How to foster STEM learning during Covid-19 remote schooling: Combining virtual and video experiments

Understanding scientific concepts is a fundamental aim of science education. Conceptual understanding can be fostered through inquiry learning with experiments. However, during the Covid-19 pandemic school closures hands-on experiments could hardly be realized. Fortunately, digital technologies allow for conducting experiments virtually by using interactive simulations or observing video recordings of hands-on experiments. In the present study, 154 seventh graders in remote schooling were involved in inquiry learning using either a combination of virtual and video experiments in two different orders or only virtual experiments. We hypothesized that in general inquiry learning fosters students' conceptual understanding in physics, which could be confirmed. Moreover, we expected the combinations to be more effective than learning with virtual experiments only due to the complementary roles of the prior, which was, however, not the case. We conclude that virtual and video experiments can be recommended to teachers if hands-on experimentation is not possible.

The relation of representational competence and conceptual knowledge in female and male undergraduates

Background

Representational competence is commonly considered a prerequisite for the acquisition of conceptual knowledge, yet little exploration has been undertaken into the relation between these two constructs. Using an assessment instrument of representational competence with vector fields that functions without confounding topical context, we examined its relation with N = 515 undergraduates' conceptual knowledge about electromagnetism.

Results

Applying latent variable modeling, we found that students' representational competence and conceptual knowledge are related yet clearly distinguishable constructs (manifest correlation: r = .54; latent correlation: r = .71). The relation was weaker for female than for male students, which could not be explained by measurement differences between the two groups. There were several students with high representational competence and low conceptual knowledge, but only few students with low representational competence and high conceptual knowledge.

Conclusions

These results support the assumption that representational competence is a prerequisite, yet insufficient condition for the acquisition of conceptual knowledge. We provide suggestions for supporting learners in building representational competence, and particularly female learners in utilizing their representational competence to build conceptual knowledge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40594-023-00435-6.

Representational scaffolding in digital simulations – learning professional practices in higher education

Purpose

To advance the learning of professional practices in teacher education and medical education, this conceptual paper aims to introduce the idea of representational scaffolding for digital simulations in higher education.

Design/methodology/approach

This study outlines the ideas of core practices in two important fields of higher education, namely, teacher and medical education. To facilitate future professionals’ learning of relevant practices, using digital simulations for the approximation of practice offers multiple options for selecting and adjusting representations of practice situations. Adjusting the demands of the learning task in simulations by selecting and modifying representations of practice to match relevant learner characteristics can be characterized as representational scaffolding. Building on research on problem-solving and scientific reasoning, this article identifies leverage points for employing representational scaffolding.

Findings

The four suggested sets of representational scaffolds that target relevant features of practice situations in simulations are: informational complexity, typicality, required agency and situation dynamics. Representational scaffolds might be implemented in a strategy for approximating practice that involves the media design, sequencing and adaptation of representational scaffolding.

Originality/value

The outlined conceptualization of representational scaffolding can systematize the design and adaptation of digital simulations in higher education and might contribute to the advancement of future professionals’ learning to further engage in professional practices. This conceptual paper offers a necessary foundation and terminology for approaching related future research.

Augmented Reality for Presenting Real-Time Data During Students' Laboratory Work: Comparing a Head-Mounted Display With a Separate Display

Multimedia learning theories suggest presenting associated pieces of information in spatial and temporal contiguity. New technologies like Augmented Reality allow for realizing these principles in science laboratory courses by presenting virtual real-time information during hands-on experimentation. Spatial integration can be achieved by pinning virtual representations of measurement data to corresponding real components. In the present study, an Augmented Reality-based presentation format was realized via a head-mounted display and contrasted to a separate display, which provided a well-arranged data matrix in spatial distance to the real components and was therefore expected to result in a spatial split-attention effect. Two groups of engineering students (N = 107; Augmented Reality vs. separate display) performed six experiments exploring fundamental laws of electric circuits. Cognitive load and conceptual knowledge acquisition were assessed as main outcome variables. In contrast to our hypotheses and previous findings, the Augmented Reality group did not report lower extraneous load and the separate display group showed higher learning gains. The pre- and posttest assessing conceptual knowledge were monitored by eye tracking. Results indicate that the condition affected the visual relevancy of circuit diagrams to final problem completion. The unexpected reverse effects could be traced back to emphasizing coherence formation processes regarding multiple measurements.

Smart Sensors for Augmented Electrical Experiments

With the recent increase in the use of augmented reality (AR) in educational laboratory settings, there is a need for new intelligent sensor systems capturing all aspects of the real environment. We present a smart sensor system meeting these requirements for STEM (science, technology, engineering, and mathematics) experiments in electrical circuits. The system consists of custom experiment boxes and cables combined with an application for the Microsoft HoloLens 2, which creates an AR experiment environment. The boxes combine sensors for measuring the electrical voltage and current at the integrated electrical components as well as a reconstruction of the currently constructed electrical circuit and the position of the sensor box on a table. Combing these data, the AR application visualizes the measurement data spatially and temporally coherent to the real experiment boxes, thus fulfilling demands derived from traditional multimedia learning theory. Following an evaluation of the accuracy and precision of the presented sensors, the usability of the system was evaluated with n=20 pupils in a German high school. In this evaluation, the usability of the system was rated with a system usability score of 94 out of 100.

Validation of Cognitive Load During Inquiry-Based Learning With Multimedia Scaffolds Using Subjective Measurement and Eye Movements

Subject-method barriers and cognitive load (CL) of students have a particular importance in the complex learning process of scientific inquiry. In this work, we investigate the valid measurement of CL as well as different scaffolds to reduce it during experimentation. Specifically, we examine the validity of a subjective measurement instrument to assess CL [in extraneous cognitive load (ECL), intrinsic cognitive load, and germane cognitive load (GCL)] during the use of multimedia scaffolds in the planning phase of the scientific inquiry process based on a theoretical framework of the CL theory. The validity is analyzed by investigating possible relationships between causal (e.g., cognitive abilities) and assessment (e.g., eye-tracking metrics) factors in relation to the obtained test scores of the adapted subjective measurement instrument. The study aims to elucidate possible relationships of causal factors that have not yet been adequately investigated in relation to CL. Furthermore, a possible, still inconclusive convergence between subjective test scores on CL and objectively measured indicators will be tested using different eye-tracking metrics. In two studies (n=250), 9th and 11th grade students experimentally investigated a biological phenomenon. At the beginning of the planning phase, students selected one of four multimedia scaffolds using a tablet (Study I: n=181) or a computer with a stationary eye-tracking device (Study II: n=69). The subjective cognitive load was measured via self-reports using a standardized questionnaire. Additionally, we recorded students’ gaze data during learning with the scaffolds as objective measurements. Besides the causal factors of cognitive-visual and verbal abilities, reading skills and spatial abilities were quantified using established test instruments and the learners indicated their representation preference by selecting the scaffolds. The results show that CL decreases substantially with higher grade level. Regarding the causal factors, we observed that cognitive-visual and verbal abilities have a significant influence on the ECL and GCL in contrast to reading skills. Additionally, there is a correlation between the representation preference and different types of CL. Concerning the objective measurement data, we found that the absolute fixation number is predictive for the ECL. The results are discussed in the context of the overall methodological research goal and the theoretical framework of CL.

ARETT: Augmented Reality Eye Tracking Toolkit for Head Mounted Displays

Currently an increasing number of head mounted displays (HMD) for virtual and augmented reality (VR/AR) are equipped with integrated eye trackers. Use cases of these integrated eye trackers include rendering optimization and gaze-based user interaction. In addition, visual attention in VR and AR is interesting for applied research based on eye tracking in cognitive or educational sciences for example. While some research toolkits for VR already exist, only a few target AR scenarios. In this work, we present an open-source eye tracking toolkit for reliable gaze data acquisition in AR based on Unity 3D and the Microsoft HoloLens 2, as well as an R package for seamless data analysis. Furthermore, we evaluate the spatial accuracy and precision of the integrated eye tracker for fixation targets with different distances and angles to the user (n=21). On average, we found that gaze estimates are reported with an angular accuracy of 0.83 degrees and a precision of 0.27 degrees while the user is resting, which is on par with state-of-the-art mobile eye trackers.

Changes in Students' Understanding of and Visual Attention on Digitally Represented Graphs Across Two Domains in Higher Education: A Postreplication Study

Domain-specific understanding of digitally represented graphs is necessary for successful learning within and across domains in higher education. Two recent studies conducted a cross-sectional analysis of graph understanding in different contexts (physics and finance), task concepts, and question types among students of physics, psychology, and economics. However, neither changes in graph processing nor changes in test scores over the course of one semester have been sufficiently researched so far. This eye-tracking replication study with a pretest–posttest design examines and contrasts changes in physics and economics students’ understanding of linear physics and finance graphs. It analyzes the relations between changes in students’ gaze behavior regarding relevant graph areas, scores, and self-reported task-related confidence. The results indicate domain-specific, context- and concept-related differences in the development of graph understanding over the first semester, as well as its successful transferability across the different contexts and concepts. Specifically, we discovered a tendency of physics students to develop a task-independent overconfidence in the graph understanding during the first semester.

Vaccination, Autonomy, Complexity, Solidarity - Ethical analyses of a German policy discourse

Background

Currently, measles immunization is high on the agenda of academic and public discourses - on both sides of the Atlantic. In Germany, the discussion of mandatory (measles) immunization was intensively publicly discussed in Spring 2019. Many stakeholders, including federal politicians, plea for mandatory measles immunization. In our paper we analyse the discourse from an ethical point of view.

Methods

Statements and arguments from German stakeholders in the public debate in 2019 are analysed (among them statements of the federal minister of health, the German Medical Association, NGOs and the National Ethics Council). A vaccination ethics framework and a public trust framework are applied in the analysis.

Results

Politicians and other public stakeholders debate (measles) immunization and increasingly demand mandatory (measles) vaccination. However, frequently it is unclear which vaccinations or immunization programmes they refer to. They often do ignore the epidemiological situation of immunization rates in Germany, regional differences, relevant target groups and implementation mechanisms, including potential sanctions. This way they simplify the complex problem and offer (populist) simplistic solutions. Normative arguments of stakeholders repeatedly use conceptions of ’autonomy’ and ’harm’; but sometimes also ’solidarity’ is mentioned.

Conclusions

The call for mandatory measles immunization of school and kindergarten children is offering no adequate and sufficient solution to the problem of elimination of measles. Nevertheless, it contributes to reducing infection risks for the children in care and schooling facilities. Rather, the problem has to be understood in its complexity before discussing the ethical challenges and making effective policy recommendations. When discussing ways to increase immunization rates, ethical values like public trust and solidarity have to be in the foreground - not (only) the debate of autonomy and its restriction.

Key messages

In German policy discourses 2019, the discussion of “mandatory (measles) vaccination” often shows inaccuracies regarding definitions and facts. These have to be clarified before ethical analysis. Ethical issues regarding the voluntariness of measles vaccination relate also to the ethical concepts of solidarity and public trust and not only to autonomy.

Heart Transplantation in Systemic Sclerosis: New Impulses for Conventional Scleroderma Transplantation Regimen and Scleroderma Diagnostic Monitoring: 2 Case Reports

BACKGROUND

Although low (but increasing) rates of lung/lung-heart transplantations of scleroderma (systemic sclerosis [SSc]) patients have been reported, exclusive heart transplantation is a rare approach for treatment of heart failure due to SSc.

CASES

We report on 2 cases of SSc patients receiving a heart transplantation (HTx) due to severe and progressive right heart failure without pulmonary artery hypertension. One patient received a hepatitis C virus (HCV)-positive donor heart and recovered excellently from viral transmission after administration of a direct-acting antiviral (DAA) regimen. This is the first published case of an SSc patient who underwent HTx using an HCV-positive donor heart. The clinical course of both patients was monitored by different serum SSc biomarkers. Only xylosyltransferase activity proved to be a promising biomarker for disease stage determination and therapeutic monitoring, precisely reflecting fibrotic remodeling and successful organ recovery.

CONCLUSIONS

Successful implementation of the 2 cases described here demonstrates that HTx is a safe and effective therapeutic option for defined SSc sub-patient groups despite the progressive character of the underlying disease. In the future, xylosyltransferase activity might be conducive to simplify the identification of patients with low systemic involvement but a strong indication for single heart transplantation. Finally, we demonstrate that treatment of HCV viral transmission from HCV-positive donor to organ recipient using DAA gives us new opportunities to consider HCV-positive donor organs for HTx and might reveal new possibilities to ease the lack of donor organs.

Vitamin D supplementation and bone turnover in advanced heart failure: the EVITA trial

Low vitamin D status is common in patients with heart failure and may influence bone health. A daily vitamin D dose of 4000 IU (moderately high dose) for 3 years had however no effect on parameters of bone metabolism, even in patients with very low vitamin D status.

INTRODUCTION

Low vitamin D status is common in patients with heart failure (HF) and has been related to disturbed bone turnover. The present study investigated the effect of a daily vitamin D₃ dose of 4000 IU on bone turnover markers (BTMs) in patients with advanced HF and 25-hydroxyvitamin D (25OHD) concentrations < 75 nmol/L.

METHODS

In this pre-specified secondary analysis of a randomized controlled trial, we assessed in 158 male HF patients (vitamin D group: n = 80; placebo group: n = 78) between-group differences in calciotropic hormones (25OHD, 1,25-dihydroxyvitamin D [1,25(OH)₂D], intact parathyroid hormone [iPTH]), and BTMs (cross-linked C-telopeptide of type I collagen, bone-specific alkaline phosphatase, undercarboxylated osteocalcin). Comparisons were performed at the end of a 3-year vitamin D supplementation period with adjustments for baseline values.

RESULTS

Compared with placebo, vitamin D increased 25OHD on average by 54.3 nmol/L. At study termination, 25OHD and 1,25(OH)₂D were significantly higher (P < 0.001 and P = 0.007, respectively), whereas iPTH tended to be lower in the vitamin D group than in the placebo group (P = 0.083). BTMs were initially within their reference ranges and did not differ significantly between groups at study termination, neither in the entire study cohort nor when data analysis was restricted to the subgroup of patients with initial 25OHD concentrations < 30 nmol/L (n = 54) or to patients with initial hyperparathyroidism (n = 65) (all P values > 0.05).

CONCLUSIONS

A daily vitamin D₃ dose of 4000 IU did not influence BTMs. Data indicate that vitamin D supplementation will not lower bone turnover in male patients with heart failure.

Abstract P3-03-02: Inhibition of NOS promotes ER stress response and augments docetaxel-mediated apoptosis in TNBC

Introduction: Chemoresistance in triple negative breast cancer (TNBC) is related to an activation of a survival response orchestrated by endoplasmic reticulum (ER) stress. We hypothesize that attenuation of nitric oxide (NO) signaling pathway can overcome treatment resistance, preventing relapse, ultimately improving survival of TNBC patients. Here, we aimed to investigate the effects of pharmacological iNOS (inducible nitric oxide synthase) inhibition by L-NMMA on docetaxel-meditated ER stress response and to determine whether the therapeutic NOS inhibition may improve chemotherapy-based response.

Methods: BT-549, SUM-149, MDA-MB-436, and MDA-MD-468 TNBC cell lines were treated with docetaxel (D; 5 nm)/ L-NMMA (L; 4mM)/ amlodipine (A; 5 µm) daily for 48 and 72 hours. Cell death and proliferation were assayed by Annexin V and ATP quantification, respectively. Western Blot (WB) was used to measure ER stress markers. In vivo regimen treatment followed three 2-weekscycles of D (20 mg/kg intraperitoneal [IP] on day 1) and L (200 mg/kg oral gavage on day 2-6); A (10 mg/kg IP on day 2-6) A was administered together with L to counteract the well-known effects of L on blood pressure (hypertension). TNBC Patient derived xenograft (PDX) models #2147, #5998, #3107 and #4664 were transplanted into the mammary fat pad of SCID Beige mice. PDX #2147 received either, single drug (vehicle, L, A, D), double (L+A, D+L, D+A), or triple drug combination (L+A+D). Models #4664, #3107 and #5998 received only vehicle, D or D+ L+A. Mice weight and tumor volumes were recorded twice weekly. D concentration was measured by mass spectrometry.

Results: Studies on SUM-159 cell line showed that, when compared to the docetaxel-treated group, D+L+A increased cell death significantly, as indicated by a rise in annexin V/propidium iodide-positive cells. Increase in cell death by D+L+A was further demonstrated by accumulation of mitochondrial cleaved BAX. The enhanced apoptotic effects of D+L+A in MDA MD 468, BT 549 and MDA MD TNBC cell lines were confirmed by a decrease in ATP levels compared to D alone. WB revealed a survival stress response activated by docetaxel. When it was coupled with NOS inhibition, ER stress response showed higher expression of ATF4 and CHOP, triggering a proapoptotic response by pASK1/JNK pathway and cleaved caspases (CC3 and CC9). PDX #2147 showed that L, A and L+A treatment groups had similar tumor volume growth as the untreated group. However, combination therapy, D+L+A, significantly reduced the tumor volume and increased survival proportions compared with vehicle and docetaxel. Combination therapy also dramatically reduced tumor size on TNBC #4664 and #3107, and significantly improved response on #5998 compared with docetaxel alone. Intratumoral docetaxel concentration was 5.3-fold higher in mice receiving D+L+A than in those receiving docetaxel alone (#5998). In both groups, docetaxel was not detected in the plasma one week after injection.

Conclusion: The present data suggest that iNOS may be a critical target for docetaxel resistance in TNBC. iNOS inhibition enhanced chemotherapy response in TNBC PDX models indicating that addition of iNOS inhibitor may improve prognosis and prevent relapse in TNBC patients who have failed conventional chemotherapy.

Citation Format: Davila-Gonzalez D, Choi DS, Kuhn J, Granados SM, Rosato RR, Dave B, Chang JC. Inhibition of NOS promotes ER stress response and augments docetaxel-mediated apoptosis in TNBC [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-03-02.

[Alienation: Differential Psychopathology of Ego-Disturbances]

Alienation, i. e. disorders of the inner experience of integrity, continuity, and agency, represents a feature of both psychotic and non-psychotic disorders. Thereby, ego disturbances are thought to be specific for schizophrenia. Depersonalisation, in contrast, has been reported in schizophrenia as well as a neurotic, probably distinct syndrome. The differentiation of psychotic vs. non-psychotic alienation is often all but trivial. The present paper provides an overview of the historical roots and the psychopathological conceptualizations of alienation. Clinically relevant features of psychotic alienation are highlighted. Experience of passivity, loss of authenticity and disturbances of striving and volition appear as psychotic characteristics.

[Primary Prevention And Health Promotion in Bavaria: Taking Stock]

Background: Health promotion and prevention are key elements of Bavarian health policy and are currently being re-oriented along the framework of the "Bavarian Prevention Plan". In this context, a stock taking of prevention and health promotion in Bavaria was conducted with the aim to contribute to the continued strategic and quality-orientated development of this field. Methods: The investigation was restricted to activities of primary prevention and health promotion with a focus on the action areas of the Bavarian Prevention Plan. The prevention actors, not projects, were the smallest units that were surveyed. During the 3-month field phase in 2014/2015, 595 prevention players were contacted and asked to complete an online questionnaire on their activities and target groups as well as quality and structural aspects. In addition, 9 expert interviews were conducted in an urban and a rural area in order to explore the field of small commercial and civic prevention actors. Results: 135 prevention players took part in the survey (return rate 23%). The most commonly cited themes of activities are health literacy (62% of players) and mental health (58%). The target groups are often broadly defined, gender specific measures and those for socially disadvantaged groups are comparatively rare. Provision of health-related information is the most commonly used approach (58-69% of players depending on the action area), least used are community work approaches (9-12%). 77% of the respondents state to use models of best practice and 55% scientific results in the development of measures; 43% conduct outcome evaluations and 80% take part in committee work and networks. The latter are mainly used to exchange information (90% of actors), 55 and 54% state to use them for joint planning and delivery of interventions, respectively. Conclusions: The most important prevention players took part in the survey. Methodologically it proved difficult to achieve a meaningful depiction of central aspects of the prevention scene via a quantitative survey approach. There is a lack of well-tried instruments and approaches for such cross-agency surveys. Nevertheless, the study allows trend statements on the spectrum, structure and quality of prevention in Bavaria. Thus, a starting line for the implementation of the Bavarian Prevention Plan as well as the basis of prevention reporting as intended by the new national prevention law could be established.

Ratenbildung bei KV-Daten mit GKV-Versicherten auf Kreisebene – ein empirisches Schätzmodell auf der Basis des Mikrozensus

Hintergrund: Daten aus der kassenärztlichen Versorgung werden u. a. in der Gesundheitsberichterstattung und der Versorgungsforschung auf Kreisebene genutzt. Für eine korrekte Ratenbildung müsste die Zahl der GKV-Versicherten im Nenner zugrunde gelegt werden, diese steht aber in einigen Bundesländern auf Kreisebene nicht zur Verfügung. Die Raten werden daher im kassenärztlichen System mit einer Surrogatgröße (definiert über die Arztkontakte) gebildet. Dies führt zu Unschärfen, sodass kleinräumige Regionalvergleiche nur bedingt möglich sind. Ziel der vorliegenden Arbeit ist ein besseres Schätzmodell für die Zahl der GKV-Versicherten auf Kreisebene.

Methodik: Der Anteil der GKV-Versicherten in den bayerischen Kreisen wird durch ein multiples lineares Regressionsmodell geschätzt. Im Modell wird der Anteil der GKV-Versicherten in den Anpassungsschichten des Mikrozensus (einer Zusammenfassung von mehreren Kreisen) erklärt durch Einflussfaktoren auf den Versicherungsstatus, die auf Kreisebene vorliegen (verfügbares Einkommen, Beamten- und Selbständigenanteil). Die durch das Modell berechneten GKV-Versichertenzahlen werden mit der Surrogatgröße verglichen. Eine konkrete Anwendung erfolgt am Beispiel der regionalen Diabetesdiagnosen aus den Daten der Kassenärztlichen Vereinigung Bayerns.

Ergebnisse: Durch das Regressionsmodell werden für die bayerischen Kreise GKV-Versichertenanteile zwischen 74,7 und 91,6% geschätzt. Der Unterschied zu der bisher genutzten Ersatzgröße beträgt bis zu 18,6 Prozentpunkte. Dies spiegelt sich dementsprechend in den Behandlungsprävalenzen wider, hier am Beispiel des Diabetes mellitus veranschaulicht.

Schlussfolgerung: Die vorliegende Analyse zeigt, mit welchen Unsicherheiten die Ratenbildung bei Daten aus der kassenärztlichen Versorgung derzeit behaftet ist und was daraus für kleinräumige Vergleiche, etwa in der Gesundheitsberichterstattung, folgt. Die Aufbereitung valider Nennerdaten im Rahmen der Datentransparenzregelung nach SGB V ist anzustreben.

Effects of deep brain stimulation on prepulse inhibition in obsessive-compulsive disorder

Owing to a high response rate, deep brain stimulation (DBS) of the ventral striatal area has been approved for treatment-refractory obsessive-compulsive disorder (tr-OCD). Many basic issues regarding DBS for tr-OCD are still not understood, in particular, the mechanisms of action and the origin of side effects. We measured prepulse inhibition (PPI) in treatment-refractory OCD patients undergoing DBS of the nucleus accumbens (NAcc) and matched controls. As PPI has been used in animal DBS studies, it is highly suitable for translational research. Eight patients receiving DBS, eight patients with pharmacological treatment and eight age-matched healthy controls participated in our study. PPI was measured twice in the DBS group: one session with the stimulator switched on and one session with the stimulator switched off. OCD patients in the pharmacologic group took part in a single session. Controls were tested twice, to ensure stability of data. Statistical analysis revealed significant differences between controls and (1) patients with pharmacological treatment and (2) OCD DBS patients when the stimulation was switched off. Switching the stimulator on led to an increase in PPI at a stimulus-onset asynchrony of 200 ms. There was no significant difference in PPI between OCD patients being stimulated and the control group. This study shows that NAcc-DBS leads to an increase in PPI in tr-OCD patients towards a level seen in healthy controls. Assuming that PPI impairments partially reflect the neurobiological substrates of OCD, our results show that DBS of the NAcc may improve sensorimotor gating via correction of dysfunctional neural substrates. Bearing in mind that PPI is based on a complex and multilayered network, our data confirm that DBS most likely takes effect via network modulation.

Changes in Nutritional Status after Deep Brain Stimulation of the Nucleus Basalis of Meynert in Alzheimer's Disease--Results of a Phase I Study

OBJECTIVE

The progression of Alzheimer's disease (AD) is associated with impaired nutritional status. New methods, such as deep brain stimulation (DBS), are currently being tested to decrease the progression of AD. DBS is an approved method in the treatment of Parkinson's disease, and its suitability for the treatment of AD patients is currently under experimental investigation. To evaluate the advantages and disadvantages of this new treatment, it is important to assess potential side effects of DBS regarding the nucleus basalis of Meynert; this new treatment is thought to positively affect cognition and might counteract the deterioration of nutritional status and progressive weight loss observed in AD. This study aims to assess the nutritional status of patients with AD before receiving DBS of the nucleus basalis of Meynert and after 1 year, and to analyze potential associations between changes in cognition and nutritional status.

DESIGN

A 1-year phase I proof-of-concept study.

SETTING

The Department of Psychiatry and Psychotherapy at the University of Cologne.

PARTICIPANTS

We assessed a consecutive sample of patients with mild to moderate AD (n=6) who fulfilled the inclusion criteria and provided written informed consent.

INTERVENTION

Bilateral low-frequency DBS of the nucleus basalis of Meynert.

MEASUREMENTS

Nutritional status was assessed using a modified Mini Nutritional Assessment, bioelectrical impedance analysis, a completed 3-day food diary, and analysis of serum levels of vitamin B12 and folate.

RESULTS

With a normal body mass index (BMI) at baseline (mean 23.75 kg/m²) and after 1 year (mean 24.59 kg/m²), all but one patient gained body weight during the period of the pilot study (mean 2.38 kg, 3.81% of body weight). This was reflected in a mainly stable or improved body composition, assessed by bioelectrical impedance analysis, in five of the six patients. Mean energy intake increased from 1534 kcal/day (min 1037, max 2370) at baseline to 1736 kcal/day (min 1010, max 2663) after 1 year, leading to the improved fulfillment of energy needs in four patients. The only nutritional factors that were associated with changes in cognition were vitamin B12 level at baseline (Spearman's rho = 0.943, p = 0.005) and changes in vitamin B12 level (Spearman's rho = -0.829, p = 0.042).

CONCLUSION

Patients with AD that received DBS of the nucleus basalis of Meynert demonstrated a mainly stable nutritional status within a 1-year period. Whether DBS is causative regarding these observations must be investigated in additional studies.

[Memorandum on sustainable reinforcement of prevention and health promotion: challenges at the federal, state and local level]

Research-based evidence and practice-based experience are core requirements for the effective implementation of preventive interventions. The knowledge gained in the Prevention Research Funding Initiative of the German Federal Ministry of Education and Research (2004-2013) was therefore amalgamated, reflected and consolidated in the Cooperation for Sustainable Prevention Research (KNP) meta-project. In annual strategy meetings, researchers and practitioners from the field and other experts developed 3 memoranda providing recommendations for the further development of research and practice in the field of prevention and health promotion. Memorandum III is primarily aimed at decision-makers in politics and administration at the federal, state and local level, in civil society and in the workplace. Its recommendations show that structuring efforts are urgently needed to achieve sustainable policy, particularly in the fields of health, education, employment and social affairs. Memorandum III brings together the knowledge extracted and problems identified in research projects. More so than its 2 predecessors, Memorandum III abstracts knowledge from the individual projects and attempts to derive guidance for action and decision-making, as shown by the 7 recommendations that appear to useful for consensus-building in practice and research. Value judgments are inevitable. Prevention and health promotion are an investment in the future: of social health, social capital and social peace. Improvement of the framework conditions is needed to achieve the harmonized awareness and the sustained effectiveness of these structure-building efforts in different policy areas, spheres of life, fields of action, and groups of actors. This includes the implementation of an overall national strategy as well as the expansion of sources of funding, extension of the legal framework, overarching coordination, and the establishment of a National Center of Excellence to develop and safeguard prevention and health promotion. The memorandum is intended to stimulate a discourse resulting in structure-building and stabilizing measures designed to ensure the sustainability of prevention and health promotion.

Deep brain stimulation of the nucleus basalis of Meynert in Alzheimer's dementia

Cholinergic neurons of the medial forebrain are considered important contributors to brain plasticity and neuromodulation. A reduction of cholinergic innervation can lead to pathophysiological changes of neurotransmission and is observed in Alzheimer's disease. Here we report on six patients with mild to moderate Alzheimer's disease (AD) treated with bilateral low-frequency deep brain stimulation (DBS) of the nucleus basalis of Meynert (NBM). During a four-week double-blind sham-controlled phase and a subsequent 11-month follow-up open label period, clinical outcome was assessed by neuropsychological examination using the Alzheimer's Disease Assessment Scale-cognitive subscale as the primary outcome measure. Electroencephalography and [(18)F]-fluoro-desoxyglucose positron emission tomography were, besides others, secondary endpoints. On the basis of stable or improved primary outcome parameters twelve months after surgery, four of the six patients were considered responders. No severe or non-transitional side effects related to the stimulation were observed. Taking into account all limitations of a pilot study, we conclude that DBS of the NBM is both technically feasible and well tolerated.

Association between circulating 25-hydroxyvitamin D levels and medication use in patients scheduled for cardiac surgery

BACKGROUND AND AIM

Low vitamin D status, i.e. circulating 25-hydroxyvitamin D (25OHD) levels <50 nmol/l, is independently associated with increased CVD risk. Medication use may influence 25OHD levels. We therefore investigated the association of circulating 25OHD with medication use in patients scheduled for cardiac surgery.

METHODS AND RESULTS

A total of 11,256 patients were included in this cross-sectional study. We compared 25OHD levels of medication users (18 groups of continuously used and 5 groups of intermittently used medications) with levels of non-users. Moreover, we assessed variables (medications, demographic and clinical parameters) that were independently associated with 25OHD levels <50 nmol/l. The prevalence of 25OHD levels <50 nmol/l was 65.7%. The use of statins and immunosuppressive agents was significantly associated with higher 25OHD levels and lower odds ratios of 25OHD levels <50 nmol/l. The use of ACE-inhibitors, catecholamines and antibiotics was associated with lower 25OHD levels and higher odds ratios of 25OHD levels <50 nmol/l. However, only use of antibiotics, immunosuppressive agents and catecholamines showed clinically relevant differences in 25OHD levels, i.e. differences of more than +4 nmol/l or -4 nmol/l, compared with respective non-users. These medications were prescribed either intermittently (antibiotics, catecholamines) and/or infrequently (<2%; immunosuppressive agents, catecholamines) and/or its causal relationship with circulating 25OHD is questionable (antibiotics). Female sex and blood drawing during wintertime were associated with the highest odds ratios of 25OHD levels <50 nmol/l.

CONCLUSION

Data indicate that in patients with high cardiovascular risk profile medication use does not substantially contribute to 25OHD levels <50 nmol/l.

Vitamin D metabolites and fibroblast growth factor-23 in patients with left ventricular assist device implants: association with stroke and mortality risk

PURPOSE

Stroke and mortality risk in patients with left ventricular assist device (LVAD) implants continue to be high. Whether nonclassical cardiovascular risk markers such as vitamin D metabolites and fibroblast growth factor (FGF)-23 contribute to this risk remains to be studied, and this was the objective of our work.

METHODS

In 154 LVAD patients (91 HeartWare and 63 HeartMate II implants), we measured circulating 25-hydroxyvitamin D (25OHD), 1,25-dihydroxyvitamin D3 (1,25[OH]2D3), parathyroid hormone (PTH) and FGF-23 shortly before LVAD implantation and investigated their association with stroke and mortality risk during 1-year follow-up.

RESULTS

Of the study cohort, 34.4 and 92.2%, respectively, had deficient 25OHD (<25 nmol/l) and 1,25(OH)2D3 (<41 pmol/l) values, whereas 42.6 and 98.7%, respectively, had elevated PTH levels (>6.7 pmol/l) and FGF-23 values above the reference range (100 RU/ml). One-year freedom from stroke was 80.9 %, and 1-year survival was 64.3%. The multivariable-adjusted hazard ratio of stroke was 2.44 (95% CI: 1.09-5.45; P = 0.03) for the subgroup of 25OHD levels <25 nmol/l (reference group: 25OHD levels ≥25 nmol/l). The multivariable-adjusted hazard ratio of 1-year mortality was 2.78 (95% CI: 1.52-5.09; P = 0.001) for patients with 25OHD levels <25 nmol/l compared with patients with 25OHD levels ≥25 nmol/l. PTH, FGF-23 and 1,25(OH)2D3 were not associated with stroke or mortality risk.

CONCLUSIONS

In LVAD patients, deficient 25OHD levels are independently associated with high stroke and mortality risk. If confirmed in randomized controlled trials, preoperative correction of deficient vitamin D status could be a promising measure to reduce stroke and mortality risk in LVAD patients.