Drive-thru continuing education to meet learners' needs.

BACKGROUND: Continuing education is a requirement for emergency medical services practitioners in Ohio, and simulation-based learning has been effective for this purpose. Limitations to providing simulation for emergency medical services practitioners include a lack of simulation resources or equipment and a lack of trained simulationists to adequately use existing equipment, such as high-fidelity manikins. Here, we sought to provide simulation-based learning in the ambulance bays of our local hospitals to meet these needs. METHODS: The OhioHealth simulation team, in conjunction with OhioHealth Emergency Medical Services, conducted simulation-based education sessions in ambulance bays scheduled in 2-h blocks for 3 consecutive days at 3 different hospitals in Columbus, Ohio. The outcomes of the education sessions were evaluated based on the ability to meet the educational objectives and the suitability of the environment for learning. In total, 171 learners completed educational sessions and evaluations. RESULTS: Modified Likert scale surveys were completed by learners to assess their confidence in the learning objectives. For each session, the learners were able to meet the determined learning objectives after the education. Regarding the feasibility of using ambulance bays for education, 90% of learners (155/171) responded that they "Agree" or "Strongly Agree" that the environment was conducive to learning. CONCLUSION: Using care site ambulance bays with simulation staff and content experts, we were able to effectively deliver simulation-based education. Based on learner perception and ability for education to meet its determined objectives, the ambulance bay provides a feasible way to address existing barriers (cost, access to equipment, and trained staff) to simulation-based education for emergency medical services practitioners.

Integrated multi-omics reveals anaplerotic rewiring in methylmalonyl-CoA mutase deficiency.

Methylmalonic aciduria (MMA) is an inborn error of metabolism with multiple monogenic causes and a poorly understood pathogenesis, leading to the absence of effective causal treatments. Here we employ multi-layered omics profiling combined with biochemical and clinical features of individuals with MMA to reveal a molecular diagnosis for 177 out of 210 (84%) cases, the majority (148) of whom display pathogenic variants in methylmalonyl-CoA mutase (MMUT). Stratification of these data layers by disease severity shows dysregulation of the tricarboxylic acid cycle and its replenishment (anaplerosis) by glutamine. The relevance of these disturbances is evidenced by multi-organ metabolomics of a hemizygous Mmut mouse model as well as through identification of physical interactions between MMUT and glutamine anaplerotic enzymes. Using stable-isotope tracing, we find that treatment with dimethyl-oxoglutarate restores deficient tricarboxylic acid cycling. Our work highlights glutamine anaplerosis as a potential therapeutic intervention point in MMA.

Does Delaying Surgical Resection After Neoadjuvant Chemoradiation Impact Clinical Outcomes in Locally Advanced Rectal Adenocarcinoma?: A Single-Institution Experience.

OBJECTIVES: Surgical resection for locally advanced rectal adenocarcinoma commonly occurs 6 to 10 weeks after completion of neoadjuvant chemoradiation (nCRT). We sought to determine the optimal timing of surgery related to the pathologic complete response rate and survival endpoints. METHODS: The study is a retrospective analysis of 92 patients treated with nCRT followed by surgery from 2004 to 2011 at our institution. Univariate and multivariate analyses were performed to assess the impact of timing of surgery on locoregional control, distant failure (DF), disease-free survival, and overall survival (OS). RESULTS: Time-to-surgery was ≤8 weeks (group A) in 72% (median 6.1 wk) and >8 weeks (group B) in 28% (median 8.9 wk) of patients. No significant differences in patient characteristics, locoregional control, or pathologic complete response rates were noted between the groups. Univariate analysis revealed that group B had significantly shorter time to DF (group B, median 33 mo; group A, median not reached, P=0.047) and shorter OS compared with group A (group B, median 52 mo; group A, median not reached, P=0.03). Multivariate analysis revealed that increased time-to-surgery showed a significant increase in DF (HR=2.96, P=0.02) and trends toward worse OS (HR=2.81, P=0.108) and disease-free survival (HR=2.08, P=0.098). CONCLUSIONS: We found that delaying surgical resection longer than 8 weeks after nCRT was associated with an increased risk of DF. This study, in combination with a recent larger study, questions the recent trend in promoting surgical delay beyond the traditional 6 to 10 weeks. Larger, prospective databases or randomized studies may better clarify surgical timing following nCRT in rectal adenocarcinoma.

N(8)-acetylspermidine as a potential plasma biomarker for Snyder-Robinson syndrome identified by clinical metabolomics.

Clinical metabolomics has emerged as a powerful tool to study human metabolism in health and disease. Comparative statistical analysis of untargeted metabolic profiles can reveal perturbations of metabolite levels in diseases and thus has the potential to identify novel biomarkers. Here we have applied a simultaneous genetic-metabolomic approach in twin boys with epileptic encephalopathy of unclear etiology. Clinical exome sequencing identified a novel missense mutation in the spermine synthase gene (SMS) that causes Snyder-Robinson syndrome (SRS). Untargeted plasma metabolome analysis revealed significantly elevated levels of N(8)-acetylspermidine, a precursor derivative of spermine biosynthesis, as a potential novel plasma biomarker for SRS. This result was verified in a third patient with genetically confirmed SRS. This study illustrates the potential of metabolomics as a translational technique to support exome data on a functional and clinical level.

Combined Microsatellite Instability, MLH1 Methylation Analysis, and Immunohistochemistry for Lynch Syndrome Screening in Endometrial Cancers From GOG210: An NRG Oncology and Gynecologic Oncology Group Study.

PURPOSE: The best screening practice for Lynch syndrome (LS) in endometrial cancer (EC) remains unknown. We sought to determine whether tumor microsatellite instability (MSI) typing along with immunohistochemistry (IHC) and MLH1 methylation analysis can help identify women with LS. PATIENTS AND METHODS: ECs from GOG210 patients were assessed for MSI, MLH1 methylation, and mismatch repair (MMR) protein expression. Each tumor was classified as having normal MMR, defective MMR associated with MLH1 methylation, or probable MMR mutation (ie, defective MMR but no methylation). Cancer family history and demographic and clinical features were compared for the three groups. Lynch mutation testing was performed for a subset of women. RESULTS: Analysis of 1,002 ECs suggested possible MMR mutation in 11.8% of tumors. The number of patients with a family history suggestive of LS was highest among women whose tumors were classified as probable MMR mutation (P = .001). Lynch mutations were identified in 41% of patient cases classified as probable mutation (21 of 51 tested). One of the MSH6 Lynch mutations was identified in a patient whose tumor had intact MSH6 expression. Age at diagnosis was younger for mutation carriers than noncarriers (54.3 v 62.3 years; P < .01), with five carriers diagnosed at age > 60 years. CONCLUSION: Combined MSI, methylation, and IHC analysis may prove useful in Lynch screening in EC. Twenty-four percent of mutation carriers presented with ECs at age > 60 years, and one carrier had an MSI-positive tumor with no IHC defect. Restricting Lynch testing to women diagnosed at age < 60 years or to women with IHC defects could result in missing a substantial fraction of genetic disease.

Highly oxygenated sesquiterpenes in Artemisia alba Turra.

Ten new sesquiterpene alcohols of which seven germacranes, a eudesmane, a guaiane and an oplopane were isolated from the aerial parts of Artemisia alba Turra. Their structures and relative stereochemistry were elucidated by spectral methods ((1)H and (13)C NMR, COSY, HSQC, HMBC, NOESY, and MS). In addition, the known 7-hydroxycadin-4-en-3-one, centaureidin and axillarin were found for the first time in the studied species.

Activity-guided screening of bioactive natural compounds implementing a new glucocorticoid-receptor-translocation assay and detection of new anti-inflammatory steroids from bacteria.

Using an in vitro cell-based assay in a flow-design, we have applied activity-guided screening to search for new bioactive compounds isolated from microorganisms. A first assay employs the stable expression of nuclear factor kappa B (NF-κB) while a second assay utilizes the glucocorticoid receptor (GR) coupled to green fluorescent protein. A specialized assay was implemented for both the translocation of NF-κB and to inhibit the translocation of cytokine-mediated NF-κB. In addition, we developed in a wide palette of cell lines used for a highly specialized GR-translocation assay to detect anti-inflammatory effects. This approach demonstrates the straight-forward combination of cell-based assays arranged with an automated fluorescence microscope. This allows for the direct sorting of extracts which are acting in a pharmaceutically interesting way. Initial results using this technique have led to the detection of new anti-inflammatory steroids from bacterial crude extracts.

Cytotoxic triterpenoids from Abies recurvata.

Nine triterpenoids (neoabiestrines A-I, 1-9) including six rearranged lanostanes (1-6) and a rare cycloart-7-ene (7) were isolated from Abies recurvata together with ten known compounds. Their structures were determined by detailed analysis of NMR and MS spectroscopic data. The absolute configurations of 1 and 8 were determined by Cu-Ka X-ray crystallography. Compound 6 showed potent anti-proliferative effect against THP-1 tumor cells with an IC(50) value of 17.8 µg/mL.

Bendigoles D-F, bioactive sterols from the marine sponge-derived Actinomadura sp. SBMs009.

Marine derived actinomycetes have become an important source of bioactive natural products. Here we report the structure and bioactivity of the bendigoles D-F (1-3), 3-keto sterols isolated from the new marine sponge derived bacterium, Actinomadura sp. SBMs009. The isolation of these compounds was guided by a novel high-content screen for NF-κB and glucocorticoid receptor (GR) activity, and cytotoxicity assays. The structures of 1-3 were determined by detailed analysis of NMR, MS, and single crystal X-ray diffraction data. Interestingly, 1 displayed cytotoxicity against the L929 (mouse fibroblast) cell line with an IC(50) approximated to 30 µM and was the most active inhibitor of GR-translocation, while 3 was the most effective inhibitor of NF-κB nuclear translocation with an IC(50) of 71 µM.

Visualizing the spatial distribution of secondary metabolites produced by marine cyanobacteria and sponges via MALDI-TOF imaging.

Marine cyanobacteria and sponges are prolific sources of natural products with therapeutic applications. In this paper we introduce a mass spectrometry based approach to characterize the spatial distribution of these natural products from intact organisms of differing complexities. The natural product MALDI-TOF-imaging (npMALDI-I) approach readily identified a number of metabolites from the cyanobacteria Lyngbya majuscula 3L and JHB, Oscillatoria nigro-viridis, Lyngbya bouillonii, and a Phormidium species, even when they were present as mixtures. For example, jamaicamide B, a well established natural product from the cyanobacterium Lyngbya majuscula JHB, was readily detected as were the ions that correspond to the natural products curacin A and curazole from Lyngbya majuscula 3L. In addition to these known natural products, a large number of unknown ions co-localized with the different cyanobacteria, providing an indication that this method can be used for dereplication and drug discovery strategies. Finally, npMALDI-I was used to observe the secondary metabolites found within the sponge Dysidea herbacea. From these sponge data, more than 40 ions were shown to be co-localized, many of which were halogenated. The npMALDI-I data on the sponge indicates that, based on the differential distribution of secondary metabolites, sponges have differential chemical micro-environments within their tissues. Our data demonstrate that npMALDI-I can be used to provide spatial distribution of natural products, from single strands of cyanobacteria to the very complex marine assemblage of a sponge.