Simulation Modalities in Clinical Practice.

For maximum effectiveness of a simulation-based educational experience, the correct modality must be chosen. Modality refers to the equipment or platform used to conduct the simulation. There are a variety of options available to clinical simulation educators, ranging from simple task trainers to full-body manikins to virtual experiences. The correctly chosen modality will allow the learners to achieve the learning objectives.

A Novice Guide to Applications of Simulation in the Pediatric Emergency Department.

Healthcare systems and health professions education have gone through radical changes in the past decades. These changes have made it imperative to explore innovative and alternative ways of teaching and training. Simulation-based education has emerged as an effective teaching strategy for both learners and practicing health professionals. Simulation is an educational technique that recreates real-life experiences. Learning occurs through participation in these simulation experiences followed by a period of guided debriefing and reflection. Pediatric emergency medicine, by its very nature, can benefit greatly from a well-designed and thoughtfully implemented simulation program. This review outlines situations where simulation may be used for maximum effectiveness in a pediatric emergency department and provides an overview of the basics of debriefing. A thorough description of each identified use of simulation is beyond the scope of this article.

An evaluation of reproductive and developmental toxicity of sitaxentan (thelin) in rats.

Sitaxentan sodium (Thelin) is a once daily, orally bioavailable, highly selective endothelin A receptor antagonist. Initially approved for the treatment of pulmonary arterial hypertension, sitaxentan was withdrawn in 2010 following the recognition of a pattern of idiosyncratic liver injury. During development of this drug, a series of nonclinical studies investigated the effects of orally administered sitaxentan on fertility, embryofetal development, and pre- and postnatal development in the rat; results of these studies are reported here. In the fertility study, sitaxentan did not affect mating behavior, fertility, sperm morphology, or estrous cycle. Sitaxentan was teratogenic in the embyrofetal development study, which was expected based on its pharmacologic mechanism of action. Teratogenic effects included malformations of the head, mouth, face, and large blood vessels. In the pre- and postnatal study, sitaxentan administration was associated with reduced pup survival, large or abnormally shaped livers, and delays in markers of auditory and sexual development. Sitaxentan was detected in plasma of suckling pups receiving milk from females dosed with sitaxentan. These nonclinical study findings were reflected in the sitaxentan product label warnings.

Evaluation of sitaxentan (Thelin®) toxicity in juvenile rats and regulatory interactions during the development of a European Medicines Agency pediatric investigation plan.

Pulmonary arterial hypertension (PAH) is characterized by increasing pulmonary vascular resistance leading to right heart failure and death. Sitaxentan (Thelin®) demonstrated efficacy in adult PAH; however, PAH therapy for children is critically needed. To support development for pediatric patients, sitaxentan (10, 30, or 60mg/kg/day) toxicity was assessed in juvenile (postnatal day 22-14weeks) rats. Sitaxentan did not affect survival, clinical signs, or body weight; no target organ of toxicity was identified. Hematologic changes were decreased erythrocyte parameters, prothrombin time, and activated partial thromboplastin time. Reproductive development and function in both sexes was unaffected, as assessed by mating performance; fertility, estrous cyclicity, and maintenance of normal pregnancy up to mid-gestation; sperm count, morphology, and motility; and testicular changes. The no-observed-adverse-effect level (NOAEL) on reproductive development and function was 60mg/kg/day; for toxicity, the NOAEL was 30mg/kg/day (coagulation parameter changes). Sitaxentan did not adversely affect physical development, cognitive ability, or reproductive function at exposures that were 58- and 61-fold higher than those found in adults after therapeutic exposure (100mg/day). This study is discussed in the context of evolving European pediatric drug legislation and guidance.

An overview of the preclinical toxicity and potential carcinogenicity of sitaxentan (Thelin®), a potent endothelin receptor antagonist developed for pulmonary arterial hypertension.

Sitaxentan (Thelin®), an endothelin receptor antagonist with a long duration of action and high specificity for the endothelin receptor A subtype, was used to treat pulmonary arterial hypertension. It was withdrawn from the market due to an idiosyncratic risk of drug-induced liver injury identified from emerging clinical trial data and clinical case reports. The preclinical safety profile of sitaxentan is presented, including single- and repeat-dose toxicity in mice, rats, and dogs and carcinogenicity in mice and rats. Sitaxentan-related adverse effects included coagulopathy in rats and dogs, increased serum alkaline phosphatase activity in mice and dogs, and hepatic hypertrophy in all species. Decreased albumin, erythrocyte count, hemoglobin concentration and hematocrit, and increased coagulation times and liver weight were also noted. These effects generally occurred at systemic exposures (AUC(0-24)) that were substantially greater than those seen in humans. Twice-daily (vs. once daily) dosing resulted in increased toxicity, which correlated with increased trough plasma sitaxentan concentrations. Sitaxentan appeared to have a low potential for testicular and hepatic toxicity and was not carcinogenic. These studies suggested that sitaxentan would have a reasonable margin of safety when used as directed in humans and supported a positive benefit:risk assessment at the time of marketing approval.

Mechanism of the antioxidant to pro-oxidant switch in the behavior of dehydroascorbate during LDL oxidation by copper(II) ions.

Oxidised low density lipoprotein (LDL) may be involved in the pathogenesis of atherosclerosis. We have therefore investigated the mechanisms underlying the antioxidant/pro-oxidant behavior of dehydroascorbate, the oxidation product of ascorbic acid, toward LDL incubated with Cu(2+) ions. By monitoring lipid peroxidation through the formation of conjugated dienes and lipid hydroperoxides, we show that the pro-oxidant activity of dehydroascorbate is critically dependent on the presence of lipid hydroperoxides, which accumulate during the early stages of oxidation. Using electron paramagnetic resonance spectroscopy, we show that dehydroascorbate amplifies the generation of alkoxyl radicals during the interaction of copper ions with the model alkyl hydroperoxide, tert-butylhydroperoxide. Under continuous-flow conditions, a prominent doublet signal was detected, which we attribute to both the erythroascorbate and ascorbate free radicals. On this basis, we propose that the pro-oxidant activity of dehydroascorbate toward LDL is due to its known spontaneous interconversion to erythroascorbate and ascorbate, which reduce Cu(2+) to Cu(+) and thereby promote the decomposition of lipid hydroperoxides. Various mechanisms, including copper chelation and Cu(+) oxidation, are suggested to underlie the antioxidant behavior of dehydroascorbate in LDL that is essentially free of lipid hydroperoxides.

Maternal folate deficiency results in selective upregulation of folate receptors and heterogeneous nuclear ribonucleoprotein-E1 associated with multiple subtle aberrations in fetal tissues.

BACKGROUND: Homocysteine, which increases in folate deficiency, can upregulate folate receptors (FR) at the translational level by increasing the interaction between a short cis-element in the 5'-untranslated region of FR-alpha mRNA and heterogeneous nuclear ribonucleoprotein-E1 (hnRNP-E1). Perturbation of this RNA-protein interaction on GD8.5 induces neural tube defects and neurocristopathies in mice. FR upregulation can also reduce cell proliferation independently of folate deficiency in some human cells. Accordingly, we tested the hypothesis that sustained murine maternal folate deficiency would negatively impact pregnancy outcomes, upregulate FR, and selectively reduce fetal cell proliferation. METHODS: Dams were fed chow with various levels of folic acid added for eight weeks before and throughout pregnancy. Following sacrifice on GD17, dams were compared for folate and homocysteine status as well as pregnancy outcomes. Fetuses from some groups were evaluated by specific biochemical, molecular, and immunohistochemical studies for FR, hnRNP-E1, and apoptosis. RESULTS: When compared to dams fed a folate-replete diet, those dams on a folate-depleted diet developed reduced red cell folates and hyperhomocysteinemia and an inverse dose-dependent upregulation of FR and hnRNP-E1 on GD17 without alterations in cell number in the majority of tissues. However, FR overexpression was accompanied by a significant reduction in the net number of cells in the midgut, lung, pons, tongue, and olfactory epithelium, and with premature differentiation in dorsal root ganglion cells and dysplasia of taste buds. By contrast, in the brain, spinal cord, diaphragm, and primordium of follicles of vibrissae, there was less FR expression, which accompanied a net reduction in number of cells and architectural anomalies. Subtle "immunohistochemical footprints" of apoptosis on GD17 fetuses corresponded with net cell loss in the lung and olfactory epithelium. Upregulation of FR could be explained by a homocysteine-induced RNA-protein interaction in folate-depleted fetuses that led to a proportionate increase in murine FR biosynthesis. CONCLUSIONS: Maternal folate deficiency results in selective upregulation of FR and hnRNP-E1 associated with multiple aberrations in fetal tissues that include increased cell loss, architectural anomalies, and premature differentiation. The potential significance of these findings to explain the wide spectrum of folate-responsive birth defects in humans is discussed.

Toxicokinetics of chloral hydrate in ad libitum-fed, dietary-controlled, and calorically restricted male B6C3F1 mice following short-term exposure.

Chloral hydrate is widely used as a sedative in pediatric medicine and is a by-product of water chlorination and a metabolic intermediate in the biotransformation of trichloroethylene. Chloral hydrate and its major metabolite, trichloroacetic acid, induce liver tumors in B6C3F1 mice, a strain that can exhibit high rates of background liver tumor incidence, which is associated with increased body weight. This report describes the influence of diet and body weight on the acute toxicity, hepatic enzyme response, and toxickinetics of chloral hydrate as part of a larger study investigating the carcinogenicity of chloral hydrate in ad libitum-fed and dietary controlled mice. Dietary control involves moderate food restriction to maintain the test animals at an idealized body weight. Mice were dosed with chloral hydrate at 0, 50, 100, 250, 500, and 1000 mg/kg daily, 5 days/week, by aqueous gavage for 2 weekly dosing cycles. Three diet groups were used: ad libitum, dietary control, and 40% caloric restriction. Both dietary control and caloric restriction slightly reduced acute toxicity of high doses of chloral hydrate and potentiated the induction of hepatic enzymes associated with peroxisome proliferation. Chloral hydrate toxicokinetics were investigated using blood samples obtained by sequential tail clipping and a microscale gas chromatography technique. It was rapidly cleared from serum within 3 h of dosing. Trichloroacetate was the major metabolite in serum in all three diet groups. Although the area under the curve values for serum trichloroacetate were slightly greater in the dietary controlled and calorically restricted groups than in the ad libitum-fed groups, this increase did not appear to completely account for the potentiation of hepatic enzyme induction by dietary restriction.

Prooxidant and antioxidant properties of human serum ultrafiltrates toward LDL: important role of uric acid.

Oxidized LDL is present within atherosclerotic lesions, demonstrating a failure of antioxidant protection. A normal human serum ultrafiltrate of Mr below 500 was prepared as a model for the low Mr components of interstitial fluid, and its effects on LDL oxidation were investigated. The ultrafiltrate (0.3%, v/v) was a potent antioxidant for native LDL, but was a strong prooxidant for mildly oxidized LDL when copper, but not a water-soluble azo initiator, was used to oxidize LDL. Adding a lipid hydroperoxide to native LDL induced the antioxidant to prooxidant switch of the ultrafiltrate. Uric acid was identified, using uricase and add-back experiments, as both the major antioxidant and prooxidant within the ultrafiltrate for LDL. The ultrafiltrate or uric acid rapidly reduced Cu2+ to Cu+. The reduction of Cu2+ to Cu+ may help to explain both the antioxidant and prooxidant effects observed. The decreased concentration of Cu2+ would inhibit tocopherol-mediated peroxidation in native LDL, and the generation of Cu+ would promote the rapid breakdown of lipid hydroperoxides in mildly oxidized LDL into lipid radicals. The net effect of the low Mr serum components would therefore depend on the preexisting levels of lipid hydroperoxides in LDL. These findings may help to explain why LDL oxidation occurs in atherosclerotic lesions in the presence of compounds that are usually considered to be antioxidants.