Training the Anesthesiologist Trainer: Enhancing the Quality of Feedback during Human Patient Simulations

An essential piece of anesthesiologist training is attending resident feedback sessions. Yet, few attending anesthesiologists have formal teaching education and little time to acquire it. In this field experiment, attending physicians were randomly assigned to a control group or to receive 30 minutes of feedback training inspired by Implicit Person Theory (IPT). As such, IPT training encouraged physicians to praise process-oriented learning while discouraging performance-oriented mindsets. Attending physicians then observed residents participate in a human patient simulation (HPS) activity and provided residents with feedback. Content and statistical analyses revealed trained attending physicians praised learning goals and challenged performance goals more often than untrained physicians during feedback sessions. Thus, the training provides a rapid method of enhancing the quality of attending physicians’ training communication.     

Randomized trial of bilateral oophorectomy versus tamoxifen in premenopausal women with metastatic breast cancer

A randomized clinical trial was performed to compare the efficacy of bilateral oophorectomy with that of tamoxifen at a dose of 10 mg twice daily in premenopausal women with metastatic breast cancer, and to examine the efficacy of each as a crossover treatment. Initial treatment responses were seen in ten of 27 patients (37%) treated with oophorectomy and seven of 26 patients (27%) treated with tamoxifen. The difference was not statistically significant. Crossover responses were seen in five of 15 patients (33%) treated with oophorectomy, including three responses in ten prior tamoxifen nonresponders; and two of 18 patients (11%) treated with tamoxifen. Time to progression distributions were not significantly different during initial treatment, and no significant differences in survival were noted. Thus, there was no overall disadvantage to the use of tamoxifen as opposed to oophorectomy as initial hormonal therapy, and a failure to respond to tamoxifen did not preclude a response to subsequent oophorectomy. Exploratory data analysis within subsets indicated consistent differential treatment effects in the visceral dominant patients. Of the 16 such patients treated with oophorectomy, eight (50%) experienced objective responses but there were no responses in the 14 patients treated with tamoxifen. In the nine visceral dominant crossover patients who had not responded to initial tamoxifen, three (33%) subsequently responded to oophorectomy. Time to progression distributions within the visceral dominant subset appeared to be better for the patients treated initially with oophorectomy. However, one must be very cautious in drawing conclusions from exploratory subset analyses, especially with the small sample size. Further studies would be required to test any hypothesis of differential organ site responsiveness.     

Characterization and in vitro phase I microsomal metabolism of designer benzodiazepines: An update comprising flunitrazolam,norflurazepam, and 4'‐chlorodiazepam (Ro5–4864)

The number of newly appearing benzodiazepine derivatives on the new psychoactive substances (NPS) drug market has increased over the last couple of years totaling 23 ‘designer benzodiazepines’ monitored at the end of 2017 by the European Monitoring Centre for Drugs and Drug Addiction. In the present study, three benzodiazepines [flunitrazolam, norflurazepam, and 4′‐chlorodiazepam (Ro5–4864)] offered as ‘research chemicals' on the Internet were characterized and their main in vitro phase I metabolites tentatively identified after incubation with pooled human liver microsomes. For all compounds, the structural formula declared by the vendor was confirmed by gas chromatography?mass spectrometry (GC–MS), liquid chromatography?tandem mass spectrometry (LC MS/MS), liquid chromatography?quadrupole time of flight?mass spectrometry (LC?QTOF?MS) analysis and nuclear magnetic resonance (NMR) spectroscopy. The metabolic steps of flunitrazolam were monohydroxylation, dihydroxylation, and reduction of the nitro function. The detected in vitro phase I metabolites of norflurazepam were hydroxynorflurazepam and dihydroxynorflurazepam. 4’‐Chlorodiazepam biotransformation consisted of N‐dealkylation and hydroxylation. It has to be noted that 4′‐chlorodiazepam and its metabolites show almost identical LC–MS/MS fragmentation patterns to diclazepam and its metabolites (delorazepam, lormetazepam, and lorazepam), making a sufficient chromatographic separation inevitable. Sale of norflurazepam, the metabolite of the prescribed benzodiazepines flurazepam and fludiazepam, presents the risk of incorrect interpretation of analytical findings.     

5F-Cumyl-PINACA in ‘e-liquids’ for electronic cigarettes: comprehensive characterization of a new type of synthetic cannabinoid in a trendy product including investigations on the in vitro and in vivo phase I metabolism of 5F-Cumyl-PINACA and its non-fluorinated analog Cumyl-PINACA

Purpose

In recent years e-liquids used in electronic cigarettes have become an attractive alternative to smoking tobacco. A new trend is the use of e-liquids containing synthetic cannabinoids (SCs) instead of smoking cannabis or herbal mixtures laced with SCs. In the frame of a systematic monitoring of the online market of ‘legal high’ products, e-liquids from online retailers who also sell herbal blends were bought.

Methods

The products were analyzed by gas chromatography-mass spectrometry. In some of the e-liquids an unknown compound was detected which was identified as the SC 5F-Cumyl-PINACA (1-(5-fluoropentyl)-N-(2-phenylpropan-2-yl)-1H-indazole-3-carboxamide) by nuclear magnetic resonance analysis. To investigate the phase I metabolism of this new class of compounds, 5F-Cumyl-PINACA and its non-fluorinated analog Cumyl-PINACA were incubated with pooled human liver microsomes (pHLM). Cumyl-PINACA was additionally ingested orally (0.6 mg) by a volunteer in a controlled self-experiment. To assess the relative potency of Cumyl-PINACA a set of SCs were characterized using a cAMP assay.

Results

Metabolism of 5F-Cumyl-PINACA and Cumyl-PINACA showed similarities with AM-2201 and JWH-018. The main metabolites were formed by hydroxylation at the N-pentyl side chain. The main metabolites detected in the volunteer’s urine sample were the same as in the pHLM assay. All SCs tested with the cAMP assay were full agonists at the CB₁ receptor. Cumyl-PINACA was the most potent SC among the tested compounds and showed an EC₅₀ value of 0.06 nM.

Conclusions

The increasing popularity of e-liquids particularly among young people, and the extreme potency of the added SCs, pose a serious threat to public health. To our knowledge, this is the first report describing the tentative identification of human in vivo metabolites of Cumyl-PINACA and 5F-Cumyl-PINACA.

     

Role of cellular density,in vitro,in anti-tumor activity of CFA-treated and immunized cells

Incorporation of tritiated deoxythymidine (³HdT) into DNA was used to measure growth, in vitro, of P815 tumor cells admixed with spleen and peritoneal effector cells. At a high tumor cell density (1×10⁵ cells per dish), using anti-theta and anti-macrophage sera, T-cells and macrophages from the peritoneum of immunized mice could be identified as cells possessing anti-tumor activity. A nonspecific inhibition by normal effector cells, which occurred at the high tumor cell density, did not occur at a lower tumor cell density (1×10⁴ cells per dish). Therefore, the effects of immunization and Freund's adjuvant treatment on the anti-tumor activity of effector cells were determined more accurately when normal cells were no longer inhibitory. Thus, experimental variables dealing with cellular density (cells/mm² of the culture vessel surface) and effector: tumor cell ratios play an important role in the anti-proliferative capacity of effector cells.     

Malignant nonfunctioning paraganglioma of the retroperitoneum producing renovascular hypertension

Malignant nonchromaffin paraganglioma (chemodectoma) is an unusual tumor arising from chemoreceptor cells derived from the neural crest. Although these tumors generally occur in the head and neck, where the term "carotid body tumor" applies, more than 20 cases of retroperitoneal origin have been described. This case report presents the clinical, radiographic, and pathologic features of a chemodectoma arising in the retroperitoneal area that produced severe hypertension by unilateral real vascular compression. The patient underwent exploratory laparotomy, and a left nephrectomy was done. Follow-up examination 1 year after surgery disclosed no clinical evidence of disease, and he had normal blood pressures without medication.     

Asymmetric synthesis and chromatographic resolution of all four stereomers of the alpha,beta-propanoleucine.

The paper describes the first synthesis of the enantiomerically pure cis-alpha,beta-propanoleucines 6c and 6d by means of asymmetric Strecker synthesis. Furthermore, an improved procedure for the preparation of the stereomeric trans compounds 6a and 6b is proposed. Finally, the four feasible stereomeric alpha,alpha-quaternary-alpha-amino acids are resolved on a penicillamine based chiral stationary phase allowing the determination of ee values ranging from 92.9% to > 98%.