Introduction Endotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of ...prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI. Hypothesis/Problem The availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance.
The MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis.
Nineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts.
The MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of simulated ETI performance by prehospital providers. Bischof JJ , Panchal AR , Finnegan GI , Terndrup TE . Creation and validation of a novel mobile simulation laboratory for high fidelity, prehospital, difficult airway simulation. Prehosp Disaster Med. 2016;31(5):465-470.
Objectives
Emergency medicine (EM) residents take the In‐Training Examination (ITE) annually to assess medical knowledge. Question content is derived from the Model of Clinical Practice of Emergency ...Medicine (EM Model), but it is unknown how well clinical encounters reflect the EM Model. The objective of this study was to compare the content of resident patient encounters from 2016–2018 to the content of the EM Model represented by the ITE Blueprint.
Methods
This was a retrospective cross‐sectional study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS). Reason for visit (RFV) codes were matched to the 20 categories of the American Board of Emergency Medicine (ABEM) ITE Blueprint. All analyses were done with weighted methodology. The proportion of visits in each of the 20 content categories and 5 acuity levels were compared to the proportion in the ITE Blueprint using 95% confidence intervals (CIs).
Results
Both resident and nonresident patient visits demonstrated content differences from the ITE Blueprint. The most common EM Model category were visits with only RFV codes related to signs, symptoms, and presentations regardless of resident involvement. Musculoskeletal disorders (nontraumatic), psychobehavioral disorders, and traumatic disorders categories were overrepresented in resident encounters. Cardiovascular disorders and systemic infectious diseases were underrepresented. When residents were involved with patient care, visits had a higher proportion of RFV codes in the emergent and urgent acuity categories compared to those without a resident.
Conclusions
Resident physicians see higher acuity patients with varied patient presentations, but the distribution of encounters differ in content category than those represented by the ITE Blueprint.
Abstract
Eighty-one percent of persons living with cancer have an emergency department (ED) visit within the last 6 months of life. Many cancer patients in the ED are at an advanced stage with high ...symptom burden and complex needs, and over half is admitted to an inpatient setting. Innovative models of care have been developed to provide high quality, ambulatory, and home-based care to persons living with serious, life-limiting illness, such as advanced cancer. New care models can be divided into a number of categories based on either prognosis (e.g., greater than or less than 6 months), or level of care (e.g., lower versus higher intensity needs, such as intravenous pain/nausea medication or frequent monitoring), and goals of care (e.g., cancer-directed treatment versus symptom-focused care only). We performed a narrative review to (1) compare models of care for seriously ill cancer patients in the ED and (2) examine factors that may hasten or impede wider dissemination of these models.
Promotoras Across the Border Edelblute, Heather B.; Clark, Sandra; Mann, Lilli ...
Journal of immigrant and minority health,
06/2014, Letnik:
16, Številka:
3
Journal Article
Recenzirano
Odprti dostop
The migration of working-aged men from Mexico to the United States fractures the family-centered support structures typical of Latin America and contributes to high levels of depression in women left ...behind in migratory sending communities in Mexico. Mujeres en Solidaridad Apoyandose (MESA) was developed to improve depression in women through social support in a resource poor setting. MESA is a promotora intervention that trains women in the community to lead social support groups over a five-week period. The MESA curriculum uses a combination of cognitive behavioral theory techniques, psychoeducation, and social support activities aimed at alleviating or preventing depression in women. Results from this pilot efficacy study (n = 39) show that depressed participants at baseline experienced declines in depression as measured by the Center for Epidemiologic Studies Depression Scale at follow-up. Other findings demonstrate the complexity behind addressing social support and depression for women impacted by migration in different ways.
Patients with cancer are increasingly being treated with immunotherapy resulting in acute immune-related adverse events (irAEs) and associated visits to Emergency Departments (ED) for acute ...management. This study describes the incidence, timing, type, rates of misdiagnosis, and relevant clinical characteristics of irAEs in patients on immunotherapy presenting to the ED at a large, academic medical center associated with a Comprehensive Cancer Center.
We performed a retrospective chart review as a secondary analysis of a registry of 1,148 patients treated with immune checkpoint inhibitors (ICIs) between January 1, 2010 – June 1, 2017. We assessed cancer type; immunotherapy agent; irAE type; ED diagnosis; use of a consult service in the ED; and presence or absence of a hospital admission following an ED encounter. Outcomes included diagnosis or suspicion of an irAE in the ED and time to administration of irAE treatment.
In our cohort of 1,148 patients on ICIs, 391 had at least one irAE (34.1%). Among patients with irAEs, 169 (43.2%) presented at least once to the ED during the 3 months preceding or following the diagnosis of an irAE. One hundred twenty-four unique patients had a median of 1 visit (range 1-4) prior to irAE diagnosis. Ninety-nine unique patients had a median of 1 visit (range 1-5) post irAE diagnosis. The most common irAEs included dermatitis/rash/pruritis (n=140, 35.8%), colitis/diarrhea (n=113, 28.9%), and thyroid abnormality (n=109, 27.9%). IrAEs were suspected by the ED treating team in 47.8% and 53.5% of irAE- related encounters preceding and following a documented irAE diagnosis, respectively.
Providers initiated treatment for irAEs in 39.1% of irAE-related ED encounters.
IrAEs frequently present in the acute setting. Identification of irAEs in the ED remains poor, despite the ED's affiliation with a large, Comprehensive Cancer Center. Further analysis is required to determine specific factors associated with improved irAE identification by emergency physicians.
Simultanagnosia is a neuropsychological disorder characterized by a restriction of visuospatial attention. In addition, patients are able to identify local elements of a scene, but not the global ...whole. This may be due to a failure to scan and assemble local elements into a global whole (i.e. connect-the-dots). We monitored the eye movements of a simultanagnosic patient while she identified local and global elements of hierarchical letters. Scanning each local element was not necessary, nor sufficient, for successful global level identification. Our results argue against a connect-the-dots strategy of global identification and suggest that residual global processing may be occurring.
BACKGROUNDInfectious diseases (ID) clinics are locations where members of at risk social networks, including sex partners of HIV-infected patients, make contact with a medical care setting when they ...accompany HIV-positive patients to appointments.
METHODSWe implemented a free point-of-care rapid HIV testing program for anyone accompanying a patient to the University of North Carolina ID clinic. Acceptability of the program among the general clinic population was assessed via an anonymous survey 1 year after program implementation. Basic frequencies of those who underwent and received results of rapid HIV testing, the proportion of positive rapid tests and confirmatory HIV tests performed, and the level of University of North Carolina ID clinic patient satisfaction with the HIV testing program were calculated.
RESULTSBetween October 2007 and June 2013, 450 (99.6%) of 452 individuals tested in the program received their results on the same day as testing. Twenty-two individuals (4.9%) tested HIV positive, of which 16 (72.7%) were newly positive, including 3 never previously tested. Excluding previously diagnosed individuals, HIV prevalence was 3.6% (16/446). Among those testing positive by rapid testing, 19 (86.4%) had confirmatory testing and immediately entered into HIV care at the clinic.
CONCLUSIONSThe high positivity and confirmatory HIV rates in our program confirm that the provision of rapid HIV testing in an ID clinic capitalizes on missed opportunities among an at-risk population and allows immediate linkage to care.
Chronic cigarette smoking exposes airway epithelial cells to thousands of carcinogens, oxidants and DNA-damaging agents, creating a field of molecular injury in the airway and altering gene ...expression. Studies of cytologically normal bronchial epithelial cells from smokers have identified transcription-based biomarkers that may prove useful in early diagnosis of lung cancer, including a number of p53-regulated genes. The ability of p53 to regulate transcription is critical for tumor suppression, and this suggests that single-nucleotide polymorphisms (SNPs) in functional p53 binding sites (p53 response elements, or p53REs) that affect gene expression could influence susceptibility to cancer. To connect p53RE SNP genotype with gene expression and cancer risk, we identified a set of 204 SNPs in putative p53REs, and performed
cis
expression quantitative trait loci (eQTL) analysis, assessing associations between SNP genotypes and mRNA levels of adjacent genes in bronchial epithelial cells obtained from 44 cigarette smokers. To further test and validate these genotype–expression associations, we searched published eQTL studies from independent populations and determined that 53 % (39/74) of the bronchial epithelial eQTLs were observed in at least one of other studies. SNPs in p53REs were also evaluated for effects on p53-DNA binding using a quantitative in vitro protein–DNA binding assay. Last, based on linkage disequilibrium, we found 6 p53RE SNPs associated with gene expression were identified as cancer risk SNPs by either genome-wide association studies or candidate gene studies. We provide an approach for identifying and evaluating potentially functional SNPs that may modulate the airway gene expression response to smoking and may influence susceptibility to cancers.
Over time, Residency Match dynamics fluctuate with some specialties experiencing increases in medical student popularity. Academic departments with limited resources must devise methods for coping ...with increased demand for their specialty. Students perceive traditional programs on Match mechanics as inadequate. Subsequently, faculty are confronted with demands for more personal attention from more students.
We developed a strategy for providing specialty-specific residency match advising to large numbers of students.
The 'speed-advising' session (SAS) was developed to address the common questions and concerns that medical students pose during the Match process and to provide advisees with a breadth of faculty perspectives. Two SASs were offered over a 2-week period. After the sessions, students and faculty were surveyed regarding their experience.
Twenty-six students pursued our specialty in the 2015 Match (26 of 234, 11.1%). Twenty-three (89%) participated in the SAS. Seventy-four percent of students (17 of 23) and all faculty completed the post-session survey. Students found the SAS to be informative, helpful and an efficient use of time. Common discussion topics included: career goals, to which programs and how many to apply, and how academic record impacts their likelihood of matching in our specialty. Students would have preferred more time with each faculty; however, most (77%) conceded that their questions were adequately answered. Faculty-favored speed advising over traditional advising (86%), primarily due to estimated time savings of 7.3 h per faculty member.
In preparing students for the Match, specialty-specific speed advising offers an efficient supplement to traditional advising.
Simultanagnosia is a disorder of visual attention: the inability to see more than one object at one time. Some hypothesize that this is due to a constriction of the visual “window” of attention. ...Little is known about how simultanagnosics explore complex stimuli and how their behaviour changes with recovery. We monitored the eye movements of simultanagnosic patient SL to see how she scans social scenes shortly after onset of simultanagnosia (Time 1) and after some recovery (Time 2). At Time 1 SL had an abnormally low proportion of fixations to the eyes of the people in the scenes. She made a significantly larger proportion of fixations to the eyes at Time 2. We hypothesized that this change was related to an expansion of her restricted window of attention. Previously we simulated SL’s behaviour in healthy subjects by having them view stimuli through a restricted viewing window. We used this simulation paradigm here to test our expanding window hypothesis. Subjects viewing social scenes through a larger window allocated more fixations to the eyes of people in the scenes than subjects viewing scenes through a smaller window, supporting our hypothesis. Recovery in simultanagnosia may be related to the expansion of the restricted attentional window that characterizes the disorder.
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