Correction to: Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies.

The original article [1] contains a small mistake concerning the ARTIC Team members mentioned in the Acknowledgements. The team member, Rocco Salvatore Calabrò had their name presented incorrectly. This has now been corrected in the original article.

Students' reflections on the relationships between safe learning environments, learning challenge and positive experiences of learning in a simulated GP clinic.

Learning environments are a significant determinant of student behaviour, achievement and satisfaction. In this article we use students' reflective essays to identify key features of the learning environment that contributed to positive and transformative learning experiences. We explore the relationships between these features, the students' sense of safety in the learning environment (LE), the resulting learning challenge with which they could cope and their positive reports of the experience itself. Our students worked in a unique simulation of General Practice, the Safe and Effective Clinical Outcomes clinic, where they consistently reported positive experiences of learning. We analysed 77 essays from 2011 and 2012 using an immersion/crystallisation framework. Half of the students referred to the safety of the learning environment spontaneously. Students described deep learning experiences in their simulated consultations. Students valued features of the LE which contributed to a psychologically safe environment. Together with the provision of constructive support and immediate, individualised feedback this feeling of safety assisted students to find their own way through clinical dilemmas. These factors combine to make students feel relaxed and able to take on challenges that otherwise would have been overwhelming. Errors became learning opportunities and students could practice purposefully. We draw on literature from medical education, educational psychology and sociology to interpret our findings. Our results demonstrate relationships between safe learning environments, learning challenge and powerful learning experiences, justifying close attention to the construction of learning environments to promote student learning, confidence and motivation.

Uncontrolled Donation After Circulatory Determination of Death Donors (uDCDDs) as a Source of Lungs for Transplant.

In April 2014, the American Journal of Transplantation published a report on the first lung transplant in the United States recovered from an uncontrolled donation after circulatory determination of death donor (uDCDD), assessed by ex vivo lung perfusion (EVLP). The article identified logistical and ethical issues related to introduction of lung transplant from uDCDDs. In an open clinical trial, we have Food and Drug Administration and Institutional Review Board approval to transplant lungs recovered from uDCDDs judged suitable after EVLP. Through this project and other experiences with lung recovery from uDCDDs, we have identified solutions to many logistical challenges and have addressed ethical issues surrounding lung transplant from uDCDDs that were mentioned in this case report. Here, we discuss those challenges, including issues related to recovery of other solid organs from uDCDDs. Despite logistical challenges, uDCDDs could solve the critical shortage of lungs for transplant. Furthermore, by avoiding the deleterious impact of brain death and days of positive pressure ventilation, and by using opportunities to treat lungs in the decedent or during EVLP, lungs recovered from uDCDDs may ultimately prove to be better than lungs currently being transplanted from conventional brain-dead organ donors.

Enhancing a sedation score to include truly noxious stimulation: the Extended Observer's Assessment of Alertness and Sedation (EOAA/S).

BACKGROUND: Although the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) is frequently used in sedation-related drug and device studies, a major shortcoming is that it does not differentiate between lighter and deeper levels of general anaesthesia because the only noxious stimulus of the MOAA/S is a trapezius squeeze. The primary aim of this investigation was to expand the MOAA/S score to include truly noxious stimulation, thereby extending the dynamic range of the assessment to include sedation states consistent with deeper levels of general anaesthesia. METHODS: Twenty healthy volunteers received target controlled infusions of fentanyl (target=0.8 ng ml(-1)) and propofol (starting at 0.5 µg ml(-1) and gradually increasing to 5 µg ml(-1)). At each propofol concentration, a MOAA/S score was obtained before and after tetanic electrical stimulation. The tetanic electrical stimulation current was gradually increased until the subject responded or until 50 mA was delivered without a response. A pharmacodynamic model was constructed to characterize the concentration-effect relationship between propofol and the MOAA/S scores. RESULTS: All subjects required a significantly higher propofol concentration to produce unresponsiveness to tetanic electrical stimulation at 50 mA compared with a standardized trapezius squeeze. The pharmacodynamic model adequately characterized the concentration-effect relationship. CONCLUSIONS: The Extended Observer's Assessment of Alertness and Sedation (or EOAA/S) extends the range of the widely used MOAA/S score to include truly noxious stimulation, thereby enabling the identification of drug-induced central nervous system depression representative of surgical anaesthesia.

Attitudes and beliefs of Australian adults on reality television cooking programmes and celebrity chefs. Is there cause for concern? Descriptive analysis presented from a consumer survey.

BACKGROUND: There is evidence suggesting that the nutritional content of recipes promoted by celebrity chefs or television cooking programmes contradict healthy eating guidelines. This study aims to investigate people's attitudes and beliefs about popular television cooking programmes and celebrity chefs. METHODS: Males and females who watch television cooking programmes were recruited to participate in a self-administered online questionnaire (22-items) which included multiple-choice and rank order questions. RESULTS: A total of n = 207 participants undertook the questionnaire with fully completed questionnaires available for n = 150 participants (Males, n = 22; Females, n = 128; aged 38.4 ± 14 years). The majority of respondents watch ≤30 minutes of television cooking programming per day (total responses, n = 153/207; 74%) with almost three-quarters (total responses, n = 130/175; 74%) having attempted a recipe. New cooking ideas (total responses, n = 81/175; 46%) and entertainment (total responses, n = 64/175; 36.5%) were the two main reasons participants gave for watching these programmes. Significantly more respondents believed recipes use excessive amounts of unhealthy fat, sugar or salt (unhealthy: 24%; healthy: 7%; P < 0.0001). Almost half of all respondents (total responses, n = 67/151; 44%) believed these programmes have no impact on their habitual diet. DISCUSSION AND CONCLUSION: Our results suggest television cooking programmes and celebrity chefs are unlikely to impact habitual dietary intake; rather, vicarious viewing and entertainment appear important factors relating to why people watch these programmes. However results generated from the present study are descriptive and subjective and further investigation into the impact of television cooking programmes and celebrity chefs on behavioural change requires attention. Further investigation including a systematic investigation into the dietary quality of recipes promoted by celebrity chefs against national healthy eating benchmarks is also warranted.

Nitric oxide ventilation of rat lungs from non-heart-beating donors improves posttransplant function.

Lungs from non-heart-beating donors (NHBDs) would enhance the donor pool. Ex vivo perfusion and ventilation of NHBD lungs allows functional assessment and treatment. Ventilation of rat NHBD lungs with nitric oxide (NO) during ischemia, ex vivo perfusion and after transplant reduced ischemia-reperfusion injury (IRI) and improved lung function posttransplant. One hour after death, Sprague-Dawley rats were ventilated for another hour with either 60% O2 or 60% O2/40 ppm NO. Lungs were then flushed with 20-mL cold Perfadex, stored cold for 1 h, perfused in an ex vivo circuit with Steen solution and warmed to 37 degrees C, ventilated 15 min, perfusion-cooled to 20 degrees C, then flushed with cold Perfadex and stored cold. The left lung was transplanted and ventilated separately. Recipients were sacrificed after 1 h. NO-ventilation was associated with significantly reduced wet:dry weight ratio in the ex vivo circuit, better oxygenation, reduced pulmonary vascular resistance, increased lung tissue levels of cGMP, maintained endothelial NOS eNOS, and reduced increases in tumor necrosis factor alpha (TNF-alpha) and inducible nitric oxide synthase (iNOS). NO-ventilation had no effect on MAP kinases or NF-kappaB activation. NO administration to NHBDs before and after lung retrieval may improve function of lungs from NHBDs.

Both mu and delta opiate receptors exist on the same neuron.

Low concentrations of the relatively selective opiate receptor agonists dihydromorphine and normorphine (mu receptor agonists) and D-Ala 2-D-Leu 5-enkephalin (a delta receptor agonist) were applied to single enteric neurons while the frequency of action potential firing was recorded. Most neurons that were inhibited by the mu agonists were also inhibited by the delta agonist, but the two receptors could be distinguished by the higher concentration of naloxone required to antagonize the delta agonist. The results indicate that enteric neurons bear both mu and delta receptors and that cell firing is inhibited if either receptor type is activated.

Continuous local anaesthetic wound catheter infiltration after clamshell thoracotomy.

We report on the novel and successful use of local anaesthetic wound infusions via elastomeric pumps in a 17-year-old male who underwent emergent clamshell thoracotomy after sustaining a stab wound to the flank. This formed one component of a multi-modal analgesic regimen aimed at reducing opioid requirements and their associated side-effects. The patient was mobilising and was discharged from the intensive care unit 24 h postoperatively. There was an unplanned break in the local anaesthetic infusion during which the patient's reported pain scores increased significantly. The catheters were removed on the fifth postoperative day and he was discharged from hospital on day 7.

Beware Cold Agglutinins in Organ Donors! Ex Vivo Lung Perfusion From an Uncontrolled Donation After Circulatory-Determination-of-Death Donor With a Cold Agglutinin: A Case Report.

BACKGROUND: We began to recover lungs from uncontrolled donation after circulatory determination of death to assess for transplant suitability by means of ex vivo lung perfusion (EVLP) and computerized tomographic (CT) scan. Our first case had a cold agglutinin with an interesting outcome. CASE REPORT: A 60-year-old man collapsed at home and was pronounced dead by Emergency Medical Services personnel. Next-of-kin consented to lung retrieval, and the decedent was ventilated and transported. Lungs were flushed with cold Perfadex, removed, and stored cold. The lungs did not flush well. Medical history revealed a recent hemolytic anemia and a known cold agglutinin. Warm nonventilated ischemia time was 51 minutes. O2-ventilated ischemia time was 141 minutes. Total cold ischemia time was 6.5 hours. At cannulation for EVLP, established clots were retrieved from both pulmonary arteries. At initiation of EVLP with Steen solution, tiny red aggregates were observed initially. With warming, the aggregates disappeared and the perfusate became red. After 1 hour, EVLP was stopped because of florid pulmonary edema. The lungs were cooled to 20°C; tiny red aggregates formed again in the perfusate. Ex vivo CT scan showed areas of pulmonary edema and a pyramidal right middle lobe opacity. Dissection showed multiple pulmonary emboli-the likely cause of death. However, histology showed agglutinated red blood cells in the microvasculature in pre- and post-EVLP biopsies, which may have contributed to inadequate parenchymal preservation. CONCLUSIONS: Organ donors with cold agglutinins may not be suitable owing to the impact of hypothermic preservation.

On the contribution of the first transmembrane domain to whole-cell current through an ATP-gated ionotropic P2X receptor.

Scanning cysteine mutagenesis was used to identify potential pore-forming residues in and around the first transmembrane domains of ionotropic P2X(2) receptor subunits. Twenty-eight unique cysteine-substituted mutants (R28C-Y55C) were individually expressed in HEK293 cells by lipofection. Twenty-three of these were functional as assayed by application of ATP to transfected voltage-clamped cells. Individual mutants varied in their sensitivity to ATP; otherwise, currents through functional mutant receptors resembled those of the homomeric wild-type (WT) receptor. In five (H33C, R34C, I50C, K53C, and S54C) of 23 functional mutants, coapplication of 30 microm ATP and 500 nm Ag(+) irreversibly inhibited inward current evoked by subsequent applications of ATP alone. These inhibitions did not result in a lateral shift in the agonist concentration-response curve and are unlikely to involve a modification of the agonist binding site. Two (K53C and S54C) of the five residues modified by Ag(+) applied in the presence of ATP when the channels were gating were also modified by 1 mm (2-aminoethyl)methanethiosulfonate applied in the absence of ATP when the channels were closed. These data suggest that domains near either end of the first transmembrane domain influence ion conduction through the pore of the P2X(2) receptor.

The effects of anions on the kinetics of reductive elimination of iron from monoferrictransferrins by thiols.

The kinetics of reductive elimination of iron from the human serum monoferric transferrins by thioglycollate (TG), 3-mercaptopropionate (MP), cysteine (Cys), cysteamine (Cym) and 2-mercaptoethanol (ME) have been studied at 37 degrees C using bathophenanthroline sulphonate (BPS) as the ferrous ion acceptor. Analysis of the entire course of the reaction was possible only with thioglycollate since the other thiols cause eventual protein precipitation; in these cases, initial rates were used. The rate of iron release is linearly dependent on thiol concentration at low concentrations of reductant (less than approx. 0.2 M) and increases more rapidly with higher concentrations (up to 0.5-0.75 M). The thiols fall into two distinct groups, with TG, MP and Cys reacting at approx. the same rate, which is an order of magnitude faster than the reaction with Cym and ME. The carboxylate functionality present in the first group may be responsible for the faster reaction rate, by competitively weakening the interaction between the protein and synergistic anion. The pH-dependence of the rate of reductive elimination appears to depend on ionizable functionalities on both the protein and reducing agent. The addition of NaCl, NaClO4, NaHCO3 and Na2HPO4 increases the rate of iron release from the monoferric transferrins. The last two have particularly large accelerating effects and, in the case of the N-terminal monoferrictransferrin, gave saturation kinetics, suggesting that the observed effect is due to conformational changes in the protein caused by binding of ions. The role of the Fe-synergistic anion complex in the transferrins as a 'trapped intermediate' is considered.

Influence of arteriovenous sampling on remifentanil pharmacokinetics and pharmacodynamics.

INTRODUCTION: Remifentanil is a new, short-acting, rapidly metabolized opioid. Because remifentanil is metabolized in blood and tissues by nonspecific esterases, there is a substantial difference between arterial and venous remifentanil concentrations. This difference may greatly affect the estimation of pharmacokinetic and pharmacodynamic parameters. OBJECTIVES: To assess the effects of sampling site on the pharmacokinetic and pharmacodynamic characteristics of remifentanil. METHODS: Ten healthy female subjects received intravenous remifentanil at an infusion rate of 3 microg/kg/min for 10 minutes. Serial blood samples were collected during and after drug administration from the radial artery and antecubital vein. A spectral edge measure was derived from the processed electroencephalographic and used as a measure of opioid effect. RESULTS: Venous concentrations were lower than arterial concentrations during the infusion of remifentanil. Pharmacokinetic parameters estimated from venous and arterial data differed significantly. When arterial concentrations were plotted against electroencephalographic effect, a classic counterclockwise hysteresis loop was observed, indicating a time-lag between changes in concentration and changes in effect. However, concentrations from venous blood produced a clockwise hysteresis loop that would classically suggest the development of acute tolerance. CONCLUSIONS: If this study had been conducted with venous samples alone, inappropriate conclusions such as acute tolerance could have been inferred. When designing studies to measure the acute time course (ie, non-steady state) of concentration and effect, the potential effects of sampling site on pharmacokinetic and pharmacodynamic characteristics must be carefully considered, particularly when the arteriovenous drug concentration difference is large.

Pharmacodynamic modeling of the electroencephalographic effects of flumazenil in healthy volunteers sedated with midazolam.

The purpose of this study was to model pharmacodynamically the reversal of midazolam sedation with flumazenil. Ten human volunteers underwent four different sessions. In session 1, individual midazolam pharmacokinetics and electroencephalographic pharmacodynamics were determined. In sessions 2 and 3, a computer-controlled infusion of midazolam with individual volunteer pharmacokinetic data was administered, targeting a plasma concentration corresponding to a light or deep level of sedation (20% or 80% of the maximal midazolam electroencephalographic effect) for a period of 210 minutes. After obtaining a stable electroencephalographic effect and constant midazolam plasma concentrations, a zero-order infusion of flumazenil was started until complete reversal of midazolam electroencephalographic effect was obtained. The flumazenil infusion was then stopped and the volunteer was allowed to resedate because of the constant midazolam drug effect. The electroencephalographic response was measured during a 180-minute period and analyzed by aperiodic analysis and fast-Fourier transforms. In session 4, a midazolam plasma concentration corresponding to a deep level of sedation was targeted for 210 minutes to examine for the possible development of acute tolerance. No flumazenil was given in session 4. For a light sedation level, with a mean midazolam plasma concentration of 160 +/- 64 ng/ml, the mean half-life of the equilibration rate constant of flumazenil reversal is 5.0 +/- 2.5 minutes, and the mean effect site concentration causing 50% of Emax is 13.7 +/- 5.8 ng/ml. For a deep level of sedation, with a mean midazolam plasma concentration of 551 +/- 196 ng/ml, the mean half-life of the equilibration rate constant is 3.9 +/- 1.5 minutes, and the mean effect site concentration causing 50% of Emax is 20.6 +/- 6.8 ng/ml. This study provides an estimate of the magnitude of the blood/central nervous system equilibration delay for flumazenil antagonism of midazolam sedation and further defines the usefulness of the electroencephalogram as a measure of midazolam pharmacodynamic effect.

Molecular cloning and functional characterization of the zebrafish ATP-gated ionotropic receptor P2X(3) subunit.

We describe a P2X subunit cloned from the zebrafish (Danio rerio) that is an orthologue of the mammalian P2X(3) subunit. Like the mammalian P2X(3), this receptor desensitizes rapidly in the presence of agonist. However, it differs in that alphabeta-meATP is a much less potent agonist than ATP and the antagonist TNP-ATP is not active at low nanomolar concentrations. Similar to the rat P2X(3) subunit, the zebrafish subunit forms hetero-oligomeric assemblies with the rat P2X(2) that possesses a phenotype distinct from either parent. This novel clone will provide an important basis for future experiments investigating the structure/function relationships of P2X subunit domains.