Ca2+ Homeostasis by Plasma Membrane Ca2+ ATPase (PMCA) 1 Is Essential for the Development of DP Thymocytes.

The strength of Ca2+ signaling is a hallmark of T cell activation, yet the role of Ca2+ homeostasis in developing T cells before expressing a mature T cell receptor is poorly understood. We aimed to unveil specific functions of the two plasma membrane Ca2+ ATPases expressed in T cells, PMCA1 and PMCA4. On a transcriptional and protein level we found that PMCA4 was expressed at low levels in CD4-CD8- double negative (DN) thymocytes and was even downregulated in subsequent stages while PMCA1 was present throughout development and upregulated in CD4+CD8+ double positive (DP) thymocytes. Mice with a targeted deletion of Pmca1 in DN3 thymocytes had an almost complete block of DP thymocyte development with an accumulation of DN4 thymocytes but severely reduced numbers of CD8+ immature single positive (ISP) thymocytes. The DN4 thymocytes of these mice showed strongly elevated basal cytosolic Ca2+ levels and a pre-mature CD5 expression, but in contrast to the DP thymocytes they were only mildly prone to apoptosis. Surprisingly, mice with a germline deletion of Pmca4 did not show any signs of altered progression through the developmental thymocyte stages, nor altered Ca2+ homeostasis throughout this process. PMCA1 is, therefore, non-redundant in keeping cellular Ca2+ levels low in the early thymocyte development required for the DN to DP transition.

Implementing Multidisciplinary, Team-Based Care in an Academic Outpatient Psychiatry Department.

This column describes the implementation of a multidisciplinary, team-based model of care within an outpatient psychiatry practice at a large urban academic medical center. The authors outline the process by which the innovative team-based care model was selected, funded, and implemented to address long patient wait times, lack of clinical supports, and dissatisfaction of clinical providers. This column also describes the organizational norms that had to be adjusted or sustained to achieve the intended outcomes of reduced intake wait times and financial sustainability, while ensuring that patients continued to receive high-quality care.

Fostering Careers in Medical Education.

Many careers are available to psychiatrist-educators, and residents should learn about these pathways in addition to developing a core set of teaching skills regardless of their intended career trajectory. Clinician-Educator Programs offer structured opportunities for residents to explore advanced concepts, practice teaching skills, pursue scholarship, and receive mentorship in medical education. Women and persons from minority groups, particularly people of color and gender-diverse individuals, have long been passed over in the promotions process, and correction of these inequities is essential to creating a robust workforce of clinician-educators.

Clinician Experiences of Care Provision in the Correctional Setting: A Scoping Review.

Little is known about the experiences of correctional health care providers and how their experiences impact the correctional health care system. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines, multiple databases were searched. Each abstract was read by two reviewers with a third for consensus as needed. Full-text articles were selected through a second round of review. Of 4,467 citations, 61 were selected for full-text evaluation and 23 were ultimately included. Major themes identified were the distinctive working environment, burnout, and the presence of ethical dilemmas, including the tension between security and clinical considerations. This scoping review identified a limited number of articles centered on the health care provider experience in the correctional setting.

Substance-induced Psychosis in Youth.

Youth experiencing psychosis also frequently misuse substances, making it clinically challenging to differentiate substance-induced psychosis (SIP) from a primary psychotic disorder (PPD), which has important implications for management and prognosis. This article presents practical considerations related to differentiating SIP from PPD, including information on substances associated with symptoms of psychosis. Recommendations for management of SIP are also reviewed, including screening for and treating comorbid substance use disorders and using evidence-based medication and psychosocial interventions.

Evaluation of an Interprofessional Student-Faculty Collaborative Clinic in a Jail.

Jail-based student-run clinics, though uncommon, have the potential to impact the future health workforce. We evaluated, via a survey of student attitudes and a collection of lessons learned, a student-faculty collaborative clinic that was implemented in a jail in 2015. Clinic participation led to significantly greater student volunteer ratings of the importance of collaborating with oral health providers and of comfort in providing care to incarcerated populations. We report lessons learned regarding logistical considerations, volunteer behavior, and common issues arising in clinic visits. The clinic proved feasible and sustainable over several years, offering a new model for the involvement of trainees in correctional health care.

Continuous noninvasive arterial blood pressure monitoring using the vascular unloading technology during complex gastrointestinal endoscopy: a prospective observational study.

The innovative vascular unloading technology (VUT) allows continuous noninvasive arterial blood pressure (AP) monitoring. We aimed to investigate whether the VUT enables AP changes to be detected earlier compared with intermittent AP monitoring in patients undergoing gastrointestinal endoscopy. In this prospective observational study, we recorded continuous AP measurements with the VUT (CNAP system; CNSystems Medizintechnik AG, Graz, Austria) and intermittent AP measurements with upper arm cuff oscillometry in 90 patients undergoing complex gastrointestinal endoscopy (Department of Interventional Endoscopy at the University Medical Center Hamburg-Eppendorf, Hamburg, Germany). A "hypotensive phase" was defined as a time period of at least 30 s during which ≥ 50% of the VUT-AP values were in a predefined range of hypotension, i.e., AP value a) ≥ 10% below the last oscillometric value and b) ≤ 65 mmHg for mean AP or ≤ 90 mmHg for systolic AP. In the 5-min-interval between two oscillometric measurements, one or more hypotensive phases were detected in 26 patients (29%) for mean AP and in 27 patients (30%) for systolic AP. Hypotensive phases had a mean duration of 195 ± 99 s for mean AP and 197 ± 97 s for systolic AP with a mean procedure duration of 36 (± 21) min. Continuous noninvasive AP monitoring using the VUT enables hypotensive phases to be detected earlier compared with intermittent AP monitoring during complex gastrointestinal endoscopy. These hypotensive phases may be missed or only belatedly recognized with intermittent AP monitoring. Continuous noninvasive AP measurement facilitates detecting hemodynamic instability more rapidly and therefore may improve patient safety.

What Are Physicians' Responsibilities to Patients Whose Health Conditions Can Influence Their Legal Proceedings?

Correctional populations are disproportionately affected by conditions that affect cognition, such as psychiatric illness and head trauma. Honoring bioethical principles in the care of such patients can be particularly difficult in the correctional setting. However, the approach should not change markedly because a patient is incarcerated. That is, the same standards of respecting patient autonomy and confidentiality should be maintained, and the fact that correctional populations are already marginalized makes it all the more important for clinicians to honor these principles. Physicians should act in the best interest of their patients; in jails this might include disclosing information to and consulting with a patient's legal defense. However, this step should only be taken with a patient's consent or, in cases in which the patient does not have decision-making capacity, when it seems consistent with a patient's wishes.

Epiblast cells that express MyoD recruit pluripotent cells to the skeletal muscle lineage.

Embryonic stem cells are derived from the epiblast. A subpopulation of epiblast cells expresses MyoD mRNA and the G8 antigen in vivo. G8 positive (G8pos) and G8 negative (G8neg) populations were isolated by magnetic cell sorting. Nearly all G8pos cells switched from E- to N-cadherin and differentiated into skeletal muscle in culture. G8neg cells were impaired in their ability to switch cadherins and few formed skeletal muscle. Medium conditioned by G8pos cells stimulated skeletal myogenesis and N-cadherin synthesis in G8neg cultures. The effect of conditioned medium from G8pos cultures was inhibited by bone morphogenetic protein (BMP) 4. Treatment of G8neg cells with a soluble form of the BMP receptor-IA or Noggin promoted N-cadherin synthesis and skeletal myogenesis. These results demonstrate that MyoD-positive epiblast cells recruit pluripotent cells to the skeletal muscle lineage. The mechanism of recruitment involves blocking the BMP signaling pathway.