Training for vigilance on the move: a video game-based paradigm for sustained attention.

The capacity for superior vigilance can be trained by using knowledge of results (KR). Our present experiments demonstrate the efficacy of such training using a first-person perspective movement videogame-based platform in samples of students and Soldiers. Effectiveness was assessed by manipulating KR during a training phase and withdrawing it in a subsequent transfer phase. Relative to a no KR control condition, KR systematically improved performance for both Soldiers and students. These results build upon our previous findings that demonstrated that a video game-based platform can be used to create a movement-centred sustained attention task with important elements of traditional vigilance. The results indicate that KR effects in sustained attention extend to a first person perspective movement based paradigm, and that these effects occur in professional military as well as a more general population. Such sustained attention training can save lives and the present findings demonstrate one particular avenue to achieve this goal. Practitioner Summary: Sustained attention can be trained by means of knowledge of results using a videogame-based platform with samples of students and Soldiers. Four experiments demonstrate that a dynamic, first-person perspective video game environment can serve to support effective sustained attention training in professional military as well as a more general population.

Validation of a panel of ADAMTS13 assays for diagnosis of thrombotic thrombocytopenic purpura: activity, functional inhibitor, and autoantibody test.

INTRODUCTION: Quantitation of ADAMTS13 activity, functional inhibitors, and autoantibodies is crucial in diagnosis and management of thrombotic thrombocytopenic purpura. We compared and optimized commercial assay kits and validated a testing panel. METHODS: Citrated plasma specimens from healthy volunteers and residual samples submitted for clinical testing were used in the study. Commercially available ADAMTS13 activity assays including ACTIFLUOR(™) ADAMTS13 (Sekisui Diagnostics, Stamford, CT, USA), LIFECODES ATS-13 (Gen-Probe Inc., San Diego, CA, USA), and TECHNOZYM(®) ADAMTS-13 (Technoclone, Vienna, Austria) were evaluated. Functional inhibitor assays were performed using internally developed mixing protocols. Two autoantibody assays were also evaluated: IMUBIND(®) (Sekisui Diagnostics) and TECHNOZYM(®) ADAMTS-13 INH ELISA kits (Technoclone). RESULTS: A laboratory-developed assay using ACTIFLUOR(™) reagents showed best agreement with the reference method, and full validation showed a reportable range of 5% (LLOQ) to 114% with a reference interval of ≥68%. Both intra- and interassay coefficients of variation were <10%. Inhibitor assays performed with the kits showed 95% overall agreement with the reference method. A modification of the TECHNOZYM(®) autoantibody assay showed 85% overall agreement with the reference method with imprecision approximately 20%. CONCLUSION: ADAMTS13 activity and inhibitor tests using ACTIFLUOR(™) reagents and modified TECHNOZYM(®) autoantibody ELISA showed superior performance compared to the other kits for clinical use in this study.

Validation of a molecular diagnostic assay for CALR exon 9 indels in myeloproliferative neoplasms: identification of coexisting JAK2 and CALR mutations and a novel 9 bp deletion in CALR.

INTRODUCTION: The 2008 WHO criteria for the diagnosis and classification of myeloproliferative neoplasms (MPN) rely in part upon the assessment of mutations in JAK2 and MPL genes. Recently, mutations in calreticulin (CALR) have been identified in MPN lacking JAK2 and MPL mutations. We have validated a sensitive fragment analysis assay to detect CALR mutations. METHODS: Genomic DNA from peripheral blood, bone marrow, and FFPE bone marrow clot preparations from 52 MPN specimens with known JAK2 and MPL mutation status and 29 non-MPN specimens was analyzed. CALR mutation testing was performed by fragment length analysis, and the results were confirmed by sequencing. Accuracy, precision, sensitivity, specificity, and robustness of the assay were determined. RESULTS: Forty specimens (32 JAK2+, 2 JAK2-/MPL+, and 6 JAK2-/MPL-) were negative for CALR mutations. Twelve specimens had CALR mutations including 52 bp deletion (5), 5 bp insertion (6), and a novel 9 bp deletion (1). This 9 bp inframe deletion occurring at an allelic burden of 50% would delete three amino acids. One specimen with a 52 bp deletion also had JAK2 V617F mutation. All 29 non-MPN specimens were negative for CALR mutations. The assay accurately identified the mutation status of all 52 MPN specimens and had a coefficient of variation <3% for the fragment size and mutant peaks with a sensitivity of 5% for indels. CONCLUSIONS: Fragment analysis is an accurate and sensitive method for the detection of CALR indels. The novel 9 bp deletion is likely a germline variant. Consequence of coexisting JAK2 V617F and CALR mutations requires careful interpretation.

fMRI neurofeedback of higher visual areas and perceptual biases.

The self-regulation of brain activation via neurofeedback training offers a method to study the relationship between brain areas and perception in a more direct manner than the conventional mapping of brain responses to different types of stimuli. The current proof-of-concept study aimed to demonstrate that healthy volunteers can self-regulate activity in the parahippocampal place area (PPA) over the fusiform face area (FFA). Both areas are involved in higher order visual processing and are activated during the imagery of scenes and faces respectively. Participants (N=9) were required to upregulate PPA relative to FFA activity, and all succeeded at the task, with imagery of scenes being the most commonly reported mental strategy. A control group (N=8) underwent the same imagery and testing procedure, albeit without neurofeedback, in a mock MR scanner to account for any non-specific training effects. The upregulation of PPA activity occurred concurrently with activation of prefrontal and parietal areas, which have been associated with ideation and mental image generation. We tested whether successful upregulation of the PPA relative to FFA had consequences on perception by assessing bistable perception of faces and houses in a binocular rivalry task (before and after the scanning sessions) and categorisation of faces and scenes presented in transparent composite images (during scanning, interleaved with the self-regulation blocks). Contrary to our expectations, upregulation of the PPA did not alter the duration of face or house perception in the rivalry task and response speed and accuracy in the categorisation task. This conclusion was supported by the results of another control experiment (N=10 healthy participants) that involved intensive exposure to category-specific stimuli and did not show any behavioural or perceptual changes. We conclude that differential self-regulation of higher visual areas can be achieved, but that perceptual biases under conditions of stimulus rivalry are relatively robust against such internal modulation of localised brain activity. This study sets the basis for future investigations of perceptual and behavioural consequences of localised self-regulation of neural activity.

HOW DO WORK HIERARCHIES AND STRICT DIVISIONS OF LABOUR IMPACT CARE WORKERS' EXPERIENCES OF HEALTH AND SAFETY? CASE STUDIESOF LONG TERM CARE IN TORONTO.

BACKGROUND: According to the Canadian Health Care Association (1), there are 2,577 long-term care ("LTC") facilities across Canada, with the largest proportion (33.4%) located in Ontario. Most studies focus on residents' health, with less attention paid to the health and safety experiences of staff. Given that the work performed in Ontario LTC facilities is very gendered, increasingly racialized, task-oriented, and with strict divisions of labour, this paper explores in what ways some of these factors impact workers' experiences of health and safety. OBJECTIVES: The study objectives included the following research question: How are work hierarchies and task orientation experienced by staff? DESIGN AND SETTING: This paper draws on data from rapid team-based ethnographies of the shifting division of labour in LTC due to use of informal carers in six non-profit LTC facilities located in Toronto, Ontario. METHODS: Our method involved conducting observations and key informant interviews (N=167) with registered nurses, registered practical nurses, personal support workers, dietary aides, recreation therapists, families, privately paid companions, students, and volunteers. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed. For observations, researchers were paired and covered shifts between 7 a.m. and 11 p.m., as well as into the late night over six days, at each of the six sites. Detailed ethnographic field notes were written during and immediately following observational fieldwork. RESULTS: Our results indicate that employee stress is linked to the experiences of care work hierarchies, task orientation, and strict divisions of labour between and among various staff designations. CONCLUSION: Findings from this project confirm and extend current research that demonstrates there are challenging working conditions in LTC, which can result in occupational health and safety problems, as well as stress for individual workers.

Trends and Patterns in Reporting of Patient Safety Situations in Transplantation.

Analysis and dissemination of transplant patient safety data are essential to understanding key issues facing the transplant community and fostering a "culture of safety." The Organ Procurement and Transplantation Network's (OPTN) Operations and Safety Committee de-identified safety situations reported through several mechanisms, including the OPTN's online patient safety portal, through which the number of reported cases has risen sharply. From 2012 to 2013, 438 events were received through either the online portal or other reporting pathways, and about half were self-reports. Communication breakdowns (22.8%) and testing issues (16.0%) were the most common types. Events included preventable errors that led to organ discard as well as near misses. Among events reported by Organ Procurement Organization (OPOs), half came from just 10 of the 58 institutions, while half of events reported by transplant centers came from just 21 of 250 institutions. Thirteen (23%) OPOs and 155 (62%) transplant centers reported no events, suggesting substantial underreporting of safety-related errors to the national database. This is the first comprehensive, published report of the OPTN's safety efforts. Our goals are to raise awareness of safety data recently reported to the OPTN, encourage additional reporting, and spur systems improvements to mitigate future risk.

Successful international collaboration improves family donation conversations resulting in increased organ donation.

INTRODUCTION: Australian donation leaders recognized that to increase organ donation outcomes, health professionals conducting family donation conversations (FDCs) required support and specialist training. An international training institute with programs based on proven results was engaged to create and implement a customized training program to influence change in FDC practice and culture. The goal was to increase donation rates by developing and implementing a customized, self-sustaining training program to enhance FDC practices of health professionals. Other goals included providing training and communications skills to lead FDC, supporting families in making decisions, and influencing health professionals to adopt FDC practices. MATERIALS AND METHODS: To gain support and determine program suitability, two 1-day pilot training sessions were provided to 45 Australian donation leaders in 2011. Training was further customized with an emphasis on creating changes to achieve and sustain desired results. A comprehensive national training plan was implemented over 18 months. Twenty-six 2-day FDC training workshops were held in 8 cities (646 participants). Program evaluations and debriefings showed distinct shifts in perspectives and an enthusiasm to implement new processes. In 2012 to 2013, an instructor program was developed to transition training facilitation. The training institute remains involved in development and training to build and sustain skill and expertise. RESULTS: There was a 58% increase in organ donors in Australia from 2009 to 2013 (data reflect 2013 Australian end-of-year organ donation information). This represents a 36% increase in organ donors (2009-2011); the remaining 22% increase was achieved in the 2 years since the FDC training was implemented in Australia (2011-2013). CONCLUSIONS: Improved skills training in the conduct of FDCs seem to have contributed to improved donation outcomes in national identification, request, and consent rates. The integration of another organization's process poses distinct challenges; thoughtful collaboration, sensitive to cultural aspects and family care, communication, and donation practices, can result in successful customized training that shifts perspectives, provides new skills, and achieves and sustains an increase in organ donation rates.

Modelling of the flow field surrounding tidal turbine arrays for varying positions in a channel.

The modelling of tidal turbines and the hydrodynamic effects of tidal power extraction represents a relatively new challenge in the field of computational fluid dynamics. Many different methods of defining flow and boundary conditions have been postulated and examined to determine how accurately they replicate the many parameters associated with tidal power extraction. This paper outlines the results of numerical modelling analysis carried out to investigate different methods of defining the inflow velocity boundary condition. This work is part of a wider research programme investigating flow effects in tidal turbine arrays. Results of this numerical analysis were benchmarked against previous experimental work conducted at the University of Southampton Chilworth hydraulics laboratory. Results show significant differences between certain methods of defining inflow velocities. However, certain methods do show good correlation with experimental results. This correlation would appear to justify the use of these velocity inflow definition methods in future numerical modelling of the far-field flow effects of tidal turbine arrays.

The deceased organ donor with an "open abdomen": proceed with caution.

In solid organ transplantation, the disparity between donor supply and patients awaiting transplant continues to increase. The organ shortage has led to relaxation of historic contraindications to organ donation. A large percentage of deceased organ donors have been subjected to traumatic injuries, which can often result in intervention that leads to abdominal packing and intensive care unit resuscitation. The donor with this "open abdomen" (OA) presents a situation in which the risk of organ utilization is difficult to quantify. There exists a concern for the potential of a higher risk for both bacterial and fungal infections, including multidrug-resistant (MDR) pathogens because of the prevalence of antibiotic use and critical illness in this population. No recommendations have been established for utilization of organs from these OA donors, because data are limited. Herein, we report a case of a 21-year-old donor who had sustained a gunshot wound to his abdomen, resulting in a damage-control laparotomy and abdominal packing. The donor subsequently suffered brain death, and the family consented to organ donation. A multiorgan procurement was performed with respective transplantation of the procured organs (heart, liver, and both kidneys) into 4 separate recipients. Peritoneal swab cultures performed at the time of organ recovery grew out MDR Pseudomonas aeruginosa on the day after procurement, subsequently followed by positive blood and sputum cultures as well. All 4 transplant recipients subsequently developed infections with MDR P. aeruginosa, which appeared to be donor-derived with similar resistance patterns. Appropriate antibiotic coverage was initiated in all of the patients. Although 2 of the recipients died, mortality did not appear to be clearly associated with the donor-derived infections. This case illustrates the potential infectious risk associated with organs from donors with an OA, and suggests that aggressive surveillance for occult infections should be pursued.

Geographical location has greater impact on carotenoid content and bioaccessibility from tomatoes than variety.

The suggested health benefits of consuming tomatoes and tomato-based products have been attributed, in part, to the carotenoids present in these foods. Therefore, the objectives of the present study were to (i) analyse carotenoid content and bioaccessibility from different tomato (Lycopersicon esculentum L.) types namely cherry, plum, round, and certain tomatoes-on-the-vine; and (ii) determine if geographical location (Ireland vs Spain) influenced the content and bioaccessibility of carotenoids in tomatoes of the same variety. Carotenoid bioaccessibility is defined as the amount of ingested carotenoids that, after digestion, are available for absorption by intestinal cells. Differences were seen in carotenoid content and bioaccessibility between the different tomato types tested. For instance, Irish round high-lycopene tomatoes contained the greatest amounts of lycopene and lutein but lowest levels of beta-carotene compared with the other Irish tomatoes. Furthermore, the content and bioaccessibility of carotenoids that were sourced from Ireland and Spain also varied greatly. Spanish tomatoes were generally superior in the content, bioaccessibility, and micelle content of carotenoids. To conclude, our findings suggest that geographical location, rather than the type of tomato, seems to have a more pronounced effect on carotenoid bioaccessibility from tomatoes.

Development and validation of a phosphorylated SMAD ex vivo stimulation assay.

Assessing the pharmacodynamics (PD) of a potential therapeutic through the use of a downstream biomarker is essential. This is traditionally performed in the target tissue but limited volume and invasiveness of sampling pose challenges with solid tumours. Currently, there are several small molecule receptor kinase inhibitors and large molecule therapeutic antibodies in clinical trials that interfere with TGFbeta signalling to treat various forms of cancer. With the advent of these new therapies, there is a need for a surrogate tissue that is easily accessible and indicative of tumour response. We propose the use of an ex vivo TGFbeta1 stimulation of peripheral blood mononuclear cells (PBMCs) coupled with the measurement of phosphorylated SMAD2 (Sma/Mothers Against dpp, a downstream transcriptional activator) using a sandwich ELISA. TGFbeta is involved in many different cellular responses, such as proliferation, angiogenesis, migration, invasion and immunomodulation. SMAD2 and SMAD3 are phosphorylated as a result of the canonical cascade through ligand binding and receptor kinase activation. These phosphorylated SMADs (pSMAD) associate with SMAD4, a co-SMAD, and transcriptionally activate TGFbeta-mediated genes. This paper describes the novel method for measuring the downstream effects of inhibiting canonical TGFbeta signalling using ex vivo stimulation of surrogate tissue to predict tumour response. In addition, we present the assay validation rationale and data. This novel, validated assay can be used to gain insight into clinical trials regarding TGFbeta signal modulation by multiple inhibitor platforms for both large and small molecules.

Radiotherapy for metastatic melanoma presenting in pregnancy.

We describe the study of a patient with metastatic melanoma to axillary nodes presenting during pregnancy. The factors considered in her management are discussed, including issues related to staging, the decision not to terminate the pregnancy and the relative efficacy and fetal toxicity of the available treatment options. An overview of the known effects of radiotherapy on the fetus is presented and the technical alterations that were used to decrease the toxicity of radiotherapy are discussed.

Observation of lymphatic vessels in orbital fat of patients with inflammatory conditions: a form fruste of lymphangiogenesis?

In the absence of antibodies specific for lymphatic vessels, analysis of lymphatic vessels within different tissues has been widely performed with light microscopic and, most importantly, electron microscopic techniques. In regard to lymphatic vessels in the ocular globe and the periocular structures, controversy remains about the specific distribution of lymphatic channels. It is postulated that bulbar and retrobulbar tissues are devoid of lymphatic vessels, but lymphatic vessels have been demonstrated in lacrimal gland and epibulbar conjunctiva. In this study, we analyzed orbital fat for the presence of lymphatic tissue using D2-40, a monoclonal antibody, specific for lymphatic vessels. We found lymphatic vessels present within bulbar conjunctiva extending to the level of the ciliary apparatus. No lymphatics were identified in healthy anterior orbital adipose tissue. In two cases of orbital mucor-mycosis and one case of panendophthalmitis, significant lymphovascular proliferation was present within granulation tissue associated with the acute inflammation. We conclude that lymph vessel proliferation may be induced in inflammatory conditions in tissues which are normally devoid of lymph channels.

Identification of lymphatic vessels in malignant, adenomatous and normal colonic mucosa using the novel immunostain D2-40.

Distribution of lymphatic vessels in normal and neoplastic colon has been previously analyzed with electron microscopic techniques, as reliable antibodies have not been available for selective lymph vessel staining. A novel monoclonal antibody, D2-40, is recently available to differentiate lymphatic vessels from blood vessels. In this study, we analyzed the distribution of lymphatic vessels in normal colon, adenomas with and without superficial stalk invasion and invasive carcinomas without identifiable polypoid precursor lesions. In contrast to previous studies, we found lymphatic vessels in superficially misplaced stalk stroma in adenomas, and closely associated with early invasive epithelial nests in invasive lesions. Lymphatic vessels were identified within the lamina propria of the in situ aspect of in invasive tumors. We conclude that lymphatic vessel structures are seen more superficially in adenomas and invasive carcinomas than previously described. Since intramucosal carcinomas in adenomas do not metastasize, these lymph vessels may be immature or not communicate with deeper lymphatics. Proliferation and distribution of lymphatic vessels may be related to prognosis and early metastasis.

Increased functional expression of transgene in primary human lymphocytes using retroviral vectors modified with IRES and splicing motifs.

Genetic modification of human lymphocytes is being employed in strategies to correct enzyme deficiencies, encode cytokines and to redirect lymphocytes to antigenic targets other than those encoded by their endogenous T cell receptor. However, expression of transgenes in primary lymphocytes is generally low. Reasoning that vector modification may lead to increased transgene expression and subsequent increases in function, we have performed two retroviral vector modifications and report their effect on the functional expression in primary lymphocytes. A chimeric receptor specific for the colon carcinoma-associated antigen, EGP40, was initially incorporated into the retroviral vector LXSN. In this vector, receptor expression is driven by the Moloney murine leukemia virus LTR, and neomycin phosphotransferase expression driven by the SV40 promoter. Replacement of SV40 with an internal ribosomal entry site (IRES) increased the transgene activity of a mouse T cell line and human PBL as judged by increased cytokine release in response to antigen positive target cells. A further increase in transgene function was generated by the additional incorporation of a splice acceptor motif into the construct. Human PBL transduced with vector incorporating both IRES and intron were consistently more effective at lysing antigen positive colorectal carcinoma cells.