The PD-1/PD-L1 pathway is a key immune checkpoint that regulates T cell activation. There is strong rationale to develop PD-1 agonists as therapeutics against autoimmunity, but progress in this area ...has been limited. Here, we generated T cell receptor (TCR) targeting, PD-1 agonist bispecifics called ImmTAAI molecules that mimic the ability of PD-L1 to facilitate the colocalization of PD-1 with the TCR complex at the target cell-T cell interface. PD-1 agonist ImmTAAI molecules specifically bound to target cells and were highly effective in activating the PD-1 receptor on interacting T cells to achieve immune suppression. Potent PD-1 antibody ImmTAAI molecules closely mimicked the mechanism of action of endogenously expressed PD-L1 in their localization to the target cell-T cell interface, inhibition of proximal TCR signaling events, and suppression of T cell function. At picomolar concentrations, these bispecifics suppressed cytokine production and inhibited CD8+ T cell-mediated cytotoxicity in vitro. Crucially, in soluble form, the PD-1 ImmTAAI molecules were inactive and, hence, could avoid systemic immunosuppression. This study outlines a promising new route to generate more effective, potent, tissue-targeted PD-1 agonists that can inhibit T cell function locally with the potential to treat autoimmune and chronic inflammatory diseases of high unmet need.
The International Federation of Library Associations and Institutions (IFLA) is the leading international body representing the interests of library and information services and their users. It is ...the global voice of the information profession. The series IFLA Publications deals with many of the means through which libraries, information centres, and information professionals worldwide can formulate their goals, exert their influence as a group, protect their interests, and find solutions to global problems.
## In Detail Microsoft Windows Intune is a cloud service solution that simplifies how small and mid-sized businesses manage and secure PCs using Microsoft cloud services and Windows 7-so your ...computers and users can operate at peak performance all the time. This step-by-step guide will show you how to plan, set up and maintain Windows Intune, showing you how to manage a group of PCs (either 1 business or several if a partner) from the base operating system, through to the patches, anti- malware solution and deployed software and policies from a central console, using the Windows Intune service. This book takes you through all the steps to plan, set up and maintain Windows Intune and how to manage a group of PCs. The book starts by providing an overview of Cloud Computing and PC Management. The book then dives into topics such as Windows Intune features, signing up for Windows Intune and installing the client software, configuring Windows Intune, proactive management, and monitoring and dealing with alerts, including remote assistance amongst others. As Windows 7 is part of Windows Intune, the book will also cover the minimum steps required to move from Windows XP to Windows 7 while keeping user settings and preferences. ## Approach This book is a concise and practical tutorial that shows you how to plan, set up and maintain Windows Intune to manage one or more businesses PCs. ## Who this book is for If you are an administrator or partner who wants to plan, set up and maintain Windows Intune and manage a group of PCs then this book is for you . You should have a basic understanding of Windows administration, however, knowledge of Windows Intune would not be required.
This pulmonary edema intubation simulator is designed to instruct paramedics, medical students, emergency medicine residents, emergency medical services fellows, and attending physicians.
Acute ...pulmonary edema results in respiratory distress and may require endotracheal intubation. On occasion, pulmonary edema can result in copious amounts of pink, frothy sputum in the airway, complicating intubation by hindering the intubator's view. Although airway management skills are frequently taught in a simulation setting, the frothy sputum seen in acute pulmonary edema is not easily replicated. Several articles have been published in reference to simulation model development for difficult airway management due to emesis obscuring the view of the glottic opening.1,2 There is, however, a scarcity of literature describing pulmonary edema airway management simulator construction, with only one other model identified on our review of the literature, which utilized cadavers, baking soda, vinegar, and red food coloring.3In our simulation center, we teach a variety of learners who may be called upon to care for patients in acute pulmonary edema in their clinical practice, including medical students, residents from various specialties, practicing physicians and pre-hospital personnel. We wished to familiarize these trainees with the challenges associated with intubating patients with significant frothy secretions within the hypopharynx by developing a dynamic, realistic, portable and inexpensive model to simulate the airway manifestations associated with acute pulmonary edema.
By the end of the session, learners will be able to: 1. Discuss the pathophysiology of, and immediate stabilization management steps for, acute cardiogenic pulmonary edema. 2. List the indications, contraindications, and risks associated with intubating a patient with acute cardiogenic pulmonary edema. 3. Demonstrate effective communication and teamwork skills to manage the airway of a simulated patient in respiratory distress due to acute cardiogenic pulmonary edema. 4. Successfully and safely intubate a simulated patient with a difficult airway due to visual obstruction from frothy pulmonary edema secretions.
We adapted a previously owned commercial airway task trainer simulator using an aquarium pump, tubing, an air stone, and an endotracheal tube. Pulmonary edema solution was created with glycerin, dish soap, (distilled) water and simulated blood. The solution and air stone are placed in one of the simulator's lungs. Subsequently, turning on the aquarium air pump generates simulated pulmonary edema within the lung itself, which froths up and out of the trachea and into the hypopharynx, mimicking the gross pathophysiological process.Learners complete pre-reading assignments prior to attending a small group didactic-practical session. Following a brief case discussion, led by the instructor, about the management of a patient in respiratory distress due to acute pulmonary edema, learners transition to a hands-on experience intubating the pulmonary edema manikin with the use of direct and video laryngoscopy, aided by a large bore Yankauer for suction and a bougie. Depending on the training level of the learners, the instructor will use judgment and may elect to demonstrate intubating the manikin using video laryngoscopy before the learners attempt the procedure. The authors recommend that the instructor use video laryngoscopy for teaching purposes so that all learners can visualize the intubation techniques (Yankauer, bougie) in the context of copious pulmonary edema fluid obscuring the glottis and surrounding airway structures.The practical portion is dedicated solely to intubation, with one learner assuming the role of the intubator and another assuming the role of a respiratory therapist, while the other leaners observe and/or provide real-time feedback. Learners rotate through these aforementioned roles. To maintain efficiency of the simulation session and maximize the number of intubation attempts each learner receives, the session is designed to begin with a case discussion about the management of a patient with acute pulmonary edema up through the timepoint of successful intubation, followed by a practical portion where the learners perform multiple intubations on the innovative pulmonary edema airway management task trainer. During the practical portion, real-time constructive feedback is given to each learner. At the end of the simulation session, a debriefing is completed.This model can be used to address several ACGME Emergency Medicine Milestones,4 specifically Milestone 9 (General Approach to Procedures - PC9), Level 4 (Performs indicated procedures on any patients with challenging features eg, poorly identifiable landmarks, at extremes of age or with comorbid conditions, and also Milestone 10 (Airway Management - PC10), Level 4 (Performs airway management in any circumstance taking steps to avoid potential complications). This model can also be used to address ACGME Emergency Medical Services Milestones,5 specifically "Procedures Performed in the Pre-hospital Environment - Patient Care," Level 4 (Performs indicated procedures on any patients, including those with challenging features (eg, poorly identifiable landmarks, at extremes of age or with co-morbid conditions).
At the conclusion of the session, verbal feedback is sought from each participant by the instructor: How helpful did you find this simulation experience for learning about airway management in patients with acute pulmonary edema? Did you find the pulmonary edema intubation model to be realistic? Following this simulation experience, how would you rate your personal confidence in terms of managing an airway complicated by acute pulmonary edema?
For under fifty dollars, we have been able to adapt one of our previously owned airway management task trainers to build a pulmonary edema intubation simulator. It has been used in a wide variety of settings for different learners, including medical students, residents, fellows and pre-hospital providers. Since the 2016-2017 academic year, two hundred and twenty-six emergency medicine residents (PGY1, PGY2, and PGY3) have successfully used our innovative pulmonary edema airway management task trainer. Qualitatively it has been well-received and felt to be realistic by both our learners and instructors based on verbal feedback received following the simulation sessions.
We are aware of only one prior report attempting to simulate the frothy sputum seen in acute pulmonary edema. Lipe,
., described mixing baking soda, vinegar and red food coloring in a cadaver hypopharynx just prior to an intubation attempt.3 This combination creates a fizzy frothy solution that fills the hypopharynx and pushes proximally into the mouth. This model is limited by design, however, in that it was unable to mimic a true in vivo appearance of a continuous flow of pulmonary edema-like fluid from the glottic opening. We feel we were able to overcome this limitation and also believe it is important for the leaner to experience the challenges of intubation when faced with copious secretions originating from within the lower airways. Our model generates the froth from within the lung itself, and it migrates proximally, similar to the dynamic pathophysiological process that occurs in vivo. Since we did not compare these two techniques, it is unknown which is more realistic. Neither the Lipe cadaver model nor our manikin model has been validated in terms of the realistic nature of the simulated pulmonary edema fluid. This would be ripe for future investigation. Nonetheless, informal qualitative feedback from our learners and instructors has been positive.Resident use of our innovative dynamic pulmonary edema airway management task trainer has been incorporated into our Emergency Medicine residency and Emergency Medical Services fellowship Clinical Competency Committee discussions with respect to ACGME Milestone satisfaction. Our model addresses level 4 of Emergency Medicine Milestone 9 (General Approach to Procedures) and Milestone 10 (Airway Management). Additionally, level 4 of Emergency Medical Services Milestone 2 (Procedures Performed in the Pre-hospital Environment - Patient Care) is addressed. Incorporating successful intubation of the dynamic pulmonary edema airway management task trainer has provided the EM and EMS faculty with a more objective measure by which to score the aforementioned milestones during the mid-year and year-end Clinical Competency Committee meetings.Overall, this innovation has met our objectives well. We have added this model to our library of more complicated airway management scenarios, such as vomitus and aspiration. Our emergency medicine residency program hosts a version of the difficult airway course and includes this pulmonary edema simulation station as part of that course. The model is very portable, allowing us to transport it to different sites for use. It is inexpensive, costing less than $50 to construct. Finally, the design is readily adaptable to any standard airway training manikin that has a simulated hollow lung with a detachable connection to a conduit representing a bronchus, which has a direct connection with a simulated trachea into which an endotracheal tube can physically be passed.
Airway management, difficult airway, intubation, obstructed airway, pulmonary edema, video laryngoscopy, visual obstruction.
A Survey of Simulation Fellowship Programs Kotal, Eric R., MD; Sivertson, Ryan M., MD; Wolfe, Scott P., MD ...
The Journal of emergency medicine,
03/2015, Letnik:
48, Številka:
3
Journal Article
Recenzirano
Abstract Background A number of specialized educational programs (i.e., simulation fellowships) have been developed, but their characteristics are not well known. Objective We studied the ...characteristics of existing simulation fellowship programs. Methods Fellowships were identified and characteristics determined from public sources and direct survey. Results Seventeen fellowships were identified. The sponsoring academic unit was emergency medicine in 53%, pediatric emergency medicine in 7%, urology in 7%, emergency medicine/anesthesiology in 13%, and interdisciplinary units in 20%. Fifty-nine percent were open to emergency medicine residency graduates, and 12% were open to either anesthesia or emergency medicine graduates, or 12% to physician graduates of any specialty. One fellowship was open to pediatric emergency medicine graduates only and another specifically to surgically trained physicians. Seventy-eight percent indicated that fellows were required to work clinically as part of the fellowship, averaging 19 hours per week. Twenty-seven percent of fellowships were 1 year in length and 13% were 2 years. Common (47%) was the option of a 1- or 2-year fellowship, with those in the 2-year track earning a graduate degree or certificate. Most programs accepted a single fellow each year, and some accepted either one or two. Fellowships reported a high fill rate. Conclusions The 17 identified fellowship programs differed greatly in length, sponsoring academic unit, and prerequisites. The majority require their fellows to provide clinical service. Fellowships reported a high fill rate, suggesting substantial interest in simulation among current residents.
This paper explores the professional needs of pre-service teachers, their university tutor and in-service teachers in terms of their subject and pedagogical content knowledge. It does so through an ...examination of these professionals' participation in the learning experiences of children. The context for this participation is the children's engagement with activity in a local children's university in the UK. The study adopts a grounded theory methodology incorporating analysis of the open coding of unstructured interview transcripts. The study provides insight into practitioners' preferred modes of learning with consideration of the effectiveness of formal and non-formal contexts. There is evidence that adoption of a non-formal approach to teacher education can be beneficial if pre-service teachers can learn in the presence of practising teachers and the university tutor. The teachers learn from the practice modelled by the university tutor. The tutor benefits from developing their practice and effecting moderation of the school-university partnership.
This book is a concise and practical tutorial that shows you how to plan, set up and maintain Windows Intune and manage a group of PCs. If you are an administrator or partner who wants to plan, set ...up and maintain Windows Intune and manage a group of PCs then this book is for you . You should have a basic understanding of Windows administration, however, knowledge of Windows Intune would not be required.
This book presents step-by-step guidance through the installation and configuration process with the help of numerous screenshots. It contains many snippets of information and guidance on decision ...making. As every eventuality can't be covered, there are links to online information as well as pointers to forums the author personally interacts with to answer additional questions. This book is designed for anyone who needs to install and configure SBS 2008. You don't need to be a technical consultant who wants to tweak every setting to become an SBS success. This book will help those with a basic understanding of technology and a desire to install and use SBS 2008 quickly and continue with their business.
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