An interprofessional geriatrics faculty development program: exploration of the barriers and facilitators of capstone projects.

Faculty development programs (FDPs) are an effective, evidence-based method of promoting knowledge, skills and self-efficacy of faculty. However, implementation and sustainability of curricular capstone projects developed by faculty as part of these programs are rarely reported. Challenges to sustaining programmatic implementation of interprofessional FDP curricular content into academic and clinical settings over time were not found in peer-reviewed literature. To better understand the sustained impact of our geriatrics-focused FDP, we explored barriers and facilitators to implementation and sustainability of capstone projects designed by faculty Scholars in our FDP. Thematic analysis of virtual interviews with 17 Scholars revealed several key factors that impacted the implementation and Dynamic sustainability of curricular projects. Three major themes and sub-themes were identified: Project Implementation (Supportive Factors, Hindering Factors and Filling in Gaps in the Field); Pedagogical Development (Enhancement of Skills and Culture Change); and Sustainability Impact (Project Sustainability, Career Development and Passing the Torch). Results suggest it is important to ensure logistical support, dedicated time, and organizational or institutional support. Implementation of geriatrics-focused FDPs provides an evidence-based approach to sustainability. Further study of the ongoing barriers and facilitators to sustainability is encouraged.

Top-down effects of repatriating bald eagles hinder jointly recovering competitors.

The recovery of piscivorous birds around the world is touted as one of the great conservation successes of the 21st century, but for some species, this success was short-lived. Bald eagles, ospreys and great blue herons began repatriating Voyageurs National Park, USA, in the mid-20th century. However, after 1990, only eagles continued their recovery, while osprey and heron recovery failed for unknown reasons. We aimed to evaluate whether top-down effects of bald eagles and bottom-up effects of inclement weather, habitat quality and fish resources contributed to the failed recovery of ospreys and herons in a protected area. We quantified the relative influence of top-down and bottom-up factors on nest colonization, persistence (i.e., nest reuse) and success for ospreys, and occurrence and size of heronries using 26 years (1986-2012) of spatially explicit monitoring data coupled with multi-response hierarchical models and Bayesian variable selection approaches. Bald eagles were previously shown to recover faster due to intensive nest protection and management. Increased numbers of eagles were associated with a reduction in the numbers of osprey nests, their nesting success and heronry size, while higher local densities of nesting eagles deterred heronries nearby. We found little evidence of bottom-up limitations on the failed recovery of herons and ospreys. We present a conservation conundrum: bald eagles are top predators and a flagship species of conservation that have benefited from intensive protection, but this likely hindered the recovery of ospreys and herons. Returning top predators, or rewilding, is widely promoted as a conservation strategy for top-down ecosystem recovery, but managing top predators in isolation of jointly recovering species can halt or reverse ecosystem recovery. Previous studies warn of the potential consequences of ignoring biotic interactions amongst recovering species, but we go further by quantifying how these interactions contributed to failed recoveries via impacts on the nesting demography of jointly recovering species. Multi-species management is paramount to realizing the ecosystem benefits of top predator recovery.

Physical and Occupational Therapy Practice Improvement Following Interprofessional Evidence-Based Falls Prevention Training.

AIMS: Evaluate changes in physical therapy (PT) and occupational therapy (OT) practice following evidence-based practice (EBP) interprofessional modules that teach assessments and interventions to reduce falls in community-dwelling older adults. METHODS: Medical records of post-fall patients in three Programs of All-Inclusive Care for the Elderly (PACE) sites were analyzed to assess differences in documented falls and the OT and PT use of EBP assessment and interventions implemented following fall prevention training. RESULTS: In training year 1, PT demonstrated a 34.6% practice improvement in risk assessments performed (z=3.0, p<0.005). In training year 2, PT demonstrated a 66.7% practice change in the implementation of EBP interventions (z=2.1, p<0.05) and OT demonstrated a 22.2% practice improvement in the implementation of recommended EBP interventions (z=2.0, p<0.05). In training year 3, OT achieved a 6.8% increase in the execution of home environment modifications (z=2.0, p<0.05), and PT demonstrated a 23.3% practice improvement in the implementation of recommended EBP interventions (z=3.1, p<0.005). CONCLUSION: The delivery of EBP assessment and intervention training modules for falls prevention resulted in PT and OT practice changes and improved adherence to published guidelines.

Textured Breast Implants: A Closer Look at the Surface Debris Under the Microscope.

BACKGROUND: Texturing of breast implants is done to decrease the risk of associated complications. Each manufacturer utilizes unique and at times proprietary techniques to texture the surface of their implants. Little is known about the integrity of this surface structure texturing or the propensity for the surfaces to shed particulate matter. This study aimed to determine the extent of surface particulate shedding from 3 textured implants approved by the US Food and Drug Administration (FDA), which are manufactured by Allergan, Mentor, and Sientra. METHODS: Control images of each of the 3 textured breast implants were obtained with scanning electron microscopy (SEM). A liquid adhesive, ethylene vinyl acetate (EVA) copolymer was then applied to the external shell of the implants, allowed to cool, and peeled from the surface. Images of the EVA copolymer were taken with SEM to qualitatively analyze displacement of surface particulate debris. Scanning electron microscopy imaging of the implants was repeated for qualitative comparisons with the control images. RESULTS: The peeled copolymer of the 3 implants exhibited surface shedding. Comparison of the 3 breast implants showed the shedding to be greatest for the Allergan implant. CONCLUSIONS: This study highlights the dynamic surface material properties of the 3 FDA-approved breast implants. Shedding of particulate matter from the implant surfaces can be precipitated by moderate adhesion. Our qualitative examination of SEM findings showed more debris shed from the Allergan breast implants than from the Mentor or Sientra implants.

HISTORIQUE: La texturation des implants mammaires vise à réduire le risque de complications. Pour ce faire, chaque fabricant utilise des techniques uniques et exclusives. On ne sait pas grand-chose sur l'intégrité de la structure après texturation de la surface ni sur sa propension à excréter des particules. La présente étude vsait à déterminer l'étendue de l'excrétion des particules de surface de trois implants texturés approuvés par la Food and Drug Administration (FDA) des États-Unis, fabriqués par Allergan, Mentor et Sientra. MÉTHODOLOGIE: Les chercheurs ont obtenu des images témoin de chacun des trois implants mammaires texturés au moyen la microscopie électronique à balayage (MÉB). Ils ont ensuite appliqué un copolymère d'éthylène-acétate de vinyle (EAV) adhésif liquide sur la coquille extérieure des implants, l'ont laissé refroidir, puis l'ont décollé de la surface. Ils ont pris des images du copolymère EAV par MÉB pour procéder à l'analyse qualitative des débris des particules de surface qui s'étaient détachés. Ils ont repris des images des implants par MÉB pour procéder à des comparaisons qualitatives par rapport aux images témoins. RÉSULTATS: La pelure de copolymère des trois implants contenait des particules de surface. La comparaison entre les trois implants a révélé que l'implant Allergan excrétait plus de particules. CONCLUSIONS: La présente étude fait ressortir les propriétés dynamiques des matières de surface des trois implants mammaires approuvés par la FDA. L'excrétion de particules à la surface des implants peut être précipitée par une adhésion modérée. L'examen qualitatif des résultats de la MÉB a démontré que les implants mammaires Allergan excrétaient plus de débris que les implants Mentor ou Sientra.

Single-Stage Treatment of Osteomyelitis for Digital Salvage by Using an Antibiotic-Eluting, Methylmethacrylate Joint-Spanning Spacer.

Osteomyelitis of the digit is a challenging problem that can result in amputation. We describe 13 cases of osteomyelitis involving bones of the hand managed with a novel technique. We reviewed records of 12 patients (13 digits) who had joint-spanning, antibiotic-eluting (tobramycin or vancomycin), methylmethacrylate spacers placed as definitive, single-stage treatment for digital osteomyelitis. The primary outcome was digit salvage. Secondary outcomes were infection eradication (no recurrence at 3 months) and spacer removal. Patients were followed up until the infection resolved (ie, no cutaneous signs of infection, including pain, erythema, or swelling). At a mean of 24 months, 10 of 13 infections had successful one-stage treatment. One patient required a second operation to revise a soft tissue flap but the spacer remained in place. Two spacers were removed because of malalignment. An antibiotic-eluting methylmethacrylate spacer is an innovative treatment for digital osteomyelitis. In 12 consecutive patients (13 digits), we successfully salvaged the digit.

Saliva protein biomarkers to detect oral squamous cell carcinoma in a high-risk population in Taiwan.

Most cases of oral squamous cell carcinoma (OSCC) develop from visible oral potentially malignant disorders (OPMDs). The latter exhibit heterogeneous subtypes with different transformation potentials, complicating the early detection of OSCC during routine visual oral cancer screenings. To develop clinically applicable biomarkers, we collected saliva samples from 96 healthy controls, 103 low-risk OPMDs, 130 high-risk OPMDs, and 131 OSCC subjects. These individuals were enrolled in Taiwan's Oral Cancer Screening Program. We identified 302 protein biomarkers reported in the literature and/or through in-house studies and prioritized 49 proteins for quantification in the saliva samples using multiple reaction monitoring-MS. Twenty-eight proteins were successfully quantified with high confidence. The quantification data from non-OSCC subjects (healthy controls + low-risk OPMDs) and OSCC subjects in the training set were subjected to classification and regression tree analyses, through which we generated a four-protein panel consisting of MMP1, KNG1, ANXA2, and HSPA5. A risk-score scheme was established, and the panel showed high sensitivity (87.5%) and specificity (80.5%) in the test set to distinguish OSCC samples from non-OSCC samples. The risk score >0.4 detected 84% (42/50) of the stage I OSCCs and a significant portion (42%) of the high-risk OPMDs. Moreover, among 88 high-risk OPMD patients with available follow-up results, 18 developed OSCC within 5 y; of them, 77.8% (14/18) had risk scores >0.4. Our four-protein panel may therefore offer a clinically effective tool for detecting OSCC and monitoring high-risk OPMDs through a readily available biofluid.

Using nestling plasma to assess long-term spatial and temporal concentrations of organochlorine compounds in bald eagles within Voyageurs National Park, Minnesota, USA.

The bald eagle (Haliaeetus leucocephalus) population at Voyageurs National Park (VNP) provides an opportunity to assess long-term temporal and spatial trends of persistent environmental contaminants. Nestling bald eagle plasma samples collected from 1997 to 2010 were analyzed for polychlorinated biphenyls (PCBs) and organochlorine pesticides. Trends of total PCBs, total DDTs, 4,4'-DDE, and Dieldrin were analyzed since >50% of nestling plasma samples had detectable concentrations. Total PCBs, total DDTs, and 4,4'-DDE concentrations have all decreased over time (26.09%, 24.09%, and 40.92% respectively). Concentrations of Dieldrin have increased by 50.25%. In this study, 61.1% of all nestlings sampled had detectable concentrations of Dieldrin from all time periods and all areas of VNP. Since Dieldrin is a banned pesticide in North America, the source of this increase is unknown. However, increases and fluctuations in Dieldrin concentration suggest contaminant levels in VNP may be linked to a new source or environmental process.

Use of a furosemide drip does not improve earlier primary fascial closure in the open abdomen.

BACKGROUND: The furosemide drip (FD), in addition to improving volume overload respiratory failure, has been used to decrease fluid in attempts to decrease intra-abdominal and abdominal wall volumes to facilitate fascial closure. The purpose of this study is to evaluate the FD and the associated rate of primary fascial closure following trauma damage control laparotomy (DCL). MATERIALS AND METHODS: From January 2004 to September 2008, a retrospective review from a single institution Trauma Registry of the American College of Surgeons dataset was performed. All DCLs greater than 24 h who had a length of stay for 3 or more days were identified. The study group (FD+) and control group (FD-) were compared. Demographic data including age, sex, probability of survival, red blood cell transfusions, initial lactate, and mortality were collected. Primary outcomes included primary fascial closure and primary fascial closure within 7 days. Secondary outcomes included total ventilator days and LOS. RESULTS: A total of 139 patients met inclusion criteria: 25 FD+ and 114 FD-. The 25 FD+ patients received the drug at a median 4 days post DCL. Demographic differences between the groups were not significantly different, except that initial lactate was higher for FD- (1.7 vs 4.0; P=0.03). No differences were noted between groups regarding successful primary fascial closure (FD+ 68.4% vs FD- 64.0%; P=0.669), or closure within 7 days (FD+13.2% vs FD- 28.0%; P=0.066) of original DCL. FD+ patients suffered more open abdomen days (4 [2-7] vs 2 [1-4]; P=0.001). FD+ did not demonstrate an association with primary fascial closure [Odds ratio (OR) 1.5, 95% confidence interval (CI) 0.260-8.307; P=0.663]. FD+ patients had more ventilator days and longer Intensive Care Unit (ICU)/hospital LOS (P<0.01). CONCLUSION: FD use may remove excess volume; however, forced diuresis with an FD is not associated with an increased rate of primary closure after DCL. Further studies are warranted to identify ICU strategies to facilitate fascial closure in DCL.

Once bitten, twice incised: recurrent gallstone ileus.

Uncommon causes of small bowel obstruction can provide interesting surgical decision-making challenges. This report describes a patient with recurrent gallstone ileus. According to most current reviews, erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus appears to be the most appropriate decision. Although a rare scenario, the situation of recurrent gallstone ileus presents an interesting learning opportunity. It is important to keep in mind the need for complete examination of the abdomen. Furthermore, evacuation of any remaining stones from the gallbladder is imperative if possible. Erring on the side of enterolithotomy alone as the treatment of choice for gallstone ileus has been shown to be a safe and effective treatment decision over a single-stage removal of the stone with closure of the cholecystoduodenostomy.

Temporal coupling of spindle disassembly and cytokinesis is disrupted by deletion of LTE1 in budding yeast.

The mitotic exit network (MEN) is a signal transduction cascade that controls exit from mitosis in budding yeast by triggering the nucleolar release and hence activation of the Cdc14 phosphatase. Activation of the MEN is tightly coordinated with spindle position in such a way that Cdc14 is only fully released upon spindle pole body (SPB) migration into the daughter cell. This temporal regulation of the MEN has been proposed to rely in part on the spatial separation of the G-protein Tem1 at the SPB and its nucleotide exchange factor Lte1 confined to the daughter cell cortex. However, the dispensability of LTE1 for survival has raised questions regarding this model. Here using real-time microscopy we show that lte1Delta mutants not only delay exit from mitosis but also uncouple the normal coordination between spindle disassembly and contraction of the actomyosin ring at cell division. These mitotic defects can be suppressed by a bub2Delta mutation or by Cdc14 over-expression suggesting that they are caused by compromised MEN activity. Thus Lte1 function is important to fine-tune the timing of mitotic exit and to couple this event with cytokinesis in budding yeast.

Yeast and cancer.

The discovery of genes that control cell division in yeast, and their relation to cancer, is reviewed.

In vitro regulation of budding yeast Bfa1/Bub2 GAP activity by Cdc5.

The Cdc5 protein of budding yeast is a polo-like kinase that has multiple roles in mitosis including control of the mitotic exit network (MEN). MEN activity brings about loss of mitotic kinase activity so that the mitotic spindle is disassembled and cytokinesis can proceed. Activity of the MEN is regulated by a small GTPase, Tem1, which in turn is controlled by a two-component GTPase-activating protein (GAP) formed by Bfa1 and Bub2. Bfa1 has been identified as a regulatory target of Cdc5 but there are conflicting deductions from indirect in vivo assays as to whether phosphorylation inhibits or stimulates Bfa1 activity. To resolve this question, we have used direct in vitro assays to observe the effects of phosphorylation on Bfa1 activity. We show that when Bfa1 is phosphorylated by Cdc5, its GAP activity with Bub2 is inhibited although its ability to interact with Tem1 is unaffected. Thus, in vivo inactivation of Bfa1-Bub2 by Cdc5 would have a positive regulatory effect by increasing levels of Tem1-GTP so stimulating exit from mitosis.

Complexity of mitotic exit.

Completion of mitosis in budding yeast is triggered by activation of the protein phosphatase Cdc14, which is the ultimate effector of a signalling cascade, known as the mitotic exit network. Cdc14 activation leads to eradication of mitotic kinase activity, which is pivotal for mitotic exit and cytokinesis in all eukaryotes. The complexity in mitotic exit regulation is underscored by the recent discovery of a novel network, the so-called FEAR pathway that regulates early Cdc14 activation. Surprisingly, this has revealed an unexpected role for Spo12, a protein involved in meiosis, in Cdc14 activation. In this review, we will discuss these findings together with recent advances in deciphering the function of the FEAR circuit, which has unravelled an exciting new side of Cdc14.

Spatial regulation of the guanine nucleotide exchange factor Lte1 in Saccharomyces cerevisiae.

In budding yeast, activation of the small Ras-like GTPase Tem1 triggers exit from mitosis and cytokinesis. Tem1 is regulated by Bub2/Bfa1, a two-component GTPase-activating protein (GAP), and by Lte1, a putative guanine nucleotide exchange factor. Lte1 is confined to the bud cortex, and its spatial separation from Tem1 at the spindle pole body (SPB) is important to prevent untimely exit from mitosis. The pathways contributing to Lte1 asymmetry have not been elucidated. Here we show that establishment of Lte1 at the cortex occurs by an actin-independent mechanism, which requires activation of Cdc28/Cln kinase at START and Cdc42, a key regulator of cell polarity and cytoskeletal organisation. This defines a novel role for Cdc42 in late mitotic events. In turn, dissociation of Lte1 from the cortex in telophase depends on activation of the Cdc14 phosphatase. Ectopic expression of Cdc14 at metaphase results in premature dephosphorylation of Lte1 coincident with its release from the cortex. In vitro phosphatase assays confirm that Lte1 is a direct substrate for Cdc14. Our results suggest that the asymmetry in Lte1 localisation is imposed by Cdc28-dependent phosphorylation. Finally, we report a mutational analysis undertaken to investigate intrinsic Lte1 determinants for localisation. Our data suggest that an intrameric interaction between the N-and C-terminal regions of Lte1 is important for cortex association.

Mitotic exit: the Cdc14 double cross.

The release of Cdc14 from the nucleolus occurs in two waves in early and late anaphase, controlled by the FEAR and MEN pathways, respectively. Two new papers report the localisation at the spindle pole body of the Cdc14 released in early anaphase and, surprisingly, show that the two pulses of released Cdc14 have opposite effects on MEN activation.

Control of mitotic exit in budding yeast. In vitro regulation of Tem1 GTPase by Bub2 and Bfa1.

The elimination of mitotic kinase activity at the end of mitosis is essential for progression to the next stage of the eukaryotic cell cycle. In budding yeast, this process is controlled by a regulatory cascade called the mitotic exit network. Extensive genetic data indicate that mitotic exit network activity is determined by a GTP-binding protein, Tem1, and its putative regulators, Bub2, Bfa1, and Lte1. Here we describe the purification and in vitro activities of Tem1, Bub2, and Bfa1. We describe the nucleotide binding properties of Tem1 and characterize its intrinsic GTPase activity. The combination of Bfa1 and Bub2 acts as a two-component GTPase-activating protein for Tem1. In the absence of Bub2, Bfa1 inhibits the GTPase and GTP exchange activities of Tem1. This inhibition is elicited by either the N- or C-terminal regions of Bfa1, which also retain some ability to co-activate GTPase activity in the presence of Bub2. Although the C-terminal region of Bfa1 binds to Bub2, no interaction of the N-terminal half of Bfa1 with Bub2 was detected despite their combined GAP activity. Therefore, we propose that Bfa1 acts both as an adaptor to connect Bub2 and Tem1 and as an allosteric effector that facilitates this interaction.