Simulation Use in Outreach Setting: A Novel Approach to Building Sustainability.

SUMMARY STATEMENT: Simulation is a well-studied teaching tool for multidisciplinary teamwork, crisis resource management, and communication skills. These attributes are essential for successful international medical missions, which include healthcare providers with different familiarities with the outreach environment and each team member's role. However, immersive simulation remains underused in similar settings. Our team designed a simulation-based curriculum that focuses on multidisciplinary teamwork and crisis resource management skills. In this commentary, we describe its implementation during high-risk cleft care outreach missions conducted by the Global Smile Foundation. We discuss the importance of a simple, feasible, and flexible platform to successfully overcome the limitations of time and resources inherent to outreach mission work while addressing the clinical and geographic needs specific to each site. We highlight challenges, including unpredictability of the outreach environment, a language barrier, and the short duration of missions. Finally, we offer a roadmap for groups involved in similar global health efforts.

Titration of Parameters in Shared Ventilation With a Portable Ventilator.

BACKGROUND: Dual-patient, single-ventilator protocols (ie, protocols to ventilate 2 patients with a single conventional ventilator) may be required in times of crisis. This study demonstrates a means to titrate peak inspiratory pressure (PIP), PEEP, and [Formula: see text] for test lungs ventilated via a dual-patient, single-ventilator circuit. METHODS: This prospective observational study was conducted using a ventilator connected to 2 test lungs. Changes in PIP, PEEP, and [Formula: see text] were made to the experimental lung, while no changes were made to the control lung. Measurements were obtained simultaneously from each test lung. PIP was titrated using 3D-printed resistors added to the inspiratory circuit. PEEP was titrated using expiratory circuit tubing with an attached manual PEEP valve. [Formula: see text] was titrated by using a splitter added to the ventilator tubing. RESULTS: PIP, PEEP, and [Formula: see text] were reliably and incrementally titratable in the experimental lung, with some notable but manageable changes in pressure and [Formula: see text] documented in the control lung during these titrations. Similar results were measured in lungs with identical and different compliances. CONCLUSIONS: Pressures and [Formula: see text] can be reliably adjusted when utilizing a dual-patient, single-ventilator circuit with simple, low-cost modifications to the circuit. This innovation could potentially be lifesaving in a resource-limited or crisis setting. Understanding the interactions of these circuits is imperative for making their use safer.

PEEP Generated by High-Flow Nasal Cannula in a Pediatric Model.

BACKGROUND: High-flow nasal cannulas (HFNC) have been increasingly used in the pediatric critical care patient population. There are different theories about the mechanism by which HFNC reduces work of breathing, including diminishing upper airway dead space by the washout of carbon dioxide. However, one of the likely primary mechanisms by which HFNC reduces work of breathing is by generating PEEP. There are limited data assessing the PEEP delivered by moderate flows (8-50 L/min) of HFNC, which are used most commonly in pediatric patients. METHODS: Pediatric upper-airway models were created with 5 different nares produced by a 3-dimensional printer and connected to a lung simulator. Age-specific flows were delivered via the 5 different setups. Pressure throughout the simulated airway was measured at HFNC flows of 6-60 L/min with 25%, 50%, and 75% air leak to simulate open-mouth breathing. RESULTS: PEEPs of 1.2-36 cm H2O were generated with HFNC flows of 6-60 L/min. In general, for each specific cannula, increasing the flow and decreasing the air leak resulted in higher levels of PEEP delivered (P < .001 and > 10% difference). Changes in lung mechanics as generated by the lung simulator to simulate different patient ages resulted in the establishment of different levels of PEEP. CONCLUSIONS: HFNCs deliver varying amounts of PEEP at the alveolar level with flows of 6-60 L/min. Increasing flow and decreasing leak resulted in the generation of greater PEEP. PEEP levels differed across cannulas and model weights at the same leak level, likely due to differences in the nasal interface between the HFNC device and the model nares.

New directions in point-of-care ultrasound at the crossroads of paediatric emergency and critical care.

PURPOSE OF REVIEW: The diagnostic capability, efficiency and versatility of point-of-care ultrasound (POCUS) have enabled its use in paediatric emergency medicine (PEM) and paediatric critical care (PICU). This review highlights the current applications of POCUS for the critically ill child across PEM and PICU to identify areas of progress and standardized practice and to elucidate areas for future research. RECENT FINDINGS: POCUS technology continues to evolve and advance bedside clinical care for critically ill children, with ongoing research extending its use for an array of clinical scenarios, including respiratory distress, trauma and dehydration. Rapidly evolving and upcoming applications include diagnosis of pneumonia and acute chest syndrome, identification of intra-abdominal injury via contrast-enhancement, guidance of resuscitation, monitoring of increased intracranial pressure and procedural guidance. SUMMARY: POCUS is an effective and burgeoning method for both rapid diagnostics and guidance for interventions and procedures. It has clinical application for a variety of conditions that span PEM and PICU settings. Formal POCUS training is needed to standardize and expand use of this valuable technology by PICU and PEM providers alike.

Utility of the urine reagent strip leucocyte esterase assay for the diagnosis of meningitis in resource-limited settings: meta-analysis.

OBJECTIVE: Diagnosis of bacterial meningitis often requires cytometry, chemistry and/or microbiologic culture capabilities. Unfortunately, laboratory resources in low-resource settings (LRS) often lack the capacity to perform these studies. We sought to determine whether the presence of white blood cells in CSF detected by commercially available urine reagent strips could aid in the diagnosis of bacterial meningitis. METHODS: We searched PubMed for studies published between 1980 and 2016 that investigated the use of urine reagent strips to identify cerebrospinal fluid (CSF) pleocytosis. We assessed studies in any language that enrolled subjects who underwent lumbar puncture and had cerebrospinal fluid testing by both standard laboratory assays and urine reagent strips. We abstracted true-positive, false-negative, false-positive and true-negative counts for each study using a diagnostic threshold of ≥10 white blood cells per microlitre for suspected bacterial meningitis and performed mixed regression modelling with random effects to estimate pooled diagnostic accuracy across studies. RESULTS: Our search returned 13 studies including 2235 participants. Urine reagent strips detected CSF pleocytosis with a pooled sensitivity of 92% (95% CI: 84-96), a pooled specificity of 98% (95% CI: 94-99) and a negative predictive value of 99% when the bacterial meningitis prevalence is 10%. CONCLUSIONS: Urine reagent strips could provide a rapid and accurate tool to detect CSF pleocytosis, which, if negative, can be used to exclude diagnosis of bacterial meningitis in settings without laboratory infrastructure. Further investigation of the diagnostic value of using protein, glucose and bacteria components of these strips is warranted.

Aflatoxin B(1)-Associated DNA Adducts Stall S Phase and Stimulate Rad51 foci in Saccharomyces cerevisiae.

AFB(1) is a potent recombinagen in budding yeast. AFB(1) exposure induces RAD51 expression and triggers Rad53 activation in yeast cells that express human CYP1A2. It was unknown, however, when and if Rad51 foci appear. Herein, we show that Rad53 activation correlates with cell-cycle delay in yeast and the subsequent formation of Rad51 foci. In contrast to cells exposed to X-rays, in which Rad51 foci appear exclusively in G2 cells, Rad51 foci in AFB(1)-exposed cells can appear as soon as cells enter S phase. Although rad51 and rad4 mutants are mildly sensitive to AFB(1), chronic exposure of the NER deficient rad4 cells to AFB(1) leads to increased lag times, while rad4 rad51 double mutants exhibit synergistic sensitivity and do not grow when exposed to 50 µM AFB(1). We suggest RAD51 functions to facilitate DNA replication after replication fork stalling or collapse in AFB(1)-exposed cells.