are major global public health problems, both are key human rights concerns, and both are currently prominent within the global health agenda. In this review, interactions between the two fields are explored and it is argued that strengthening links would lead to important mutual benefits and synergies. At numerous points throughout the life-cycle, malnutrition can cause or contribute to an individual's physical, sensory, intellectual or mental health disability. By working more closely together, these problems can be transformed into opportunities: nutrition services and programmes for children and adults can act as entry points to address and, in some cases, avoid or mitigate disability; disability programmes can improve nutrition for the children and adults they serve. For this to happen, however, political commitment and resources are needed, as are better data.