Microdialysis techniques and microdialysis-based patient-near diagnostics.

This article will debate the usefulness of POCT measurements and the contribution microdialysis can make to generating valuable information. A particular theme will be the rarely considered difference between ex vivo sampling, which typically generates only a static measure of concentration, and in vivo measurements that are subject to dynamic changes due to mass transfer. Those dynamic changes provide information about the patients' physiological state.

An integrated device for fast and sensitive immunosuppressant detection.

The present paper describes a compact point of care (POC) optical device for therapeutic drug monitoring (TDM). The core of the device is a disposable plastic chip where an immunoassay for the determination of immunosuppressants takes place. The chip is designed in order to have ten parallel microchannels allowing the simultaneous detection of more than one analyte with replicate measurements. The device is equipped with a microfluidic system, which provides sample mixing with the necessary chemicals and pumping samples, reagents and buffers into the measurement chip, and with integrated thin film amorphous silicon photodiodes for the fluorescence detection. Submicrometric fluorescent magnetic particles are used as support in the immunoassay in order to improve the efficiency of the assay. In particular, the magnetic feature is used to concentrate the antibody onto the sensing layer leading to a much faster implementation of the assay, while the fluorescent feature is used to increase the optical signal leading to a larger optical dynamic change and consequently a better sensitivity and a lower limit of detection. The design and development of the whole integrated optical device are here illustrated. In addition, detection of mycophenolic acid and cyclosporine A in spiked solutions and in microdialysate samples from patient blood with the implemented device are reported.

Immunosuppressant quantification in intravenous microdialysate - towards novel quasi-continuous therapeutic drug monitoring in transplanted patients.

OBJECTIVES: Therapeutic drug monitoring (TDM) plays a crucial role in personalized medicine. It helps clinicians to tailor drug dosage for optimized therapy through understanding the underlying complex pharmacokinetics and pharmacodynamics. Conventional, non-continuous TDM fails to provide real-time information, which is particularly important for the initial phase of immunosuppressant therapy, e.g., with cyclosporine (CsA) and mycophenolic acid (MPA). METHODS: We analyzed the time course over 8 h of total and free of immunosuppressive drug (CsA and MPA) concentrations measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in 16 kidney transplant patients. Besides repeated blood sampling, intravenous microdialysis was used for continuous sampling. Free drug concentrations were determined from ultracentrifuged EDTA-plasma (UC) and compared with the drug concentrations in the respective microdialysate (µD). µDs were additionally analyzed for free CsA using a novel immunosensor chip integrated into a fluorescence detection platform. The potential of microdialysis coupled with an optical immunosensor for the TDM of immunosuppressants was assessed. RESULTS: Using LC-MS/MS, the free concentrations of CsA (fCsA) and MPA (fMPA) were detectable and the time courses of total and free CsA comparable. fCsA and fMPA and area-under-the-curves (AUCs) in µDs correlated well with those determined in UCs (r≥0.79 and r≥0.88, respectively). Moreover, fCsA in µDs measured with the immunosensor correlated clearly with those determined by LC-MS/MS (r=0.82). CONCLUSIONS: The new microdialysis-supported immunosensor allows real-time analysis of immunosuppressants and tailor-made dosing according to the AUC concept. It readily lends itself to future applications as minimally invasive and continuous near-patient TDM.

Application of visible/NIR spectroscopy for the estimation of soluble solids, dry matter and flesh firmness in stone fruits.

BACKGROUND: Soluble solids concentration (SSC), dry matter concentration (DMC) and flesh firmness (FF) are important fruit quality parameters in stone fruits. This study investigated the ability of a commercial visible/near-infrared (NIR) spectrometer to determine SSC, DMC and FF in nectarine, peach, apricot and Japanese plum cultivars at harvest. The work was conducted in summer 2019/2020 on 14 stone fruit cultivars at Tatura, Australia. Two sub-samples of 100 fruit each were collected before and after commercial maturity (± 5 days) in order to maximize sample variability. RESULTS: Partial least square (PLS) regression models based on the second derivative of the absorbance in the 729-975 nm spectral region proved accurate for the prediction of SSC and DMC (R2 CV > 0.750). Only the model generated for SSC in 'Golden May' apricot was less precise compared to other cultivars. No visible/NIR models were accurate enough to predict FF in the cultivars under study (R2 CV < 0.750). CONCLUSION: This study demonstrated that the visible/NIR spectrometer was a reliable tool to monitor SSC and DMC in stone fruits at harvest but proved less useful for FF estimation. These results highlight the potential of visible/NIR spectrometry to evaluate stone fruit quality both in situ pre-harvest and in the laboratory after harvest. © 2020 Society of Chemical Industry.

Maturity Prediction in Yellow Peach (Prunus persica L.) Cultivars Using a Fluorescence Spectrometer.

Technology for rapid, non-invasive and accurate determination of fruit maturity is increasingly sought after in horticultural industries. This study investigated the ability to predict fruit maturity of yellow peach cultivars using a prototype non-destructive fluorescence spectrometer. Collected spectra were analysed to predict flesh firmness (FF), soluble solids concentration (SSC), index of absorbance difference (IAD), skin and flesh colour attributes (i.e., a* and H°) and maturity classes (immature, harvest-ready and mature) in four yellow peach cultivars-'August Flame', 'O'Henry', 'Redhaven' and 'September Sun'. The cultivars provided a diverse range of maturity indices. The fluorescence spectrometer consistently predicted IAD and skin colour in all the cultivars under study with high accuracy (Lin's concordance correlation coefficient > 0.85), whereas flesh colour's estimation was always accurate apart from 'Redhaven'. Except for 'September Sun', good prediction of FF and SSC was observed. Fruit maturity classes were reliably predicted with a high likelihood (F1-score = 0.85) when samples from the four cultivars were pooled together. Further studies are needed to assess the performance of the fluorescence spectrometer on other fruit crops. Work is underway to develop a handheld version of the fluorescence spectrometer to improve the utility and adoption by fruit growers, packhouses and supply chain managers.

Fruit and Leaf Sensing for Continuous Detection of Nectarine Water Status.

Continuous assessment of plant water status indicators provides the most precise information for irrigation management and automation, as plants represent an interface between soil and atmosphere. This study investigated the relationship of plant water status to continuous fruit diameter (FD) and inverse leaf turgor pressure rates (p p) in nectarine trees [Prunus persica (L.) Batsch] throughout fruit development. The influence of deficit irrigation treatments on stem (Ψ stem) and leaf water potential, leaf relative water content, leaf stomatal conductance, and fruit growth was studied across the stages of double-sigmoidal fruit development in 'September Bright' nectarines. Fruit relative growth rate (RGR) and leaf relative pressure change rate (RPCR) were derived from FD and p p to represent rates of water in- and outflows in the organs, respectively. Continuous RGR and RPCR dynamics were independently and jointly related to plant water status and environmental variables. The independent use of RGR and RPCR yielded significant associations with midday Ψ stem, the most representative index of tree water status in anisohydric species. However, a combination of nocturnal fruit and leaf parameters unveiled an even more significant relationship with Ψ stem, suggesting a changing behavior of fruit and leaf water flows in response to pronounced water deficit. In conclusion, we highlight the suitability of a dual-organ sensing approach for improved prediction of tree water status.

Apoplasmic and simplasmic phloem unloading mechanisms: Do they co-exist in Angeleno plums under demanding environmental conditions?

Biophysical fruit growth depends on a balance among the vascular and transpiration flows entering/exiting the fruit via phloem, xylem and through the epidermis. There is no information on vascular flows of Japanese plums, a species characterized by high-sugar content of its fruit at harvest. Vascular flows of Angeleno plums were monitored by fruit gauges during late fruit development, under the dry environment of the Goulburn Valley, Victoria, Australia. Phloem, xylem flows and skin transpiratory losses were determined, as well as diurnal leaf, stem and fruit pressure potentials. Fruit seasonal development, skin conductance and dry matter accumulation were also monitored. Fruit grew following a double-sigmoid pattern, but fruit size increased only 3.1 g over the last 3 weeks of development. Fruit grew very little in the morning, primarily due to phloem inflows (0.05 g fruit-1hr-1), while water left the fruit via the xylem. Negligible skin transpiration was recorded for vapour pressure deficit (VPD) values below 3 kPa. This growth pattern, in the absence of skin transpiration, suggests apoplastic phloem unloading. However, at VPD values over 3 kPa (e.g. from early afternoon to a peak around 18:00 h), transpiratory losses through the skin (up to 0.25 g fruit-1hr-1) caused fruit to shrink, leading to enhanced phloem and xylem inflows (ca. 0.15 g fruit-1hr-1), a scenario that would correspond to symplastic phloem unloading. Over 24 h the fruit showed a slightly negative total growth, consistent with fruit growth measured in situ during the season at weekly intervals. A few fruit species are known to alter their phloem unloading mechanism, switching from symplastic to apoplastic during the season. Our data support the coexistence in Japanese plum of different phloem unloading strategies within the same day.

Development of a Flipped Medical School Dermatology Module.

OBJECTIVES: The flipped classroom module incorporates independent study in advance of in-class instructional sessions. It is unproven whether this methodology is effective within a medical school second-year organ system module. We report the development, implementation, and effectiveness of the flipped classroom methodology in a second-year medical student dermatology module at the University of Miami Leonard M. Miller School of Medicine. METHODS: In a retrospective cohort analysis, we compared attitudinal survey data and mean scores for a 50-item multiple-choice final examination of the second-year medical students who participated in this 1-week flipped course with those of the previous year's traditional, lecture-based course. RESULTS: Each group comprised nearly 200 students. Students' age, sex, Medical College Admission Test scores, and undergraduate grade point averages were comparable between the flipped and traditional classroom students. The flipped module students' mean final examination score of 92.71% ± 5.03% was greater than that of the traditional module students' 90.92% ± 5.51% (P < 0.001) score. Three of the five most commonly missed questions were identical between the two cohorts. The majority of students preferred the flipped methodology to attending live lectures or watching previously recorded lectures. CONCLUSIONS: The flipped classroom can be an effective instructional methodology for a medical school second-year organ system module.

An overview of wetlands of Saudi Arabia: Values, threats, and perspectives.

The wetlands of Saudi Arabia are located in a water-stressed region that is highly vulnerable to climate and other global changes. Sebkhas, mudflats, mangroves, and wadis are the dominant wetlands in the arid regions of North Africa and the Arabian Peninsula. These unique wetlands are recognized as a sanctuary for biodiversity and for their economic services generated from mineral extraction, agriculture, and grazing. Despite their ecological values and societal services, the long-term permanence of Saudi Arabia's wetlands faces strong challenges resulting from human activities associated with sustained population growth, habitat degradation, and coastal development. This paper consolidates a literature review of Saudi Arabia's wetlands from local to global importance, highlights their biodiversity, and identifies threats and evolution of these vulnerable ecosystems in the arid Arabian Peninsula by focusing on the status of key freshwater taxa (Odonata, freshwater fishes, amphibians, and waterbirds) and documenting changes affecting important wetlands.

Consensus statement from the 2014 International Microdialysis Forum.

Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.

Glucose concentrations in blood and tissue - a pilot study on variable time lag.

AIM: The aim of this pilot study was to acquire insight into the parameters of glycaemic control, especially, (1) the time delay (lag phase) between plasma and tissue glucose concentrations in relation to rise and fall in glucose levels and (2) the rate of glucose increase and decrease. METHODS: Four healthy people (HP), 4 people with type 1diabetes (DM1) and 4 with type 2 diabetes (DM2) underwent concurrent glucose measurements by means of (1) the continuous glucose monitoring system (CGMS-Medtronic), Medtronic-Minimed, CA, USA, calibrated by the glucometer Calla, Wellion, Austria, and, (2) the Beckman II analyser to measure glucose concentrations in venous plasma. Samples were taken on 4 consecutive days in the fasting state and 4 times after consumption of 50 g glucose. Carelink Personal, MS Excel, Maple and Mat lab were applied to plot the evolution of glucose concentration and analyse the results. The time difference between increase and decrease was calculated for HP, DM 1 and DM 2. RESULTS: In DM1and DM2, glucose tolerance testing (GTT) resulted in slower transport of glucose into subcutaneous tissue than in HP where the lag phase lasted up to 12 min. The maximum increase/decrease rates in DM1 and DM2 vs HP were 0.25 vs < 0.1 mmol/L/min. CONCLUSION: CGMS is shown to provide reliable plasma glucose concentrations provided the system is calibrated during a steady state. The analysis of glucose change rates improves understanding of metabolic processes better than standard GTT.

Increasing access to cholesterol screening in rural communities catalyzes cardiovascular disease prevention.

PURPOSE: Despite increasing frequency, little evidence guides cholesterol screening in less traditional health care settings, such as rural health fairs. METHODS: The Miller School of Medicine Department of Community Service (DOCS) is a student-run organization providing free basic health care to underserved South Florida communities. We retrospectively reviewed all new patients seen at 2007 DOCS rural fairs to describe their low-density lipoprotein (LDL) and high-density lipoprotein (HDL) values. In addition, we assessed if patient characteristics were associated with cholesterol abnormalities and whether patients with abnormalities who returned to a subsequent fair in 2008 or 2009 improved their cholesterol. FINDINGS: Of 252 patients, 145 (58%) had an LDL cholesterol over 129 mg/dL and 61 (24%) had an HDL cholesterol below 40 mg/dL or 50 mg/dL for males and females, respectively. Baseline LDL cholesterol was not associated with body-mass index (BMI), age over 60 years, gender, healthy lifestyle habits, or insurance status. Of 36 patients with elevated LDL cholesterol and a follow-up screening, 24 (67%) reduced their LDL cholesterol by at least 16 mg/dL though reductions were not associated with BMI reduction, and 22 (61%) increased their HDL cholesterol by at least 5 mg/dL, trending with BMI reduction. CONCLUSIONS: Cholesterol screening at rural fairs can identify a high proportion of patients with abnormal cholesterol, including those who might not be considered at high risk. Although this may catalyze favorable cholesterol changes, the lack of an association with weight loss suggests patients seek additional medical care, which should be considered before offering cholesterol screening at fairs.

Medical student attitudes before and after participation in rural health fairs.

BACKGROUND: Despite an increased need, residents of rural communities have decreased access to healthcare and oftenpresentuniquehealthcare challenges associated with their rurality. Ensuring medical students receive adequate exposure to these issues is complicated by the urban location of most medical schools. Health fairs (fairs) conducted in rural communities can provide students exposure to ruralhealth;however, it is unknown how participation affects attitudes regarding these issues. MATERIALS AND METHODS: During the 2010-2011 academic year, first-year medical students were surveyed before and after participating in a rural fair regarding the importance of rural health issues, the need for exposure to rural healthcare, their plans to practice in a rural community,andthe educational impact of fairs. RESULTS: Of the 121participating students, 77% and 61% completed pre- and post-fair surveys, respectively. Few had lived in a rural area or planned to practice primary care. Participants strongly agreed that the delivery of healthcare in rural areas was important, and that all physicians should receive rural health training (4.8 and 3.7 out of 5, respectively) despite less than halfplanning to practice in a rural community. After participating in a rural fair, student attitudes were unchanged, although 87% of participants strongly agreed their involvement had contributed to improving patient health and 70% that the fairs provided rural medicine experience. CONCLUSIONS: Among urban medical school students with varied interests in primary care, there was strong interest in volunteering at rural fairs and appreciation for the importance of rural health. Fairs provided interested students with rural medicine experience that reinforced student attitudes regarding rural health. Further, students felt their participation improved patient health.

Improving access to colorectal cancer screening through medical philanthropy: feasibility of a flexible sigmoidoscopy health fair for uninsured patients.

OBJECTIVES: Only half of eligible patients in the United States undergo colorectal cancer (CRC) screening as recommended. Hypothesizing that the medical philanthropy platform may be effective in improving access to CRC screening, we aimed to demonstrate the feasibility of a flexible sigmoidoscopy (FS)-based CRC screening "health fair" for uninsured patients. METHODS: Uninsured patients older than 50 years who had not undergone CRC screening in the preceding 10 years were recruited through local free clinics and health fairs. A standard medical clinic was transformed into a fully functional endoscopy unit. Medicolegal protection for volunteers was obtained through the Florida Department of Health's Volunteer Health Care Provider Program. Unsedated FS with polypectomy was performed. Those with high-risk endoscopic features were given instructions on obtaining a full colonoscopy. RESULTS: Fifty-two patients without access to any form of CRC screening underwent FS. Ninety-four percent had an adequate bowel preparation, although 40% required on-site enema. Eighteen patients had a total of 22 polyps, 4 of which were adenomatous. There were no complications. The total cost of the fair, excluding donated resources such as endoscopes and processors, was $6,531.47, amounting to $126 per patient screened. CONCLUSIONS: Health fair-style CRC screening for uninsured patients is feasible. With improved efficiency, widespread application of CRC screening using the medical philanthropy platform may represent a viable approach to reducing the underuse of CRC screening among the uninsured.

Student-led rural health fairs: attempting to improve medical education and access to health care.

OBJECTIVES: Residents of rural communities, especially in the Southeast, have decreased access to health care. Ensuring medical students receive adequate exposure to their issues is complicated by the urban location of most schools. We describe health fairs conducted in rural communities to suggest how having medical students use screening tools can identify patients with risk factors for disease which can offer students the opportunity to learn about rural health issues through patient counseling. METHODS: The Mitchell Wolfson Sr. Department of Community Service, a University of Miami Miller School of Medicine student-led organization, conducts fairs at four sites throughout the rural Florida Keys. Medical students, under the supervision of attending physicians, offer screening and preventive health services including risk factor screening for cardiovascular disease, ophthalmological exams, dermatologic exams, osteoporosis screening, and female exams with pap smears. These fairs were reviewed. RESULTS: In the past three years, 1694 unique patients were seen. Many lacked a primary care provider (46%) or health insurance (43%) and were provided screening for several disorders including cardiovascular disease risk factors (hypertension, diabetes, dyslipidemia, and obesity). Screening revealed that many patients (41%) had multiple markers of elevated cardiovascular disease risk. This provided experiences to more than 200 students each year. CONCLUSION: Fairs provide medical students exposure to rural health issues through the valuable opportunity of using risk factor screening tools and counseling. This provides valuable information to patients of rural communities. Future research should examine how fairs influence student knowledge and attitudes toward rural health and affect health outcomes.

Barriers to effective teaching.

Medical school faculty members are charged with the critical responsibility of preparing the future physician and medical scientist workforce. Recent reports suggest that medical school curricula have not kept pace with societal needs and that medical schools are graduating students who lack the knowledge and skills needed to practice effectively in the 21st century. The majority of faculty members want to be effective teachers and graduate well-prepared medical students, but multiple and complex factors-curricular, cultural, environmental, and financial-impede their efforts. Curricular impediments to effective teaching include unclear definitions of and disagreement on learning needs, misunderstood or unstated goals and objectives, and curriculum sequencing challenges. Student and faculty attitudes, too few faculty development opportunities, and the lack of an award system for teaching all are major culture-based barriers. Environmental barriers, such as time limitations, the setting, and the physical space in which medical education takes place, and financial barriers, such as limited education budgets, also pose serious challenges to even the most committed teachers. This article delineates the barriers to effective teaching as noted in the literature and recommends action items, some of which are incremental whereas others represent major change. Physicians-in-training, medical faculty, and society are depending on medical education leaders to address these barriers to effect the changes needed to enhance teaching and learning.

Cerebral extracellular chemistry and outcome following traumatic brain injury: a microdialysis study of 223 patients.

Secondary insults can adversely influence outcome following severe traumatic brain injury. Monitoring of cerebral extracellular chemistry with microdialysis has the potential for early detection of metabolic derangements associated with such events. The objective of this study was to determine the relationship between the fundamental biochemical markers and neurological outcome in a large cohort of patients with traumatic brain injury. Prospectively collected observational neuromonitoring data from 223 patients were analysed. Monitoring modalities included digitally recorded intracranial pressure, cerebral perfusion pressure, cerebrovascular pressure reactivity index and microdialysis markers glucose, lactate, pyruvate, glutamate, glycerol and the lactate/pyruvate ratio. Outcome was assessed using the Glasgow Outcome Scale at 6 months post-injury. Patient-averaged values of parameters were used in statistical analysis, which included univariate non-parametric methods and multivariate logistic regression. Monitoring with microdialysis commenced on median (interquartile range) Day 1 (1-2) from injury and median (interquartile range) duration of monitoring was 4 (2-7) days. Averaged over the total monitoring period levels of glutamate (P = 0.048), lactate/pyruvate ratio (P = 0.044), intracranial pressure (P = 0.006) and cerebrovascular pressure reactivity index (P = 0.01) were significantly higher in patients who died. During the initial 72 h of monitoring, median glycerol levels were also higher in the mortality group (P = 0.014) and median lactate/pyruvate ratio (P = 0.026) and lactate (P = 0.033) levels were significantly lower in patients with favourable outcome. In a multivariate logistic regression model (P < 0.0001), which employed data averaged over the whole monitoring period, significant independent positive predictors of mortality were glucose (P = 0.024), lactate/pyruvate ratio (P = 0.016), intracranial pressure (P = 0.029), cerebrovascular pressure reactivity index (P = 0.036) and age (P = 0.003), while pyruvate was a significant independent negative predictor of mortality (P = 0.004). The results of this study suggest that extracellular metabolic markers are independently associated with outcome following traumatic brain injury. Whether treatment-related improvement in biochemistry translates into better outcome remains to be established.

A combined microdialysis and FDG-PET study of glucose metabolism in head injury.

BACKGROUND: Microdialysis continuously monitors the chemistry of a small focal volume of the cerebral extracellular space. Positron emission tomography (PET) establishes metabolism of the whole brain but only for the scan's duration. This study's objective was to apply these techniques together, in patients with traumatic brain injury, to assess the relationship between microdialysis (extracellular glucose, lactate, pyruvate, and the lactate/pyruvate (L/P) ratio as a marker of anaerobic metabolism) and PET parameters of glucose metabolism using the glucose analogue [(18)F]-fluorodeoxyglucose (FDG). In particular, we aimed to determine the fate of glucose in terms of differential metabolism to pyruvate and lactate. MATERIALS AND METHODS: Microdialysis catheters (CMA70 or CMA71) were inserted into the cerebral cortex of 17 patients with major head injury. Microdialysis was performed during FDG-PET scans with regions of interest for PET analysis defined by the location of the gold-tipped microdialysis catheter. Microdialysate analysis was performed on a CMA600 analyser. FINDINGS: There was significant linear relationship between the PET-derived parameter of glucose metabolism (regional cerebral metabolic rate of glucose; CMRglc) and levels of lactate (r = 0.778, p < 0.0001) and pyruvate (r = 0.799, p < 0.0001), but not with the L/P ratio. CONCLUSION: The results suggest that in this population of patients, glucose was metabolised to both lactate and pyruvate, but was not associated with an increase in the L/P ratio. This suggests an increase in glucose metabolism to both lactate and pyruvate, as opposed to a shift towards anaerobic metabolism.