Autonomous Learning in a Virtual Environment

The educational community is seizing the opportunity to link interdependent members from distant locations. Universities, colleges, and other adult education media are supplementing traditional classroom settings with virtual classrooms thereby broadening their local and regional markets. The authors argue a virtual learning paradigm can satisfy efficacious autonomous learning more effectively when social support and affective management conditions are available. Based on a qualitative analysis of data from a group of doctoral students required to engage in learning through asynchronous communications, the authors recommend conditions that are most conducive to efficacious autonomous learning

Rigid Sternal Fixation Improves Postoperative Recovery

INTRODUCTION: During the past five years, ridged sternal fixation has been utilized for sternal closure after cardiac surgery. It is known that this procedure provides better sternal stability; however, its contribution to patient recovery has not been investigated. METHODS: Retrospective chart review was conducted for patients who underwent CABG and/or valve surgery in our institution between 2009 and 2010. Preoperative, perioperative, and follow-up data of patients with ridgid fixation (group R, n=89) were collected and compared with those patients with conventional sternal closure (group C, n=133). The decision regarding the sternal closure method was based on the surgeon\u27s preferences. Univariate followed by multivariate analyses were performed to evaluate the dominant factor of sternal lock usage and to evaluate postoperative recoveries. The factors included in the analyses were; age, sex, coronary risk factors, urgency of surgery, ejection fraction, coronary anatomy, preoperative stroke, renal function, and preoperative presence of heart failure. All statistical analyses were performed by JMP software. RESULTS: Group R was younger (62 ± 9 in group R vs 69 ± 11 in group C, p CONCLUSION: Rigid sternal fixation systems were more frequently applied to low risk young male patients. Among these selected patients, ridgid sternal fixation can contribute to early patient recovery

Sternal pain after rigid fixation: a pilot study of randomization rigid vs conventional wire closure.

Objective: Rigid sternal fixation may provide better sternal closure than conventional sternal wire closure. We performed a prospective randomized study to investigate if rigid closure reduces postoperative sternal pain. Methods: Patients undergoing CABG ± valve surgery between July 2011 and January 2012 were prospectively randomized into conventional wire closure (group C) or rigid fixation using sternal plates (group R). Pain scores were determined at 6 AM using a numeric rating scale (0 no pain, 5 moderate pain, 10 worst possible pain). Narcotic pain medication requirement from day 1 to 5 was collected and converted into intravenous morphine equivalent. Results: Among the total of 26 patients, 11 patients were in Group R (10 male and 1 female, age 67 ± 8.0) and 15 patients were in Group C (13 male and 2 female, age 66 ± 9.9). Preoperative risk factors and procedure were identical between the two groups. Pain scores were not significantly different between 2 groups. Narcotic requirement was smaller in group R (15.7 mg intravenous morphine equivalent in group R in day 1vs 18.4 mg intravenous morphine equivalent in day 1 in group C in day 1, 13.1 mg vs 12.5 mg in day 2, 9.4 mg vs 10.5 mg in day 3, 6.9 mg vs 7.7 mg in day 4, and 6.2 mg vs 6.9 mg in day 5) than group C. Total iv narcotic given over 5 days was 24 ± 41 mg in group R and 34 mg ± 54 mg in group C (p=0.60). Conclusion: Randomized data rom this ongoing study showed a trend of fewer narcotic requirement especially intravenous narcotics in group R than in group C. Implications: Rigid fixation may potentially improve immediate sternal pain after open heart surgery. Less narcotic requirement potentially facilitate early return to the daily activity

Tennessee’s Youth in Juvenile Justice Facilities: Mental Health and Substance Abuse Issues

In order to assess the prevalence of mental health and substance abuse among youth in one state’s juvenile justice facilities, a survey was conducted of 40 Tennessee facilities. A total of 1215 youth were being held on the “one day census” that was taken as part of the survey. The survey documented many mental health and substance abuse issues: 1) 53 percent of the youth in juvenile justice facilities were experiencing mental health problems; 2) 15 percent were taking some type of psychiatric medicine while in the juvenile justice facility; 3) 42 percent were known to have substance abuse problems; and 4) 30 percent had co-occurring mental health and substance use problems. Policy and program recommendations based on these findings are discussed

Integration of Tumor Mutation Burden and PD-L1 Testing in Routine Laboratory Diagnostics in Non-Small Cell Lung Cancer

In recent years, Non-small cell lung cancer (NSCLC) has evolved into a prime example for precision oncology with multiple FDA-approved "precision" drugs. For the majority of NSCLC lacking targetable genetic alterations, immune checkpoint inhibition (ICI) has become standard of care in first-line treatment or beyond. PD-L1 tumor expression represents the only approved predictive biomarker for PD-L1/PD-1 checkpoint inhibition by therapeutic antibodies. Since PD-L1-negative or low-expressing tumors may also respond to ICI, additional factors are likely to contribute in addition to PD-L1 expression. Tumor mutation burden (TMB) has emerged as a potential candidate; however, it is the most complex biomarker so far and might represent a challenge for routine diagnostics. We therefore established a hybrid capture (HC) next-generation sequencing (NGS) assay that covers all oncogenic driver alterations as well as TMB and validated TMB values by correlation with the assay (F1CDx) used for the CheckMate 227 study. Results of the first consecutive 417 patients analyzed in a routine clinical setting are presented. Data show that fast reliable comprehensive diagnostics including TMB and targetable alterations are obtained with a short turn-around time. Thus, even complex biomarkers can easily be implemented in routine practice to optimize treatment decisions for advanced NSCLC

A privação materna no período neonatal não afeta a resposta nociceptiva na idade adulta

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A novel inhibitor of the alternative pathway of complement reverses inflammation and bone destruction in experimental arthritis

Complement is an important component of the innate and adaptive immune response, yet complement split products generated through activation of each of the three complement pathways (classical, alternative, and lectin) can cause inflammation and tissue destruction. Previous studies have shown that complement activation through the alternative, but not classical, pathway is required to initiate antibody-induced arthritis in mice, but it is unclear if the alternative pathway (AP) plays a role in established disease. Previously, we have shown that human complement receptor of the immunoglobulin superfamily (CRIg) is a selective inhibitor of the AP of complement. Here, we present the crystal structure of murine CRIg and, using mutants, provide evidence that the structural requirements for inhibition of the AP are conserved in human and mouse. A soluble form of CRIg reversed inflammation and bone loss in two experimental models of arthritis by inhibiting the AP of complement in the joint. Our data indicate that the AP of complement is not only required for disease induction, but also disease progression. The extracellular domain of CRIg thus provides a novel tool to study the effects of inhibiting the AP of complement in established disease and constitutes a promising therapeutic with selectivity for a single complement pathway

A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills (RATES) Study

Background and aims Based on the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers. Methods ASGE recognized training programs were invited to participate and AETs were graded on ERCP and EUS exams using a validated competency assessment tool that assesses technical and cognitive competence in a continuous fashion. Grading for each skill was done using a 4-point scoring system and a comprehensive data collection and reporting system was built to create learning curves using cumulative sum analysis. Individual results and benchmarking to peers were shared with AETs and trainers quarterly. Results Of the 62 programs invited, 20 programs and 22 AETs participated in this study. At the end of training, median number of EUS and ERCP performed/AET was 300 (range 155-650) and 350 (125-500). Overall, 3786 exams were graded (EUS:1137; ERCP–biliary 2280, pancreatic 369). Learning curves for individual endpoints, and overall technical/cognitive aspects in EUS and ERCP demonstrated substantial variability and were successfully shared with all programs. The majority of trainees achieved overall technical (EUS: 82%; ERCP: 60%) and cognitive (EUS: 76%; ERCP: 100%) competence at conclusion of training. Conclusions These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP