Adolescent Substance Use Disorder in Primary Care: Challenges in Treatment Referral Beyond Access Availability.

OBJECTIVE: Fatal overdoses are the third leading cause of death in the pediatric population. Substance use disorders (SUD) screening is not routinely done in primary care practices. Early screening and intervention for adolescent SUD could mitigate future harm. METHODS: We conducted a 3-month pilot adapting universal screening using the CRAFFT tool in patients aged 12 to 17 presenting to an urban and a rural primary care practice during well-child and acute/sick-child visits. We collaborated with our pediatric addiction service to ensure access availability for further assessment and treatment for all positively screened patients; this was broadly communicated to primary care providers. RESULTS: There was a higher CRAFFT completion rate in the urban site (90%, vs 52.6% in our rural site). The majority of CRAFFT questionnaires were completed during acute/sick-child visits in both study sites. Moreover, we found a higher positive screen rate in our rural practice (14.6%, vs 2.4% in our urban practice). Only 27% of positively screened patients had substance use addressed by their providers. No pediatric addiction referrals were made. CONCLUSIONS: Findings suggest provider-level barriers exist despite having adequate specialty referral sources and institutional encouragement. Future work is needed to explore these barriers.

A set of vertically integrated inquiry-based practical curricula that develop scientific thinking skills for large cohorts of undergraduate students.

Science graduates require critical thinking skills to deal with the complex problems they will face in their 21st century workplaces. Inquiry-based curricula can provide students with the opportunities to develop such critical thinking skills; however, evidence suggests that an inappropriate level of autonomy provided to underprepared students may not only be daunting to students but also detrimental to their learning. After a major review of the Bachelor of Science, we developed, implemented, and evaluated a series of three vertically integrated courses with inquiry-style laboratory practicals for early-stage undergraduate students in biomedical science. These practical curricula were designed so that students would work with increasing autonomy and ownership of their research projects to develop increasingly advanced scientific thinking and communication skills. Students undertaking the first iteration of these three vertically integrated courses reported learning gains in course content as well as skills in scientific writing, hypothesis construction, experimental design, data analysis, and interpreting results. Students also demonstrated increasing skills in both hypothesis formulation and communication of findings as a result of participating in the inquiry-based curricula and completing the associated practical assessment tasks. Here, we report the specific aspects of the curricula that students reported as having the greatest impact on their learning and the particular elements of hypothesis formulation and communication of findings that were more challenging for students to master. These findings provide important implications for science educators concerned with designing curricula to promote scientific thinking and communication skills alongside content acquisition.

Single-Cell Multiomics Reveals Clonal T-Cell Expansions and Exhaustion in Blastic Plasmacytoid Dendritic Cell Neoplasm.

The immune system represents a major barrier to cancer progression, driving the evolution of immunoregulatory interactions between malignant cells and T-cells in the tumor environment. Blastic plasmacytoid dendritic cell neoplasm (BPDCN), a rare acute leukemia with plasmacytoid dendritic cell (pDC) differentiation, provides a unique opportunity to study these interactions. pDCs are key producers of interferon alpha (IFNA) that play an important role in T-cell activation at the interface between the innate and adaptive immune system. To assess how uncontrolled proliferation of malignant BPDCN cells affects the tumor environment, we catalog immune cell heterogeneity in the bone marrow (BM) of five healthy controls and five BPDCN patients by analyzing 52,803 single-cell transcriptomes, including 18,779 T-cells. We test computational techniques for robust cell type classification and find that T-cells in BPDCN patients consistently upregulate interferon alpha (IFNA) response and downregulate tumor necrosis factor alpha (TNFA) pathways. Integrating transcriptional data with T-cell receptor sequencing via shared barcodes reveals significant T-cell exhaustion in BPDCN that is positively correlated with T-cell clonotype expansion. By highlighting new mechanisms of T-cell exhaustion and immune evasion in BPDCN, our results demonstrate the value of single-cell multiomics to understand immune cell interactions in the tumor environment.

Urinary cadmium and age-related macular degeneration.

PURPOSE: To evaluate the association between urinary and blood cadmium (Cd) levels with age-related macular degeneration (AMD). DESIGN: Prospective case-control study. METHODS: In 53 participants older than 60 years with AMD in both eyes and in 53 age-matched (+/- 3 years) controls without AMD, Cd levels were measured in blood and urine specimens (with and without creatinine adjustment) by using inductively coupled plasma-mass spectrometry. Data on age, gender, smoking status, and family history were obtained. By using color stereoscopic fundus photographs, the degree of AMD was graded using the Age-Related Eye Disease Study's 4-stage AMD severity scale. The inclusion criterion for AMD cases was a photographic severity level of two to four in both eyes. Median blood and urine Cd and median urine Cd/creatinine concentrations in cases and controls were compared by using the rank-sum test, stratifying for smoking status. RESULTS: Current and former smokers with AMD had median urine Cd/creatinine levels (1.18 microg/g; range, 0.84 to 1.44 microg/g) that were 97% higher than smokers without AMD (0.60 microg/g; range, 0.49 to 0.90 microg/g; P = .02), 111% higher than never smokers with AMD (0.56 microg/g; range, 0.40 to 0.80 microg/g; P < .001) and 107% higher than never smokers without AMD (0.57 microg/g; 0.40 to 0.65 microg/g; P < .001). Blood Cd levels, indicative of short-term exposure levels, were not associated with AMD (P >/= .06). CONCLUSIONS: A higher urinary Cd level, which reflects the total body burden of Cd, was associated with AMD in smokers. Accumulated Cd exposure may be important in the development of smoking-related AMD.

Heavy metal concentrations in human eyes.

PURPOSE: To measure the concentration of toxic heavy metals in the fluids and tissues of human eyes. DESIGN: Laboratory investigation. METHODS: Thirty autopsy eyes of 16 subjects were dissected to obtain the aqueous, vitreous, lens, ciliary body, retina, and retinal pigment epithelium/choroid. Concentrations of lead, cadmium, mercury, and thallium in ocular tissues, ocular fluids, and blood were determined using an inductively coupled plasma-mass spectrometer and expressed as ng/g. Heavy metal concentrations in ocular tissues were compared using a paired t test. RESULTS: Lead and cadmium were found in all of the pigmented ocular tissues studied, concentrating to the greatest extent in the retinal pigment epithelium/choroid (mean, 432 +/- 485 ng/g and 2,358 +/- 1,522 ng/g). Cadmium was found in the retina in all eyes (mean, 1,072 +/- 489 ng/g) whereas lead was found in the retina in 9 (30%) of 30 eyes (mean, 53 +/- 54 ng/g). Trace concentrations of lead and cadmium were detected in the vitreous (mean, 0.5 +/- 1.0 ng/dl and 19 +/- 29 ng/dl), lens (mean, 13 +/- 18 ng/g and 20 +/- 18 ng/g), and blood (mean, 0.5 +/- 1.2 mug/dl and 3.1 +/- 4.1 mug/l) but were not detected in the aqueous. Mercury and thallium were not detected in any ocular tissues or fluids or in the blood. CONCLUSIONS: Lead and cadmium accumulate in human ocular tissues, particularly in the retinal pigment epithelium and choroid. The potential ocular toxicity of these heavy metals and their possible role in eye disease requires further study.

Urea based osmoregulation and endocrine control in elasmobranch fish with special reference to euryhalinity.

Since the landmark contributions of Homer Smith and co-workers in the 1930s there has been a considerable advance in our knowledge regarding the osmoregulatory strategy of elasmobranch fish. Smith recognised that urea was retained in the body fluids as part of the 'osmoregulatory ballast' of elasmobranch fish so that body fluid osmolality is raised to a level that is iso- or slightly hyper-osmotic to that of the surrounding medium. From studies at that time he also postulated that many marine dwelling elasmobranchs were not capable of adaptation to dilute environments. However, more recent investigations have demonstrated that, at least in some species, this may not be the case. Gradual acclimation of marine dwelling elasmobranchs to varying environmental salinities under laboratory conditions has demonstrated that these fish do have the capacity to acclimate to changes in salinity through independent regulation of Na(+), Cl(-) and urea levels. This suggests that many of the presumed stenohaline marine elasmobranchs could in fact be described as partially euryhaline. The contributions of Thomas Thorson in the 1970s demonstrated the osmoregulatory strategy of a fully euryhaline elasmobranch, the bull shark, Carcharhinus leucas, and more recent investigations have examined the mechanisms behind this strategy in the euryhaline elasmobranch, Dasyatis sabina. Both partially euryhaline and fully euryhaline species utilise the same physiological processes to control urea, Na(+) and Cl(-) levels within the body fluids. The role of the gills, kidney, liver, rectal gland and drinking process is discussed in relation to the endocrine control of urea, Na(+) and Cl(-) levels as elasmobranchs acclimate to different environmental salinities.

Learning style preferences and academic success of preclinical allied health students.

Student learning style modality preferences, in preclinical classes, were assessed using the visual-aural-read/write-kinesthetic (VARK) inventory. Preferences were assessed for 137 preclinical students, including those in nursing, physician's assistant, physical therapy, athletic training, and natural science programs using the online VARK inventory. All classes contained a majority of multimodal and a significantly high proportion of kinesthetic learners. No correlations were noted between modality preference strength and assessment performance in general biology classes; significant correlations were discovered for kinesthetic preference among the same cohort in subsequent human anatomy (negative correlation) and general physiology (positive correlation) classes. Assessment performance of nursing students in an anatomy and physiology class resulted in correlations with aural (negative correlation) and visual (positive correlation) preference strengths. Study findings are used to evaluate the efficacy of non-omnimodal delivery of content-focused science classes, before the students have developed the background knowledge or skills required to contextualize the learning.

Excess lead in the neural retina in age-related macular degeneration.

PURPOSE: To measure lead and cadmium in retinal tissues of human donor eyes with and without age-related macular degeneration (AMD). DESIGN: Laboratory investigation. METHODS: Lead and cadmium concentrations in retinal tissues (neural retina and retinal pigment epithelium [RPE]-choroid complex) in 25 subjects with AMD (50 donor eyes) and 36 normal subjects (72 donor eyes) were determined by using inductively coupled plasma-mass spectrometry. Severity of AMD was graded by using color fundus photographs and the Minnesota Grading System. Differences in metal concentrations were compared by using Wilcoxon rank-sum tests. RESULTS: The neural retinas of subjects with AMD had increased lead concentrations (median, 12.0 ng/g; 25% to 75% interquartile range, 8 to 18 ng/g; n = 25) compared with normal subjects (median, 8.0 ng/g; 25% to 75% interquartile range, 0 to 11 ng/g; P = .04; n = 36). There was no difference in lead concentration in the RPE-choroid complex between subjects with AMD (median, 198 ng/g; 25% to 75% interquartile range, 87 to 381 ng/g) and normal subjects (median, 172 ng/g; 25% to 75% interquartile range, 100 to 288 ng/g; P = .25). Cadmium concentration in the neural retina (median, 0.9 microg/g; 25% to 75% interquartile range, 0.7 to 1.8 microg/g) and RPE-choroid complex (median, 2.2 microg/g; 25% to 75% interquartile range, 1.8 to 3.7 microg/g) in subjects with AMD was not different from concentrations in the neural retina (median, 0.9 microg/g; 25% to 75% interquartile range, 0.7 to 1.4 microg/g; P = .32) and RPE-choroid complex (median, 1.5 microg/g; 25% to 75% interquartile range, 0.9 to 2.5 microg/g; P = .12) of normal subjects. CONCLUSIONS: AMD is associated with excess lead in the neural retina, and this relationship suggests that metal homeostasis in AMD eyes is different from normal.

Reduced zinc and copper in the retinal pigment epithelium and choroid in age-related macular degeneration.

PURPOSE: To measure zinc and copper levels in the retinal pigment epithelium (RPE) and choroid complex and in the neural retina in subjects with and without age-related macular degeneration (AMD). DESIGN: Laboratory investigation. METHODS: Eighty-eight donor eyes (44 subjects) were analyzed. After retinal dissection, the RPE and choroid complex was photographed. Using the Minnesota Grading System (MGS), the RPE and choroid complex was classified into 1 of 4 stages as defined by the Age-Related Eye Disease Study. Subjects without AMD were defined as both eyes having MGS stage 1; subjects with AMD were defined as both eyes having MGS stages 2 through 4. Zinc and copper levels were determined by using an inductively coupled plasma-mass spectrometer. Metal levels from two eyes of the same subject were averaged and treated as one observation. Differences in metal levels were examined by using Wilcoxon rank-sum tests. RESULTS: The mean RPE and choroid complex zinc level in subjects with AMD (+/- standard deviation, 223.7 +/- 94.0 microg/g; n = 15) was reduced 24% when compared with that of subjects without AMD (292.1 +/- 98.5 microg/g; n = 29; P = .01). The mean RPE and choroid complex copper level in subjects with AMD (5.1 +/- 1.1 microg/g) was reduced 23% when compared with that of subjects without AMD (6.6 +/- 1.4 microg/g; P = .002). No difference was detected in retinal zinc and copper levels in subjects with and without AMD (P > .09). CONCLUSIONS: Reduced RPE and choroid complex zinc and copper levels in AMD eyes combined with previous information that oral supplementation of zinc plus copper reduces the risk of progression of AMD suggests that metal homeostasis plays a role in AMD and in retinal health.

Chelation of gadolinium with deferoxamine in a patient with nephrogenic systemic fibrosis.

A 65-year-old female with biopsy-confirmed nephrogenic systemic fibrosis (NSF) received a kidney transplantation. Despite good kidney function, her symptoms continued to progress. Deferoxamine was administered intramuscularly at 500 mg/day and later 1000 mg/day after 1 week with no adverse effects. Urine excretion of gadolinium increased from 6.0 µg/day to 11.6 µg/day and subsequently to 13.0 µg/day with 500 mg/day and 1000 mg/day of deferoxamine, respectively. Serum levels, however, remain unchanged from 1.7 ng/ml to 1.4 ng/ml. Although chelation therapy may have a role in the treatment of NSF, deferoxamine is too weak and a stronger chelator is needed.

Body fluid volume regulation in elasmobranch fish.

This review addresses an often overlooked aspect of elasmobranch osmoregulation, i.e., control of body fluid volume. More specifically the review addresses the impact of changes in blood volume in elasmobranchs exposed to different environmental salinities. Measurement of blood volume in the European lesser-spotted dogfish, Scyliorhinus canicula, following acute and chronic exposure to 80% and 120% seawater (SW) is reported. In 80%, 100% and 120% SW-adapted S. canicula, blood volume was 6.3+/-0.2, 5.6+/-0.2 and 4.6+/-0.2 mL 100 g(-1) body mass, respectively. Blood volume was significantly higher and lower in 80% and 120% SW-acclimated animals compared to 100% SW controls. Comparisons are made between these results and previously published data. The role of drinking and volume regulation in elasmobranchs is discussed. For the first time measured water reabsorption rates and solute flux rates across the elasmobranch intestinal epithelia are presented. Water reabsorption rates did not differ between 100% SW-adapted bamboo shark, Chiloscyllium plagiosum, and fish acutely transferred to 140% SW. For the most part net solute flux rates and direction for both the 100% and 140% SW groups were the same with the exception of a net efflux of chloride and potassium in the 140% group and influx of these ions in the 100% adapted group. The significance of the intestine as part of the overall elasmobranch osmoregulatory strategy is discussed as is the role of the kidneys, rectal gland and gills in the regulation of body fluid volume in this class of vertebrates.

The effects of freshwater to seawater transfer on circulating levels of angiotensin II, C-type natriuretic peptide and arginine vasotocin in the euryhaline elasmobranch, Carcharhinus leucas.

This study examined the effect of transfer to increased environmental salinity on the circulating levels of angiotensin II (ANG II), C-type natriuretic peptide (CNP), and arginine vasotocin (AVT) in the euryhaline elasmobranch, Carcharhinus leucas. Plasma levels of ANG II and CNP were significantly increased in C. leucas chronically acclimated to seawater (SW) in comparison to freshwater (FW) acclimated fish. There was no difference in plasma AVT levels. Acute transfer of FW fish to 75% SW induced an increase in plasma ANG II levels within 12 h, and subsequent transfer from 75 to 100% SW further increased plasma ANG II levels at both 24 and 72 h. No change in plasma CNP was observed during acute transfer to increased salinity. However, a significant increase in plasma AVT levels was observed following 96 h in 75% SW and 24 h in 100% SW. In chronically SW acclimated C. leucas plasma osmolality, sodium, chloride, and urea were all significantly higher than FW acclimated fish but there was no difference in haematocrit. Acute transfer of C. leucas to 75% SW induced a significant increase in plasma osmolality, sodium and urea concentrations within 96 h of transfer. Subsequent transfer from 75 to 100% SW induced a further increase in these variables within 24 h in addition to a significant increase in plasma chloride above control levels. Haematocrit did not differ between the experimental and control groups throughout the acute study. Circulating levels of ANG II were significantly correlated to plasma, sodium, chloride, and urea concentrations during acclimation to SW. Conversely, circulating levels of CNP and AVT did not correlate to plasma osmolytes, however, CNP was significantly correlated to haematocrit during acclimation to seawater.

Hepatic urea biosynthesis in the euryhaline elasmobranch Carcharhinus leucas.

Plasma urea levels and hepatic urea production in the euryhaline bull shark, Carcharhinus leucas, acclimated to freshwater and seawater environments were measured. It was found that plasma urea concentration increased with salinity and that this increase was, in part, the result of a significant increase in hepatic production of urea. This study provides direct evidence that hepatic production of urea plays an important role in the osmoregulatory strategy of C. leucas.

Freshwater to seawater acclimation of juvenile bull sharks (Carcharhinus leucas): plasma osmolytes and Na+/K+-ATPase activity in gill, rectal gland, kidney and intestine.

This study examined the osmoregulatory status of the euryhaline elasmobranch Carcharhinus leucas acclimated to freshwater (FW) and seawater (SW). Juvenile C. leucas captured in FW (3 mOsm l(-1) kg(-1)) were acclimated to SW (980-1,000 mOsm l(-1) kg(-1)) over 16 days. A FW group was maintained in captivity over a similar time period. In FW, bull sharks were hyper-osmotic regulators, having a plasma osmolarity of 595 mOsm l(-1) kg(-1). In SW, bull sharks had significantly higher plasma osmolarities (940 mOsm l(-1) kg(-1)) than FW-acclimated animals and were slightly hypo-osmotic to the environment. Plasma Na(+), Cl(-), K(+), Mg(2+), Ca(2+), urea and trimethylamine oxide (TMAO) concentrations were all significantly higher in bull sharks acclimated to SW, with urea and TMAO showing the greatest increase. Gill, rectal gland, kidney and intestinal tissue were taken from animals acclimated to FW and SW and analysed for maximal Na(+)/K(+)-ATPase activity. Na(+)/K(+)-ATPase activity in the gills and intestine was less than 1 mmol Pi mg(-1) protein h(-1) and there was no difference in activity between FW- and SW-acclimated animals. In contrast Na(+)/K(+)-ATPase activity in the rectal gland and kidney were significantly higher than gill and intestine and showed significant differences between the FW- and SW-acclimated groups. In FW and SW, rectal gland Na(+)/K(+)-ATPase activity was 5.6+/-0.8 and 9.2+/-0.6 mmol Pi mg(-1) protein h(-1), respectively. Na(+)/K(+)-ATPase activity in the kidney of FW and SW acclimated animals was 8.4+/-1.1 and 3.3+/-1.1 Pi mg(-1) protein h(-1), respectively. Thus juvenile bull sharks have the osmoregulatory plasticity to acclimate to SW; their preference for the upper reaches of rivers where salinity is low is therefore likely to be for predator avoidance and/or increased food abundance rather than because of a physiological constraint.

Sequence, circulating levels, and expression of C-type natriuretic peptide in a euryhaline elasmobranch, Carcharhinus leucas.

The present study has examined expression and circulating levels of C-type natriuretic peptide (CNP) in the euryhaline bull shark, Carcharhinus leucas. Complementary DNA and deduced amino acid sequence for CNP in C. leucas were determined by RACE methods. Homology of CNP amino acid sequence in C. leucas was high both for proCNP and for mature CNP when compared with previously identified elasmobranch CNPs. Mature CNP sequence in C. leucas was identical to that in Triakis scyllia and Scyliorhinus canicula. Levels of expression of CNP mRNA were significantly decreased in the atrium but did not change in either the brain or ventricle following acclimation to a SW environment. However, circulating levels of CNP significantly increased from 86.0+/-7.9 fmol ml(-1) in FW to 144.9+/-19.5 fmol ml(-1) in SW. The results presented demonstrate that changes in environmental salinity influences both synthesis of CNP from the heart and also circulating levels in C. leucas. Potential stimulus for release and modes of action are discussed.