Covid-19 Epidemic Impact on Clinical Training in Irish GP Training.

Aim To describe the effect of the Covid pandemic on the general practice workplace based learning of GP training in Ireland. Methods A prospective national survey of GP trainees who were in their GP practice placements on three separate occasions throughout the winter pandemic of 2020/2021 Results The average response rate to the three surveys was 19.4%. As the pandemic worsened, the number of face to face consultations dropped so that 51% (n=41) of trainees were seeing less than 5 patients face to face by the third survey. Conversely, the number of telephone/video consultations rose so that by the third survey 54% (n=44) of trainees were conducting more than 16 consultations per day remotely. Examinations and GP presentations expected to be daily occurrences diminished as the pandemic grew more severe, such that by the third survey 24-25% of trainees had not conducted a respiratory examination or dealt with new/unexpected hypertension in the previous month. Conclusion This study demonstrates abrupt change to the normal course of their training which was experienced by Irish GP trainees as a result of Covid, with examples from clinical practice. Adaptions of the training programme helped mitigate against the effects of the pandemic.

Performance in practice; exploring trainer and trainee experiences of user-designed formative assessment tools.

INTRODUCTION: General Practice training in Ireland currently has various methods of formative assessment and feedback delivered to trainees. In 2018 the Irish College of General Practitioners commissioned the generation of two new user-designed formative feedback tools that would allow trainee feedback to drive learning. These tools became known as the Performance in Practice (PiP) tools. AIMS: To explore the experiences of General Practice (GP) trainers and trainees having completed a pilot of using the PiP tools for 4 months. METHODS: An explorative phenomenological approach was taken to understand the experiences of trainers and trainees. One to one interviews were conducted, and the transcripts analysed for themes and sub-theme via Template analysis. RESULTS: User experiences focused on two main areas; educational value and acceptability. In relation to educational value, the PiP tools were seen as an improvement over established forms of formative feedback, as they were centred around the curriculum and therefore reflected the unique multifaceted requirements of an independently practising GP. Acceptability primarily focused around data governance and structures, as well as practical issues such as ease of software use. CONCLUSIONS: Overall, the experience of using the PiP tools was positive for both trainers and trainees. Future plans to further explore implementation of the PiP tools have been significantly informed by this research.

Role of ghrelin isoforms in the mitigation of hepatic inflammation, mitochondrial dysfunction, and endoplasmic reticulum stress after bariatric surgery in rats.

BACKGROUND/OBJECTIVES: Bariatric surgery improves nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), but the underlying mechanisms remain elusive. We evaluated the potential role of ghrelin isoforms in the amelioration of hepatic inflammation after sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB). SUBJECTS/METHODS: Plasma ghrelin isoforms were measured in male Wistar rats (n = 129) subjected to surgical (sham operation, sleeve gastrectomy, or RYGB) or dietary interventions [fed ad libitum a normal (ND) or a high-fat diet (HFD) or pair-fed diet]. The effect of acylated and desacyl ghrelin on markers of inflammation, mitochondrial dysfunction, and endoplasmic reticulum (ER) stress in primary rat hepatocytes under palmitate-induced lipotoxic conditions was assessed. RESULTS: Plasma desacyl ghrelin was decreased after sleeve gastrectomy and RYGB, whereas the acylated/desacyl ghrelin ratio was augmented. Both surgeries diminished obesity-associated hepatic steatosis, CD68+- and apoptotic cells, proinflammatory JNK activation, and Crp, Tnf, and Il6 transcripts. Moreover, a postsurgical amelioration in the mitochondrial DNA content, oxidative phosphorylation (OXPHOS) complexes I and II, and ER stress markers was observed. Specifically, following bariatric surgery GRP78, spliced XBP-1, ATF4, and CHOP levels were reduced, as were phosphorylated eIF2α. Interestingly, acylated and desacyl ghrelin inhibited steatosis and inflammation of palmitate-treated hepatocytes in parallel to an upregulation of OXPHOS complexes II, III, and V, and a downregulation of ER stress transducers IRE1α, PERK, ATF6, their downstream effectors, ATF4 and CHOP, as well as chaperone GRP78. CONCLUSIONS: Our data suggest that the increased relative acylated ghrelin levels after bariatric surgery might contribute to mitigate obesity-associated hepatic inflammation, mitochondrial dysfunction, and ER stress.

Clinical outcomes and the role of adjuvant therapy sequencing in Type II uterine cancer following definitive surgical treatment.

PURPOSE OF INVESTIGATION: Because of rarity, consensus on adjuvant therapies for Type II endometrial cancers (BC) remains undefined. Reporting their institutional outcomes, the present authors assessed the impact of adjuvant therapies on recurrence and overall survival in women with 2009 FIGO Stage I-III Type II BC. MATERIAL AND METHODS: The authors identified 108 women, treated with definitive surgery between 2000-2013, with pathologically-confirmed Type II EC (non-endometrioid [NEM, n=801 and high grade endometrioid [G3EEC, n=28]) Cox proportional hazard models were used to assess the effect of prognostic variables on disease-free (DFS) and overall survival (OS). Kaplan-Meier method was used to assess survival. RESULTS: Of the 108 women, 83 (77%) were African American (AA). Fifty-nine (55%), 12 (11%), and 37 (34%) were Stage I, II, and III, respectively. Ninety-seven patients received adjuvant therapy: 52 (radiation only), four (chemotherapy only), and 40 (combined). During follow-up (median 41 months), 44 patients (41%) recurred. Five-year DFS was 53% overall (48% [NEM], 80% [G3EEC]). Five-year OS was 75% overall (68% [NEM], 95% [G3EEC]). On multivariate analysis, lower stage and adjuvant radiation improved DFS. Higher stage, NEM, and increasing age were poor prognostic indicators of OS. CONCLUSION: Representing a large single institutional cohort for Type II BC, the present study's observed sur- vival rates are consistent with previous studies, despite the relatively high frequency of carcinosarcoma and Stage III/nodal disease. The protective effect on recurrence was not lost when radiation was delayed for chemotherapy. The present results support a multimodal adjuvant approach for treating all stages of invasive NEM EC.

Donegal Going against the Flow: National Differences in Long-Term Urinary Catheterisation Rates in Men (> 65 Years) With Benign Prostatic Hypertrophy.

An analysis of Primary Care Reimbursement Service (PCRS, 2013) data demonstrated high rates of urinary catheter changes in Donegal compared to other regions of Ireland. There is a catheter change rate of 10.2% in Donegal men over 65 with medical cards (GMS) compared to rates of 2.7% and 0.17% in Waterford and South Dublin, respectively1. This 60-fold difference between an area with perceived good access to services (South Dublin) and Donegal an area that does not, prompted a survey of general practitioners in each of these areas to assess whether true male catheterisation rates were similarly disproportionate in Donegal. Based on this, data was collected from a population of 23,794 GMS patients in GP training practices in Donegal (Rural), Leinster (Urban) and Waterford (Suburban). The data sampled for Donegal demonstrated 19 long-term catheters (LTCs per 8603 GMS) compared to four LTCs (per 5,800 GMS) in Leinster and 3 LTCs (per 9,391 GMS) in Waterford (Table 1). This anomaly in LTC rates may be a proxy for lack of access to basic Urology services.

Rise and fall of vector infectivity during sequential strain displacements by mosquito-borne dengue virus.

Each of the four serotypes of mosquito-borne dengue virus (DENV-1-4) comprises multiple, genetically distinct strains. Competitive displacement between strains within a serotype is a common feature of DENV epidemiology and can trigger outbreaks of dengue disease. We investigated the mechanisms underlying two sequential displacements by DENV-3 strains in Sri Lanka that each coincided with abrupt increases in dengue haemorrhagic fever (DHF) incidence. First, the post-DHF strain displaced the pre-DHF strain in the 1980s. We have previously shown that post-DHF is more infectious than pre-DHF for the major DENV vector, Aedes aegypti. Then, the ultra-DHF strain evolved in situ from post-DHF and displaced its ancestor in the 2000s. We predicted that ultra-DHF would be more infectious for Ae. aegypti than post-DHF but found that ultra-DHF infected a significantly lower percentage of mosquitoes than post-DHF. We therefore hypothesized that ultra-DHF had effected displacement by disseminating in Ae. aegypti more rapidly than post-DHF, but this was not borne out by a time course of mosquito infection. To elucidate the mechanisms that shape these virus-vector interactions, we tested the impact of RNA interference (RNAi), the principal mosquito defence against DENV, on replication of each of the three DENV strains. Replication of all strains was similar in mosquito cells with dysfunctional RNAi, but in cells with functional RNAi, replication of pre-DHF was significantly suppressed relative to the other two strains. Thus, differences in susceptibility to RNAi may account for the differences in mosquito infectivity between pre-DHF and post-DHF, but other mechanisms underlie the difference between post-DHF and ultra-DHF.

Carbon Ion Fluxes at Mars: First Results of Tailward Flows From MAVEN-STATIC.

Characterizing C+ ions in the Martian ionosphere is important for understanding the history of the Martian atmosphere and surface due to its place in understanding carbon escape. Measuring minor ions, like C+, which are close in mass to major atmospheric ions, in this case O+, is difficult, requiring fitting algorithms and accurate background subtraction. Accurate measurement of these species is essential for understanding chemistry and transport in the ionosphere. In this paper, we use data from the Mars Atmospheric and Volatile EvolutioN SupraThermal And Thermal Ion Composition (MAVEN-STATIC) sensor to report the first C+ fluxes measured in the Martian magnetotail. We will describe a multistep method of background subtraction as well as fitting routines that are used to extract C+ fluxes from a 40-orbit subset of STATIC data. Our results show tailward fluxes in both optical shadow and the adjacent sunlit magnetotail at high altitudes ( > 3,000 km) and Mars-ward at low altitudes ( < 2,000 km) in shadow. These local flux values are similar to estimates of neutral carbon fluxes from photochemical escape. However, total carbon loss comparisons will require a more comprehensive study of integrated C+ loss over a larger data set from the Martian magnetotail.

Survival of adenovirus types 2 and 41 in surface and ground waters measured by a plaque assay.

To manage artificial recharge systems, it is necessary to understand the inactivation process of microorganisms within aquifers so that requirements regarding storage times and treatment strategies for ground and surface waters can be developed and modeled to improve water management practices. This study was designed to investigate the survival of representative adenoviruses in surface- and groundwaters using a cell culture plaque assay with human lung carcinoma cells (A549) to enumerate surviving viruses. Adenovirus types 2 (Ad2) and 41 (Ad41) were seeded into 50 mL of three sterilized surface waters and groundwaters, and incubated at 10 and 19 °C for up to 301 days. Concentrations of Ad2 and Ad41 were relatively stable in all waters at 10 °C for at least 160 days and in some instances up to 301 days. At 19 °C, virus concentrations were reduced by 99.99% (4 log) after 301 days in surface water. There was approximately 90% (1 log) reduction of both viruses at 19 °C after 160 days of incubation in groundwater samples. There was no overall difference in survival kinetics in surface waters compared to groundwaters. The relatively high stability and long-term survival of adenoviruses in environmental waters at elevated temperatures should be considered in risk assessment models and drinking water management strategies.

Plant-produced idiotype vaccines for the treatment of non-Hodgkin's lymphoma: safety and immunogenicity in a phase I clinical study.

Plant-made vaccines have been the subject of intense interest because they can be produced economically in large scale without the use of animal-derived components. Plant-made therapeutic vaccines against challenging chronic diseases, such as cancer, have received little research attention, and no previous human clinical trials have been conducted in this vaccine category. We document the feasibility of using a plant viral expression system to produce personalized (patient-specific) recombinant idiotype vaccines against follicular B cell lymphoma and the results of administering these vaccines to lymphoma patients in a phase I safety and immunogenicity clinical trial. The system allowed rapid production and recovery of idiotypic single-chain antibodies (scFv) derived from each patient's tumor and immunization of patients with their own individual therapeutic antigen. Both low and high doses of vaccines, administered alone or co-administered with the adjuvant GM-CSF, were well tolerated with no serious adverse events. A majority (>70%) of the patients developed cellular or humoral immune responses, and 47% of the patients developed antigen-specific responses. Because 15 of 16 vaccines were glycosylated in plants, this study also shows that variation in patterns of antigen glycosylation do not impair the immunogenicity or affect the safety of the vaccines. Collectively, these findings support the conclusion that plant-produced idiotype vaccines are feasible to produce, safe to administer, and a viable option for idiotype-specific immune therapy in follicular lymphoma patients.

In Situ Measurements of Thermal Ion Temperature in the Martian Ionosphere.

In situ measurements of ionospheric and thermospheric temperatures are experimentally challenging because orbiting spacecraft typically travel supersonically with respect to the cold gas and plasma. We present O 2 + temperatures in Mars' ionosphere derived from data measured by the SupraThermal And Thermal Ion Composition instrument onboard the Mars Atmosphere and Volatile EvolutioN spacecraft. We focus on data obtained during nine special orbit maneuvers known as Deep Dips, during which MAVEN lowered its periapsis altitude from the nominal 150 to 120 km for 1 week in order to sample the ionospheric main peak and approach the homopause. We use two independent techniques to calculate ion temperatures from the measured energy and angular widths of the supersonic ram ion beam. After correcting for background and instrument response, we are able to measure ion temperatures as low as 100 K with associated uncertainties as low as 10%. It is theoretically expected that ion temperatures will converge to the neutral temperature at altitudes below the exobase region (∼180-200 km) due to strong collisional coupling; however, no evidence of the expected thermalization is observed. We have eliminated several possible explanations for the observed temperature difference between ions and neutrals, including Coulomb collisions with electrons, Joule heating, and heating caused by interactions with the spacecraft. The source of the energy maintaining the high ion temperatures remains unclear, suggesting that a fundamental piece of physics is missing from existing models of the Martian ionosphere.

Activators of the nuclear hormone receptors PPARalpha and FXR accelerate the development of the fetal epidermal permeability barrier.

Members of the superfamily of nuclear hormone receptors which are obligate heterodimeric partners of the retinoid X receptor may be important in epidermal development. Here, we examined the effects of activators of the receptors for vitamin D3 and retinoids, and of the peroxisome proliferator activated receptors (PPARs) and the farnesoid X-activated receptor (FXR), on the development of the fetal epidermal barrier in vitro. Skin explants from gestational day 17 rats (term is 22 d) are unstratified and lack a stratum corneum (SC). After incubation in hormone-free media for 3-4 d, a multilayered SC replete with mature lamellar membranes in the interstices and a functionally competent barrier appear. 9-cis or all-trans retinoic acid, 1,25 dihydroxyvitamin D3, or the PPARgamma ligands prostaglandin J2 or troglitazone did not affect the development of barrier function or epidermal morphology. In contrast, activators of the PPARalpha, oleic acid, linoleic acid, and clofibrate, accelerated epidermal development, resulting in mature lamellar membranes, a multilayered SC, and a competent barrier after 2 d of incubation. The FXR activators, all-trans farnesol and juvenile hormone III, also accelerated epidermal barrier development. Activities of beta-glucocerebrosidase and steroid sulfatase, enzymes previously linked to barrier maturation, also increased after treatment with PPARalpha and FXR activators. In contrast, isoprenoids, such as nerolidol, cis-farnesol, or geranylgeraniol, or metabolites in the cholesterol pathway, such as mevalonate, squalene, or 25-hydroxycholesterol, did not alter barrier development. Finally, additive effects were observed in explants incubated with clofibrate and farnesol together in suboptimal concentrations which alone did not affect barrier development. These data indicate a putative physiologic role for PPARalpha and FXR in epidermal barrier development.

Hormonal basis for the gender difference in epidermal barrier formation in the fetal rat. Acceleration by estrogen and delay by testosterone.

Previous studies have shown that ontogeny of the epidermal permeability barrier and lung occur in parallel in the fetal rat, and that pharmacologic agents, such as glucocorticoids and thyroid hormone, accelerate maturation at comparable developmental time points. Gender also influences lung maturation, i.e., males exhibit delayed development. Sex steroid hormones exert opposite effects on lung maturation, with estrogens accelerating and androgens inhibiting. In this study, we demonstrate that cutaneous barrier formation, measured as transepidermal water loss, is delayed in male fetal rats. Administration of estrogen to pregnant mothers accelerates fetal barrier development both morphologically and functionally. Competent barriers also form sooner in skin explants incubated in estrogen-supplemented media in vitro. In contrast, administration of dihydrotestosterone delays barrier formation both in vivo and in vitro. Finally, treatment of pregnant rats with the androgen antagonist flutamide eliminates the gender difference in barrier formation. These studies indicate that (a) estrogen accelerates and testosterone delays cutaneous barrier formation, (b) these hormones exert their effects directly on the skin, and (c) sex differences in rates of barrier development in vivo may be mediated by testosterone.

Ecotoxicological characterization of biochars: role of feedstock and pyrolysis temperature.

Seven contrasting feedstocks were subjected to slow pyrolysis at low (300 or 350°C) and high temperature (550 or 600°C), and both biochars and the corresponding feedstocks tested for short-term ecotoxicity using basal soil respiration and collembolan reproduction tests. After a 28-d incubation, soil basal respiration was not inhibited but stimulated by additions of feedstocks and biochars. However, variation in soil respiration was dependent on both feedstock and pyrolysis temperature. In the last case, respiration decreased with pyrolysis temperature (r=-0.78; p<0.0001, n=21) and increased with a higher volatile matter content (r=0.51; p<0.017), these two variables being correlated (r=-0.86, p<0.0001). Collembolan reproduction was generally unaffected by any of the additions, but when inhibited, it was mostly influenced by feedstock, and generally without any influence of charring itself and pyrolysis temperature. Strong inhibition was only observed in uncharred food waste and resulting biochars. Inhibition effects were probably linked to high soluble Na and NH4 concentrations when both feedstocks and biochars were considered, but mostly to soluble Na when only biochars were taken into account. The general lack of toxicity of the set of slow pyrolysis biochars in this study at typical field application rates (≤20 Mg ha(-1)) suggests a low short-term toxicity risk. At higher application rates (20-540 Mg ha(-1)), some biochars affected collembolan reproduction to some extent, but only strongly in the food waste biochars. Such negative impacts were not anticipated by the criteria set in currently available biochar quality standards, pointing out the need to consider ecotoxicological criteria either explicitly or implicitly in biochar characterization schemes or in management recommendations.

Amiloride blocks a keratinocyte nonspecific cation channel and inhibits Ca(++)-induced keratinocyte differentiation.

Proliferation and differentiation in many cells are linked to specific changes in transmembrane ion fluxes. Previously, we have identified a nonspecific cation channel in keratinocytes, which is permeable to and activated by Ca++. To test whether this cation channel might serve as a pathway for Ca++ entry, we examined the effect of blocking this channel on membrane currents, markers of differentiation, and intracellular Ca++. In patch clamp studies, 10(-8) to 10(-6) M amiloride decreased the single-channel open probability. The same concentrations of amiloride inhibited the calcium-induced formation of cornified envelopes and activity of transglutaminase in a dose-dependent fashion. Amiloride inhibited the long-term rise of intracellular Ca++ induced by raised extracellular Ca++, without blocking the initial increase of intracellular Ca++. Amiloride at concentrations of 10(-7) to 10(-3) M did not change the resting intracellular pH of keratinocytes, although concentrations of 10(-6) M or greater inhibited the recovery from NH4(+)-induced acidification. To test whether the effect of amiloride was toxic, we measured DNA synthesis in the presence or absence of amiloride. DNA synthesis was unchanged, suggesting that amiloride's actions were not due to toxic effects. Although the exact mechanisms of amiloride's action remains to be determined, these experiments suggest that this compound may inhibit keratinocyte differentiation by blocking the nonspecific cation channel.

Keratinocyte K+ channels mediate Ca2+-induced differentiation.

K+ channel activation has been associated with growth or differentiation in many cells. We have previously identified a 70-pS K+ channel that was found only in differentiated involucrin-positive cells. In this study we examined the role of K+ channels in Ca2+-induced keratinocyte differentiation. Consistent with our previous report, we found that a K+ conductance developed only in cells cultured in high extracellular Ca2+. Addition of charybdotoxin or verapamil blocked these K+ channels and inhibited Ca2+-induced differentiation, as assessed by cornified envelope formation or transglutaminase activity. These results suggest that K+ channel activation is necessary for Ca2+-induced differentiation. Finally, we used (125)I-labeled charybdotoxin to demonstrate the presence of K+ channels in intact human and mouse epidermis, hair follicles, and eccrine glands, indicating that these channels are found in keratinocytes both in vitro and in vivo. Thus K+ channels may moderate Ca2+ influx in more differentiated keratinocytes and may play a central role in keratinocyte differentiation.

Epidermal steroid sulfatase and cholesterol sulfotransferase are regulated during late gestation in the fetal rat.

Lipids in the stratum corneum (SC) are organized into lamellar membrane unit structures that provide the permeability barrier. Cholesterol sulfate, a SC membrane lipid, is synthesized by cholesterol sulfotransferase (CSTase) in the lower epidermis and hydrolyzed to cholesterol by steroid sulfatase (SSase) in the SC. To determine whether these enzymes are induced during barrier ontogenesis, we examined their activity in epidermis of fetal rats before (gestational day 17), during (day 19), and after (day 21) barrier formation. CSTase activity increased approximately 10-fold between day 17 and day 19, then declined between day 19 and day 21. In contrast, SSase activity reached its peak activity on day 21, increasing >5-fold. Fetal rat skin explants develop a SC and barrier over the same time course in vitro as in utero. Likewise, CSTase and SSase activities during in vitro ontogenesis precisely mirrored those obtained in utero. Moreover, hormones that accelerate barrier ontogenesis (e.g. glucocorticoids, thyroid hormone, and estrogen) accelerated the increase in CSTase and SSase activities during in vitro ontogenesis. mRNA levels of SSase increased in parallel with enzymatic activity, suggesting that these developmental changes are regulated at the genomic level. Finally, addition of exogenous cholesterol sulfate to explants in vitro did not accelerate either SC development or barrier formation. These studies suggest that induction of the cholesterol sulfate cycle enzymes during SC ontogenesis is a component of the fetal epidermal differentiation program and that the synthetic and degradative enzymes of this pathway are differentially regulated.

Epidermal barrier ontogenesis: maturation in serum-free media and acceleration by glucocorticoids and thyroid hormone but not selected growth factors.

Because the cutaneous permeability barrier develops late in gestation, prematurity may result in increased morbidity and mortality due to barrier incompetence. The purpose of the present study was to develop an in vitro model of barrier ontogenesis in order to identify those factors critical for fetal barrier formation. Skin explants from gestational day 17 fetal rats (term is 22 days) were incubated in hormone- and serum-free media. After 4 d in culture, a multi-layered stratum corneum (SC) developed that demonstrated a membrane pattern of fluorescence using the hydrophobic probe, nile red, and the deposition of mature lamellar unit structures throughout the SC interstices, ultrastructurally. Transepidermal water loss rates declined during explant culture such that after 4 d a competent barrier was present. Similarly, lanthanum permeation studies showed tracer penetration into all cell layers in 2-d explants, whereas it did not penetrate above the stratum granulosum in 4-d explants. Thus, the chronology of epidermal development in the explants precisely mirrored that observed in utero. Treatment with either 10 nM dexamethasone or 10 nM triiodothyronine accelerated SC development and barrier formation by 2 d. These results indicate that (i) the late events of fetal epidermal development progress in vitro under serum- and growth factor-free conditions, culminating in the formation of a functional barrier, and (ii) both dexamethasone and triiodothyronine accelerate barrier development.