Health Care Utilization and End-of-Life Care Outcomes for Patients With Decompensated Cirrhosis Based on Transplant Candidacy.

CONTEXT: Patients with decompensated cirrhosis have high rates of health care utilization at end of life (EOL). However, the impact of transplant candidacy on intensity of EOL care is currently unknown. OBJECTIVES: To assess the relationship between transplant candidacy and intensity of EOL care in the last year of life in an ambulatory cohort of patients with decompensated cirrhosis. METHODS: We performed a retrospective analysis of 230 patients with decompensated cirrhosis who were evaluated for liver transplantation in a large health care system between 1/1/2010 and 12/31/2017 and died by 6/20/2018. We compared health care utilization in the last year of life and EOL care outcomes between transplant-listed (n = 133) and nonlisted (n = 97) patients. We examined predictors of palliative and hospice care utilization using multivariate logistic regression. RESULTS: During the last year of life, patients had a median of three hospitalizations (IQR 2-5) and spent a median of 31 days (IQR 16-49) in the hospital. In all, 80% of patients died in the hospital, with 70% dying in the intensive care unit. The majority (70.0%) received a life-sustaining procedure (mechanical ventilation, renal replacement therapy, or cardiopulmonary resuscitation) during their terminal hospitalization, which did not differ between transplant-listed and nonlisted patients (74.4% vs. 63.9%, P = 0.09). Transplant-listed patients had lower odds of receiving specialty palliative care (odds ratio 0.43, P = 0.005). Patients with hepatocellular carcinoma had higher odds of receiving hospice care (odds ratio 2.03, P = 0.049). CONCLUSION: Patients with decompensated cirrhosis had intensive health care utilization during their last year of life regardless of transplant candidacy. Further work is needed to optimize their EOL care, particularly for patients who are ineligible for transplantation.

Polymer Capacitor Dielectrics for High Temperature Applications.

Much effort has been invested for nearly five decades to identify and develop new polymer capacitor dielectrics for higher than ambient temperature applications. Simultaneous demands of processability, dielectric permittivity, thermal conductivity, and dielectric breakdown strength dictated by increasing high power performance criteria limit the number of available materials. The present review first explains the advantages of metallized polymer film capacitors over the film-foil, ceramic, and electrolytic counterparts and then presents a comprehensive review on both past developmental effort of commercial resins and recent research progress on new polymers targeted for operating temperature above 150 °C. Some historical background and discussion on the limitation of the commercially available polymer film dielectrics for high temperature applications are also given. In many cases, further development of promising polymers that appear to possess all or most of the important criteria is limited by lack of large scale market incentives but could be of great value to niche applications in the military or aerospace realm.

Surveillance of drug abuse in Hong Kong by hair analysis using LC-MS/MS.

The aim of this study is to reveal the habits of drug abusers in hair samples from drug rehabilitation units in Hong Kong. With the application of liquid chromatography-tandem mass spectrometry (LC-MS/MS) technology, a total of 1771 hair samples were analyzed during the period of hair testing service (January 2012 to March 2016) provided to 14 drug rehabilitation units including non-governmental organizations (NGOs), rehabilitation centers, and medical clinics. Hair samples were analyzed for abused drugs and their metabolites simultaneously, including ketamine, norketamine, cocaine, benzoylecgonine, cocaethylene, norcocaine, codeine, MDMA, MDA, MDEA, amphetamine, methamphetamine, morphine, 6-acetylmorphine, phencyclidine, and methadone. The results showed that ketamine (77.2%), cocaine (21.3%), and methamphetamine (16.5%) were the frequently detected drugs among those drug abusers, which is consistent with the reported data. In addition, the usage of multiple drugs was also observed in the hair samples. About 29% of drug-positive samples were detected with multiple drug use. Our studies prove that our locally developed hair drug-testing method and service can be a valid tool to monitor the use of abused drugs, and which could facilitate rehabilitation program management.

An International Collaboration for the Training of Medical Chief Residents in Rwanda.

BACKGROUND: The year-long position of chief medical resident is a time-honored tradition in the United States that serves to provide the trainee with an opportunity to gain further skills as a clinician, leader, teacher, liaison, and administrator. However, in most training programs in the developing world, this role does not exist. OBJECTIVES: We sought to develop a collaborative program to train the first medical chief residents for the University of Rwanda and to assess the impact of the new chief residency on residency training, using questionnaires and qualitative interviews with Rwandan faculty, chief residents, and residents. METHODS: The educational context and the process leading up to the appointment of Rwandan chief residents, including selection, job description, and necessary training (in the United States and Rwanda), are described. One year after implementation, we used a parallel, mixed methods approach to evaluate the new chief medical resident program through resident surveys as well as semistructured interviews with key informants, including site chief residents, chief residents, and faculty. We also observed chief residents and site chief residents at work and convened focus groups with postgraduate residents to yield additional qualitative information. RESULTS: Rwandan faculty and residents generally felt that the new position had improved the educational and administrative structure of the teaching program while providing a training ground for future academicians. CONCLUSIONS: A collaborative training program between developing and developed world academic institutions provides an efficient model for the development of a new chief residency program in the developing world.

Improvement of medical education through the establishment of a medical chief resident position in Rwanda

Background: The Chief Medical Resident (CMR) role is a well established, one-year position that has existed in the United States (US) for many years. Through collaboration between Yale University Primary Care Internal Medicine Residency Program and the University of Rwanda/College of Medicine and Health Sciences, the Internal Medicine Residency Program in Rwanda began a collaborative training program for Rwandan medical chief residents two years ago. Aims:This paper describes the selection and collaborative training process of the new Rwandan CMRs in teaching hospitals in Rwanda. We also report on evaluation of the role, its impact, and evolving challenges from the perspectives of the current residents through a quantitative survey. Methodology: A survey was directed to residents of the Internal Medicine residency training program. The survey was conducted at the two tertiary teaching sites in Rwanda: Butare University Teaching Hospital (CHUB) and Kigali University Teaching Hospital (CHUK) where chief residents are assigned. On a Likert scale, a group of continuing residents were asked to grade items assessing a change in several educational aspects. The second group of residents, which consisted of first-year residents, was mainly asked questions directed at describing their perception on the chief resident role. Results: In total, 38 residents out of the 40 at the two tertiary hospitals took the survey. Of the 38 residents who took the survey,74% of respondents agreed or strongly agreed on the statement about improvement in educational conferences. 69.6 % of residents noted an improvement in medical education due to having a chief resident in the program. An overall improvement of the residency training program was observed by 78.3% of our study participants. In general (73.7%), residents perceive chief residents as their role model, with first-year residents (100%) being the most enthusiastic about this statement. Conclusion: The chief resident role establishment has made a positive impact in medical education in Internal Medicine/ University of Rwanda. Chief residents play a big role in medical education and are regarded as role models by their fellow residents

Determination of hair ketamine cut-off value from Hong Kong ketamine users by LC-MS/MS analysis.

Ketamine is one of the most frequent abused drugs in Hong Kong and South-East Asia, and the cases of ketamine abused have been reported worldwide. Hair has been commonly used as a specimen for the proof of chronic drug abused because of its non-invasiveness and long detection windows. The determinations of ketamine in hair with varieties of state-of-the-art instruments and detection methods have been developed in the past decade; however, the cut-off value for ketamine abuser has not been developed according to the international guidelines. The aim of this study is to propose a cut-off value for ketamine in hair by analyzing ketamine and its metabolite norketamine by LC-MS/MS method in a population of ketamine users in Hong Kong. The limit of detection (LOD) and limit of quantification (LOQ) for ketamine and norketamine were 20pg/mg and 100pg/mg, respectively. From 977 ketamine abusers, the cut-off value for ketamine in hair was proposed to be 400pg/mg of hair. This proposed cut-off value is the concentration of hair ketamine when over 90% of samples are being detected with the presence of norketamine, which is a proof of ketamine abuse. This value could be applied as a screening or occupational cut-off for reference.

Understanding Nonlinear Dielectric Properties in a Biaxially Oriented Poly(vinylidene fluoride) Film at Both Low and High Electric Fields.

Understanding nonlinear dielectric behavior in polar polymers is crucial to their potential application as next generation high energy density and low loss dielectrics. In this work, we studied nonlinear dielectric properties of a biaxially oriented poly(vinylidene fluoride) (BOPVDF) film under both low and high electric fields. For fundamental nonlinear dielectric constants at low fields (<30 MV/m), Novocontrol high-voltage broadband dielectric spectroscopy (HVBDS) was accurate enough to measure up to the third harmonics. It was observed that the low-field dielectric nonlinearity for the BOPVDF disappeared above 10 Hz at room temperature, suggesting that the low-field dielectric nonlinearity originated from ionic migration of impurity ions rather than dipolar relaxation of the amorphous segments. Above the coercive field (EC ≈ 70 MV/m), bipolar electric displacement-electric field (D-E) loop tests were used to extract the nonlinear behavior for pure PVDF crystals, which had a clear origin of ferroelectric switching of polar crystalline dipoles and domains and nonpolar-to-polar (α → δ → ß) phase transformations. By using HVBDS, it was observed that the ferroelectric switching of polar crystalline dipoles and domains in BOPVDF above the EC always took place between 20 and 500 Hz regardless of a broad range of temperature from -30 to 100 °C. This behavior was drastically different from that of the amorphous PVDF dipoles, which had a strong dependence on frequency over orders of magnitude.

"Water-in-salt" electrolyte enables high-voltage aqueous lithium-ion chemistries.

Lithium-ion batteries raise safety, environmental, and cost concerns, which mostly arise from their nonaqueous electrolytes. The use of aqueous alternatives is limited by their narrow electrochemical stability window (1.23 volts), which sets an intrinsic limit on the practical voltage and energy output. We report a highly concentrated aqueous electrolyte whose window was expanded to ~3.0 volts with the formation of an electrode-electrolyte interphase. A full lithium-ion battery of 2.3 volts using such an aqueous electrolyte was demonstrated to cycle up to 1000 times, with nearly 100% coulombic efficiency at both low (0.15 coulomb) and high (4.5 coulombs) discharge and charge rates.

Semicrystalline Structure-Dielectric Property Relationship and Electrical Conduction in a Biaxially Oriented Poly(vinylidene fluoride) Film under High Electric Fields and High Temperatures.

Poly(vinylidene fluoride) (PVDF)-based homopolymers and copolymers are attractive for a broad range of electroactive applications because of their high dielectric constants. Especially, biaxially oriented PVDF (BOPVDF) films exhibit a DC breakdown strength as high as that for biaxially oriented polypropylene films. In this work, we revealed the molecular origin of the high dielectric constant via study of a commercial BOPVDF film. By determination of the dielectric constant for the amorphous phase in BOPVDF, a high value of ca. 21-22 at 25 °C was obtained, and a three-phase (i.e., lamellar crystal/oriented interphase/amorphous region) semicrystalline model was proposed to explain this result. Meanwhile, electronic conduction mechanisms in BOPVDF under high electric fields and elevated temperatures were investigated by thermally stimulated depolarization current (TSDC) spectroscopy and leakage current studies. Space charge injection from metal electrodes was identified as a major factor for electronic conduction when BOPVDF was poled above 75 °C and 20 MV/m. In addition, when silver or aluminum were used as electrodes, new ions were generated from electrochemical reactions under high fields. Due to the electrochemical reactions between PVDF and the metal electrode, a question is raised for practical electrical applications using PVDF and its copolymers under high-field and high-temperature conditions. A potential method to prevent electrochemical degradation of PVDF is proposed in this study.

Baboon lipoprotein(a) binds very weakly to lysine-agarose and fibrin despite the presence of a strong lysine-binding site in apolipoprotein(a) kringle IV type 10.

Human apolipoprotein(a) kringle IV type 10 [apo(a) KIV(10)] contains a strong lysine-binding site (LBS) that mediates the interaction of Lp(a) with biological substrates such as fibrin. Mutations in the KIV(10) LBS have been reported in both the rhesus monkey and chimpanzee, and have been proposed to explain the lack of ability of the corresponding Lp(a) species to bind to lysine and fibrin. To further the comparative analyses with other primate species, we sequenced a segment of baboon liver apo(a) cDNA spanning KIV(9) through the protease domain. Like rhesus monkey apo(a), baboon apo(a) lacks a kringle V (KV)-like domain. Interestingly, we found that the baboon apo(a) KIV(10) sequence contains all of the canonical LBS residues. We sequenced the apo(a) KIV(10) sequence from an additional 10 unrelated baboons; 17 of 20 alleles encoded Trp at position 70, whereas only two alleles encoded Arg at this position and thus a defective LBS. Despite the apparent presence of a functional KIV(10) LBS in most of the baboons, none of the Lp(a) in the plasma of the corresponding baboons bound specifically to lysine-Sepharose (agarose) even upon partial purification. Moreover, baboon Lp(a) bound very poorly to plasmin-modified fibrinogen. Expression of baboon and human KIV(10) in bacteria allowed us to verify that these domains bind comparably to lysine and lysine analogues. We conclude that presentation of KIV(10) in the context of apo(a) lacking KV may interfere with the ability of KIV(10) to bind to substrates such as fibrin; this paradigm may also be present in other non-human primates.

Constitutive activation of met kinase in non-small-cell lung carcinomas correlates with anchorage-independent cell survival.

Lung cancer is currently the most frequent cause of cancer death in North America. Hepatocyte growth factor (HGF) and its receptor Met are frequently over-expressed in non-small-cell lung carcinomas (NSCLC), but their potential role in tumor progression is not clearly known. To assess the role of HGF/Met signaling in lung carcinomas, we have examined the expression, activation status, and function of Met in NSCLC cell lines (n = 7), established from primary tumors or pleural fluids of cancer patients. We observed Met expression in three NSCLC cell lines, two of which exhibited constitutive tyrosine-phosphorylation of Met, and Met kinase activity. In addition, the observed constitutive activation of Met was sustained under anchorage-independent conditions, and correlated with phosphatidyl inositol 3-kinase-dependent cell survival. Immunoreactive HGF-like protein was secreted by two Met-positive and two Met-negative NSCLC cell lines. However HGF activity, as determined by the ability to induce cell scattering and tyrosine-phosphorylation of Met in reporter cell lines, was detected in conditioned medium from only one Met-negative NSCLC cell line: none of the conditioned media from Met-expressing NSCLC cell lines showed detectable HGF activity. Thus, constitutive activation of Met in NSCLC cell lines may occur at least in part through intracrine, or HGF-independent mechanisms. Interestingly, additional paracrine stimulation with exogenous recombinant HGF was required for DNA synthesis and correlated with increased activation of ERK1/2 in all Met-positive NSCLC cell lines, regardless of the basal activation status of Met. These findings indicate that a medium level of constitutive activation of Met occurs in some NSCLC cell lines, and correlates with survival of detached carcinoma cells; whereas additional paracrine stimulation by recombinant HGF is required for DNA synthesis. Thus constitutive and paracrine activation of Met may provide complementary signals that promote survival and proliferation, respectively, during tumor progression of NSCLC.