Point-of-Care Ultrasound Curriculum for Internal Medicine Residents During the COVID-19 Era: A Pilot Study.

INTRODUCTION: The use of point-of-care ultrasound (POCUS) by internal medicine physicians and residents is increasing. We present the results of a pilot study to implement a POCUS curriculum that was interrupted by the Coronavirus Disease 2019 (COVID-19) pandemic at an internal medicine residency program at a community hospital. The purpose of this study is to inquire about the attitude and interest of our medical residents in POCUS. Additionally, we also plan to examine whether a curriculum that lacks some practical aspects due to COVID-19 restrictions can still improve the residents' confidence in recognizing common POCUS applications and improve image interpretation skills. METHODS: We conducted a prospective, pre-, and post-curriculum pilot study to examine the POCUS skills of categorical internal medicine residents in Post-Graduate Years (PGY) 1 through 3 at a community hospital. The two POCUS-related skills examined were self-reported confidence level in recognizing certain POCUS examination findings and POCUS image interpretation skills. Due to social distancing guidelines, we were unable to host hands-on sessions as originally planned, but residents did receive lectures via Zoom regarding POCUS training and also organ-specific diagnoses. Three primary outcomes were measured: (1) baseline difference in confidence level between interns (PGY-1) and senior residents (PGY-2 and 3) at the beginning of the curriculum, (2) improvement in POCUS confidence level before and after the curriculum considering interns and senior residents all together and also separately, and (3) improvement in image interpretation skills before and after the curriculum. RESULTS: Of 41 residents, 23 participants completed the pre- and post-curriculum test. Of the 23 participants, 12 participants were interns, and 11 were senior residents. Overall, interns showed a statistically significant improvement in the confidence level in almost all diagnoses except pulmonary embolism (p = 0.084). For image interpretation tests, significant improvement was found only in recognizing the two signs of pneumothorax: pleural line absent sliding (X2 = 4.00, p < 0.05) and the barcode sign (X2 = 6.13, p < 0.05). The pre-curriculum confidence level questionnaire included a question about residents' interest in learning POCUS during residency. It showed that the vast majority of residents (21 residents [91%]) are either extremely or mostly interested in POCUS. Most of our residents (18 [78%]) did not have formal exposure to POCUS during medical school. CONCLUSION: A POCUS curriculum that lacks hands-on workshops and longitudinal image saving and reviewing due to the COVID-19 pandemic restrictions did not improve the residents' image interpretation skills, although the confidence levels of the interns statistically improved. After the pandemic, we plan to implement the full curriculum and examine whether it will improve the residents' image acquisition and interpretation skills.

Scenarios of intermittent E. coli contamination from sewer overflows to shellfish growing waters: The Dart Estuary case study.

Sewage overflows (SOs) and Combined Sewer Overflows (CSOs) significantly contribute to the bacterial contamination of coastal waters, which is of especial concern for aquaculture, a growing industry worldwide. Hydrodynamic and water quality models were used to investigate impacts of CSO discharge frequency and duration, river discharge and tides on Escherichia coli levels at shellfish farming sites in the Dart Estuary (UK), being the employed methodology generally applicable. High E. coli contamination occurred during neap tides and high river discharges due to higher retention and lower bacterial decay. Synchronicity of CSO spills affected the duration of the pollution episodes rather than peak concentrations, more influenced by discharges of the neighbouring CSOs. During peak discharges, E. coli concentrations could be 10 times higher than during average flows. CSO spills were more frequent when rainfall was >20 mm. Model outputs combined with rainfall forecasts can indicate microbiological contamination risk in the aquaculture sites.

Increased dispersion of oil from a deep water seabed release by energetic mesoscale eddies.

Hydrodynamics play a critical role in determining the trajectory of an oil spill. Currents, stratification and mesoscale processes all contribute to how a spill behaves. Using an industry­leading oil spill model, we compare forecasts of oil dispersion when forced with two different hydrodynamic models of the North-West European Shelf (7 km and 1.5 km horizontal resolution). This demonstrates how the trajectory of a deep water (>1000 m) release in the central Faroe-Shetland Channel is influenced by explicitly resolving mesoscale processes. The finer resolution hydrodynamic model dramatically enhances the horizontal dispersion of oil and transports pollutant further afield. This is a consequence of higher mesoscale variability. Stratification influences the depth of subsurface plume trapping and subsequently the far-field transport of oil. These results demonstrate that the choice of hydrodynamic model resolution is crucial when designing particle tracking or tracer release experiments.

Modelling pollution dispersal around Solomon Islands and Vanuatu.

To assess potential dispersion of pollutants around Honiara, Solomon Islands, and Port Vila, Vanuatu, 3D ocean circulation models were developed using Telemac-3D. A series of scenarios then explore the vulnerability of the system and test potential control measures. Results show that high coastal concentrations are most likely during the wet season, with increased volumes of discharge as well as favourable wind speed and direction. Buoyant plumes flow along the coastline, and high concentrations build up in enclosed bays. Control measures tested focus on consolidating existing outflows at depth off-shore. This results in an overall reduction of surface concentrations along the coastline. However, the reduction is dependent on the depth, off-shore positioning, and volume of outflow. With increased concentrations then found at depth, the subsequent impact on off-shore and benthic ecosystems would also need to be considered.

Interleukin-12 and -23 blockade mitigates elastase-induced abdominal aortic aneurysm.

Macrophages play an important role in the inflammatory process that contributes to the development of abdominal aortic aneurysm (AAA). Studies of human and mouse AAA tissue reveal expanded populations of macrophages producing an abundance of pro-inflammatory cytokines, including TNF-α, IL-12p40 and high level of metalloprotease 9 (MMP-9) at the late stages of disease. Herein, we show that blockade of IL-12p40 in the early phase of aneurysm development suppresses macrophage expansion, inflammatory cytokine and MMP-9 production and mitigates AAA development. Since IL-12 and IL-23 are related cytokines that share the common p40 subunit, we also evaluate the effect of direct IL-23 blockade on the development of AAA. Specific IL-23p19 blockade prevents AAA progression with the same efficiency as IL-12p40 antagonism, suggesting that the efficacy of anti-IL-12p40 treatment may reflect IL-23 blockade. IL-12p40 and IL-23p19 are also abundantly expressed in human AAA tissue. Our findings have potential translational value since IL-12p40 and IL-23p19 antagonists already exist as FDA-approved therapeutics for various chronic inflammatory conditions.

Anti-JNK2 peptide-siRNA nanostructures improve plaque endothelium and reduce thrombotic risk in atherosclerotic mice.

BACKGROUND: A direct and independent role of inflammation in atherothrombosis was recently highlighted by the Canakinumab Antiinflammatory Thrombosis Outcome Study (CANTOS) trial, showing the benefit of inhibiting signaling molecules, eg, interleukins. Accordingly, we sought to devise a flexible platform for preventing the inflammatory drivers at their source to preserve plaque endothelium and mitigate procoagulant risk. METHODS: p5RHH-siRNA nanoparticles were formulated through self-assembly processes. The therapeutic efficacy of p5RHH-JNK2 siRNA nanoparticles was evaluated both in vitro and in vivo. RESULTS: Because JNK2 is critical to macrophage uptake of oxidized lipids through scavenger receptors that engender expression of myriad inflammatory molecules, we designed an RNA-silencing approach based on peptide-siRNA nanoparticles (p5RHH-siRNA) that localize to atherosclerotic plaques exhibiting disrupted endothelial barriers to achieve control of JNK2 expression by macrophages. After seven doses of p5RHH-JNK2 siRNA nanoparticles over 3.5 weeks in ApoE-/- mice on a Western diet, both JNK2 mRNA and protein levels were significantly decreased by 26% (P=0.044) and 42% (P=0.042), respectively. Plaque-macrophage populations were markedly depleted and NFκB and STAT3-signaling pathways inhibited by 47% (P<0.001) and 46% (P=0.004), respectively. Endothelial barrier integrity was restored (2.6-fold reduced permeability to circulating 200 nm nanoparticles in vivo, P=0.003) and thrombotic risk attenuated (200% increased clotting times to carotid artery injury, P=0.02), despite blood-cholesterol levels persistently exceeding 1,000 mg/dL. No adaptive or innate immunoresponses toward the nanoparticles were observed, and blood tests after the completion of treatment confirmed the largely nontoxic nature of this approach. CONCLUSION: The ability to formulate these nanostructures rapidly and easily interchange or multiplex their oligonucleotide content represents a promising approach for controlling deleterious signaling events locally in advanced atherosclerosis.

The effects of functional limitations on soldier common tasks.

This paper describes the findings associated with the ability of an individual to perform the United States Army's Common Soldier Tasks of: "Maintaining an M16-Series Rifle" , "Protect Yourself from Chemical, Biological, Radiological, and Nuclear (CBRN) Injury or Contamination with Mission-Oriented Protective Posture (MOPP) Gear", and "Protect Yourself from Chemical and Biological (CB) Contamination Using Your Assigned Protective Mask." The analysis was conducted using data compiled from videos of a Soldier performing the given tasks at Walter Reed Army Medical Center. The findings reflect the opinions of researchers in identifying potential elements, which impose abnormal, irregular, and/or extraneous effort when performing the tasks as outlined in STP-21-1-SMCT - Soldier's Manual of Common Tasks: Skill Level I.