Osmotic Pressure Enables High-Yield Assembly of Giant Vesicles in Solutions of Physiological Ionic Strengths.

Giant unilamellar vesicles (GUVs) are micrometer-scale minimal cellular mimics that are useful for bottom-up synthetic biology and drug delivery. Unlike assembly in low-salt solutions, assembly of GUVs in solutions with ionic concentrations of 100-150 mM Na/KCl (salty solutions) is challenging. Chemical compounds deposited on the substrate or incorporated into the lipid mixture could assist in the assembly of GUVs. Here, we investigate quantitatively the effects of temperature and chemical identity of six polymeric compounds and one small molecule compound on the molar yields of GUVs composed of three different lipid mixtures using high-resolution confocal microscopy and large data set image analysis. All the polymers moderately increased the yields of GUVs either at 22 or 37 °C, whereas the small molecule compound was ineffective. Low-gelling temperature agarose is the singular compound that consistently produces yields of GUVs of greater than 10%. We propose a free energy model of budding to explain the effects of polymers in assisting the assembly of GUVs. The osmotic pressure exerted on the membranes by the dissolved polymer balances the increased adhesion between the membranes, thus reducing the free energy for bud formation. Data obtained by modulating the ionic strength and ion valency of the solution shows that the evolution of the yield of GUVs supports our model's prediction. In addition, polymer-specific interactions with the substrate and the lipid mixture affects yields. The uncovered mechanistic insights provide a quantitative experimental and theoretical framework to guide future studies. Additionally, this work shows a facile means for obtaining GUVs in solutions of physiological ionic strengths.

Meningitis in the Guise of Dementia: Lyme-Induced Normal Pressure Hydrocephalus.

While the cause of altered mentation in the elderly may be multifactorial, infectious etiologies may be missed. This case report aims to detail an account of a patient with dementia, found to have Lyme meningitis in the setting of a normal pressure hydrocephalus (NPH). The patient smelled of urine and presented with ambulatory dysfunction, fitting the "wet, wacky, and wobbly" triad of NPH while also having subjective chills and leukocytosis. Non-contrast brain CT scan showed dilated ventricles. Cerebrospinal fluid (CSF) studies suggested aseptic meningitis. Serum studies using a modified two-tiered algorithm confirmed the diagnosis of Lyme disease. Treatment of the underlying condition with a prolonged course of doxycycline improved symptoms and clinical course. Review of the literature on the association between Lyme meningitis and NPH reveals that few cases of Lyme-related NPH have been reported worldwide and further research into the pathophysiology, diagnostic approach, treatment modalities, and management of NPH secondary to Lyme meningitis may be warranted.

Childhood Eye Examination in Primary Care.

Approximately 7% of children in the United States younger than 18 years have a diagnosed eye disorder, and 1 in 4 children between two and 17 years of age wears glasses. Routine eye examinations during childhood can identify abnormalities necessitating referral to ophthalmology, which optimizes children's vision through the early diagnosis and treatment of abnormalities. The U.S. Preventive Services Task Force recommends vision screening at least once in children three to five years of age to detect amblyopia or its risk factors to improve visual acuity. The American Academy of Family Physicians supports this recommendation. The American Academy of Pediatrics recommends screening starting at three years of age and at regular intervals in childhood, and that instrument-based screening (e.g., photoscreening, autorefraction) is an alternative to vision charts for testing visual acuity in patients three to five years of age. Eye examinations include visual acuity testing, external examinations, assessing ocular alignment and pupillary response, and assessing for opacities with the red reflex examination. Common abnormalities include refractive errors, amblyopia (reduction in visual acuity in one eye not attributable to structural abnormality), and strabismus (misalignment of the eye). Rare diagnoses include retinoblastoma (often detectable through loss of red reflex), cataracts (detectable by an abnormal red reflex), and glaucoma (often manifests as light sensitivity with corneal cloudiness and enlargement).

Disparities in Cancer Screening: The Role of County-Level Metropolitan Status and Racial Residential Segregation.

Mortality from cervical and colorectal cancers can be reduced through routine screening, which can often be accessed through primary care. However, uptake of screening in the US remains suboptimal, with disparities observed across geographic characteristics, such as metropolitan status or level of racial residential segregation. Little is known about the interaction of metropolitan status and segregation in their relationship with cancer screening. We conducted a quantitative survey of 474 women aged 45-65 in central Pennsylvania. The survey collected county-level characteristics and participant-level demographics, beliefs, cancer screening barriers, and cervical and colorectal cancer screening. We used bivariate and multivariable logistic regression to analyze relationships between metropolitan status and segregation with screening. For cervical cancer screening, 82.8% of participants were up-to-date, which did not differ by county type in the final analysis. Higher healthcare trust, higher cancer fatalism, and reporting cost as a barrier were associated with cervical cancer screening. For colorectal cancer screening, 55.4% of participants were up-to-date, which differed by county type. In metropolitan counties, segregation was not associated with colorectal cancer screening, but in non-metropolitan counties, segregation was associated with greater colorectal cancer screening. The relationship between metropolitan status and being up-to-date with colorectal, but not cervical, cancer screening varied by segregation. Other important beliefs and barriers to screening varied by county type. This research can guide future cancer screening interventions in primary care settings in underserved communities.

Preparing for the future of medical education: A case series of traditional and virtual clinical rotations in addiction medicine spanning the COVID pandemic.

Background: Substance use accounts for more than 400,000 deaths annually in the United States and overdose rates surged during the COVID pandemic. While the pandemic created increased pressure for better prepared providers, it simultaneously placed restrictions on medical training programs. The purpose of this educational case series is to assess the feasibility of a virtual addiction medicine training program and conduct a qualitative evaluation of medical student attitudes toward caring for people with substance use disorders, both before and after their addiction medicine training experience. Methods: We conducted a qualitative analysis related to course content focused on strengths and limitations of in-person and virtual training modalities. Individual quotes were evaluated and content themes were developed after a thorough review of all codes and detailed examination of interviewee quotes. Results: The primary themes that emerged were (1) Addiction medicine content is important to improve care of patients with substance disorders and is not fully addressed in undergraduate medical education (2) In-person and virtual training contain unique strengths and weaknesses and (3) Students perceived that both experiences provided positive and needed training in addiction medicine that shifted perspective and enhanced confidence to practice. Conclusions: Remote training via virtual lectures and patient visits may enhance training opportunities for students with limited exposure to addiction medicine patients and faculty with addiction medicine expertise. There is a need to further refine virtual care for patients with SUDs and virtual training to meet the needs of patients and learners across the country.

A novel strategy to increase the therapeutic potency of GBM chemotherapy via altering parenchymal/cerebral spinal fluid clearance rate.

Patients with glioblastoma (GBM) face a poor prognosis with a median survival of less than two years. Escalating the dose of chemotherapy is often impossible due to patient comorbidities; thus, we focused on modulating brain clearance as a mechanism to enhance drug accumulation. Given the recently identified interconnectivity between brain parenchymal fluid and cerebral spinal fluid (CSF), we reasoned enhancing drug concentration in the CSF also increases drug concentration in the parenchyma where a GBM resides. To improve drug accumulation in the CSF, we impair the motility of ependymal cell cilia. We identified FDA-approved therapeutics that interact with cilia as a "side effect." Therapeutics that inhibit airway cilia also inhibit ependymal cilia. Multiple cilia-inhibiting drugs, when administered in combination with GBM chemotherapy temozolomide (TMZ), significantly improved the overall survival of mice bearing orthotopic GBM. Combining TMZ with lidocaine results in 100% of animals surviving tumor-free to the study endpoint. This treatment results in a ~ 40-fold increase in brain TMZ levels and is well-tolerated. Mice bearing MGMT methylated, human PDX orthotopic GBM also responded with 100% of animals surviving tumor-free to the study endpoint. Finally, even mice bearing TMZ-resistant, orthotopic GBM responded to the combination treatment with 40% of animals surviving tumor-free to the study endpoint, implying this strategy can sensitize TMZ-resistant GBM. These studies offer a new concept for treating malignant brain tumors by improving the accumulation of TMZ in the CNS. In the future, this regimen may also improve the treatment of additional encephalopathies treated by brain-penetrating therapeutics. SIGNIFICANCE: We exploit the interconnectivity of parenchymal and cerebral spinal fluid to enhance the amount of temozolomide that accumulates in the central nervous system to improve the survival of mice bearing brain tumors.

Virtual Recruitment Effects on Matched Residents in Family Medicine: Experiences From Central Pennsylvania.

Background and Objectives: As a result of the COVID-19 pandemic, interviews during the 2021 US residency match were conducted virtually, a practice again recommended and repeated by many programs in 2022. The impact of virtual interviews on recruitment and match outcomes has recently been of interest, with results showing the virtual format to be mostly well received by applicants due to cost, travel, and scheduling benefits. Few studies have looked at pre/posttransition comparisons of applicant geographic and demographic data. We compared objective match outcomes between in-person and virtual interviews across three residency programs. Methods: We conducted a retrospective cross-sectional analysis of National Residency Matching Program data between 2015-2022 across three family medicine residency programs. Primary outcomes were fill rate, average rank position, distance from program, and percentage of underrepresented in medicine demographic status for matched applicants. We compared aggregate in-person data (2015-2019) to aggregate virtual data (2020-2022) for each program using χ2, Fisher Exact test, or 2-tailed t tests to 95% confidence. Results: Saint Joseph Hospital in Reading, Pennsylvania, a 3-year community-based university affiliated program, had significantly more unfilled positions during virtual recruitment (P=.0058). Mount Nittany Medical Center in State College, Pennsylvania, a 3-year community based university-affiliated program, had a significant difference in distance of matched residents' current address (P=.048). Virtual interviews were not associated with significant differences in average position on rank list, average distance from permanent address zip code, or percentage of underrepresented in medicine (URiM) demographic status for matched applicants. Conclusions: The impact of virtual interviewing on unfilled positions and geographic data is likely site specific and generally small, as some programs had significant structural changes. Further research is needed to confirm the generalizability of these results and explore future comparisons of demographic and geographic characteristics of matched applicants pre/posttransition to the virtual format.

Gatekeeping astrocyte identity.

New findings cast doubt on whether suppressing the RNA-binding protein PTBP1 can force astrocytes to become dopaminergic neurons.

Low bone mass and impaired fracture healing in mouse models of Trisomy21 (Down syndrome).

Individuals with Down syndrome (DS), the result of trisomy of human chromosome Hsa21 (Ts21), present with an array of skeletal abnormalities typified by altered craniofacial features, short stature and low bone mineral density (BMD). While bone deficits progress with age in both sexes, low bone mass is more pronounced in DS men than women and osteopenia appears earlier. In the current study, the reproductive hormone status (FSH, LH, testosterone) of 17 DS patients (males, ages range 19-52 years) was measured. Although testosterone was consistently low, the hypothalamic-pituitary-gonadal axis was intact with corresponding rises in FSH and LH. To provide further insight into the heterogeneity of the bone mass in DS, the skeletal phenotypes of three of the most used murine DS models, Ts65Dn (Ts65), TC1, and Dp16(Yey1) (Dp16) were characterized and contrasted. Evaluation of the bone phenotype of both male and female 3-month-old Dp16 mice demonstrated sexual dimorphism, with low bone mass apparent in males, as it is in Ts65, but not in female Dp16. In contrast, male TC1 mice had no apparent bone phenotype. To determine whether low bone mass in DS impacted fracture healing, fractures of the middle phalanx (P2) digits were generated in both male and female Dp16 mice at 15 weeks of age, an age where the sexually dimorphic low BMD persisted. Fracture healing was assessed via in vivo microCT over (13 weeks) 93 days post fracture (DPF). At 93 DPF, 0 % of DS male (n = 12) or female (n = 8) fractures healed, compared to 50 % of the male (n = 28) or female (n = 8) WT littermate fractures. MicroCT revealed periosteal unbridged mineralized callus formation across the fracture gap in Dp16 mice, which was confirmed by subsequent histology. These studies provide the first direct evidence of significantly impaired fracture healing in the setting of DS.

Bisphosphonates in veterinary medicine: The new horizon for use.

Bisphosphonates (BPs) are characterized by their ability to bind strongly to bone mineral and inhibit bone resorption. However, BPs exert a wide range of pharmacological activities beyond the inhibition of bone resorption, including the inhibition of cancer cell metastases and angiogenesis and the inhibition of proliferation and apoptosis in vitro. Additionally, the inhibition of matrix metalloproteinase activity, altered cytokine and growth factor expression, as well as reductions in parameters of pain have also been reported. In humans, clinical BP use has transformed the treatment of post-menopausal osteoporosis, rare bone diseases such as osteogenesis imperfecta, as well as multiple myeloma and metastatic breast and prostate cancer, albeit not without infrequent but significant adverse events. Despite the well-characterized health benefits of BP use in humans, the evidence-base for the therapeutic efficacy of BPs in veterinary medicine is, by comparison, limited. Notwithstanding, BPs are used widely in small animal veterinary practice for the medical management of hyperparathyroidism, idiopathic hypercalcemia in cats, as well as for the palliative care of bone tumors which are common in dogs, and in particular, primary bone tumors such as osteosarcoma. Palliative BP treatment has also recently increased in veterinary oncology to alleviate tumor-associated bone pain. In equine veterinary practice, non-nitrogen-containing BPs are FDA-approved to control clinical signs associated with navicular syndrome in adult horses. However, there are growing concerns regarding the off-label use of BPs in juvenile horses. Here we discuss the current understanding of the strengths, weaknesses and current controversies surrounding BP use in veterinary medicine to highlight the future utility of these potentially beneficial drugs.

A guide to the Tx of cellulitis and other soft-tissue infections.

Diagnostic and therapeutic priorities vary for the 8 types of infection reviewed.

Qualitative Needs Assessment for the Development of Chronic Pain Group Medical Visits.

Group medical visits (GMVs) for patients with chronic pain are becoming more accessible and have been shown to be successful in furthering patient education on multidisciplinary, nonopioid interventions. Unfortunately, evidence suggests that many group visit models lack sustainability due to recruitment issues and retention rates. Additionally, most of the studies surrounding GMVs are located in primarily urban health centers, potentially limiting their generalizability. This study aims to identify patient interest in and barriers to GMVs for chronic pain and to explore how chronic pain impacts daily lives for GMV content optimization in a nonurban population. Nineteen participants age 18 to 65 years participated in semistructured phone interviews to generate a thematic analysis. Participants received their care from family practitioners at a suburban multiclinic academic medical group and were being prescribed at least 50 morphine milligram equivalents (MME) at the time of recruitment. Analysis generated two themes: (1) Participants expressed specific interest in GMVs with few barriers identified, and (2) Pain has a negative impact on mental health and most aspects daily life, creating a foundation for discussion in GMVs. Findings support significant patient interest in group medical visits for chronic pain, but careful planning is necessary to address patient needs, expectations, and barriers in order to ensure GMV sustainability.

Loneliness in Primary Care Patients: Relationships With Body Mass Index and Health Care Utilization.

PURPOSE: Rates of loneliness and obesity have increased in recent decades. Loneliness and obesity independently have been found to be risk factors for negative physical and mental health outcomes. This study examined the rates and interrelationships of loneliness, body mass index (BMI), and health care utilization in a primary care setting. METHODS: A cross-sectional survey of adult patients presenting for outpatient care at 7 family medicine clinical practices in Pennsylvania was conducted. Survey questions included self-reported measures of loneliness, height/weight, number of health care visits, and potential confounders (eg, sociodemographic variables, health status). Bivariate and multivariable linear regression models were used to analyze associations among loneliness, BMI, and health care utilization. RESULTS: In all, 464 eligible patients returned surveys for an overall response rate of 26%. Mean (standard deviation) loneliness score was 4.2 (1.7), mean BMI was 30.4 (7.6), and mean number of visits in year prior was 2.7 (3.6). On bivariate analysis, BMI was positively associated with loneliness (effect estimate: 0.50; P=0.03). On multivariable analysis, BMI was negatively associated with attending religious services and self-reported physical health and positively associated with self-reported mental health (P<0.05 for all), but not associated with loneliness. While not associated with loneliness, health care utilization was negatively associated with Hispanic ethnicity, marital status, and self-reported physical health (P<0.05 for all). CONCLUSIONS: Given the detrimental effects loneliness and obesity have on health outcomes, it might be prudent for health care providers to prioritize health concerns for their patients by assessing loneliness and counseling regarding associated risks, particularly in patients with obesity.

Inhibition of histone deacetylation rescues phenotype in a mouse model of Birk-Barel intellectual disability syndrome.

Mutations in the actively expressed, maternal allele of the imprinted KCNK9 gene cause Birk-Barel intellectual disability syndrome (BBIDS). Using a BBIDS mouse model, we identify here a partial rescue of the BBIDS-like behavioral and neuronal phenotypes mediated via residual expression from the paternal Kcnk9 (Kcnk9pat) allele. We further demonstrate that the second-generation HDAC inhibitor CI-994 induces enhanced expression from the paternally silenced Kcnk9 allele and leads to a full rescue of the behavioral phenotype suggesting CI-994 as a promising molecule for BBIDS therapy. Thus, these findings suggest a potential approach to improve cognitive dysfunction in a mouse model of an imprinting disorder.

Understanding Perceived Barriers to Care Among Suburban Super-Utilizers Who Have an Identified Primary Care Provider.

Patients who are admitted to the hospital frequently (>3 admissions in a 6-month period) are a large driver of health care costs. Recently, research has focused on these groups of super-utilizing patients to try to find ways to meet their care needs in the outpatient setting. However, most research so far has focused on the urban underserved population who do not have a usual source of care. The goal of this study is to identify a group of patients from a suburban academic family medicine practice who have been admitted to the hospital frequently over a 6-month period and interview them to identify patient-perceived barriers to care in the outpatient setting. Nine of the 176 patients identified as frequently hospitalized were interviewed. Interpretive phenomenology analysis was used to identify perceived barriers and facilitators to care. Although some identified barriers were similar to those noted in groups of the urban underserved, including chronic disease and polypharmacy, other barriers were uniquely identified in the nonurban population, including transportation and support at home. Transportation issues, lack of support at home, and poor interdisciplinary communication were found to increase risk for readmission. Conversely, good interdisciplinary communication and ample support from family, including support services at home, were viewed as facilitators to outpatient care.

Abnormal Hypermethylation at Imprinting Control Regions in Patients with S-Adenosylhomocysteine Hydrolase (AHCY) Deficiency.

S-adenosylhomocysteine hydrolase (AHCY) deficiency is a rare autosomal recessive disorder in methionine metabolism caused by mutations in the AHCY gene. Main characteristics are psychomotor delay including delayed myelination and myopathy (hypotonia, absent tendon reflexes etc.) from birth, mostly associated with hypermethioninaemia, elevated serum creatine kinase levels and increased genome wide DNA methylation. The prime function of AHCY is to hydrolyse and efficiently remove S-adenosylhomocysteine, the by-product of transmethylation reactions and one of the most potent methyltransferase inhibitors. In this study, we set out to more specifically characterize DNA methylation changes in blood samples from patients with AHCY deficiency. Global DNA methylation was increased in two of three analysed patients. In addition, we analysed the DNA methylation levels at differentially methylated regions (DMRs) of six imprinted genes (MEST, SNRPN, LIT1, H19, GTL2 and PEG3) as well as Alu and LINE1 repetitive elements in seven patients. Three patients showed a hypermethylation in up to five imprinted gene DMRs. Abnormal methylation in Alu and LINE1 repetitive elements was not observed. We conclude that DNA hypermethylation seems to be a frequent but not a constant feature associated with AHCY deficiency that affects different genomic regions to different degrees. Thus AHCY deficiency may represent an ideal model disease for studying the molecular origins and biological consequences of DNA hypermethylation due to impaired cellular methylation status.