Pilot Testing of Simulation in the Evaluation of a Novel, Rapidly Deployable Electronic Health Record for use in Disaster Intensive Care.

OBJECTIVES: The SARS-CoV-2 pandemic has highlighted the need for rapid creation and management of ICU field hospitals with effective remote monitoring which is dependent on the rapid deployment and integration of an Electronic Health Record (EHR). We describe the use of simulation to evaluate a rapidly scalable hub-and-spoke model for EHR deployment and monitoring using asynchronous training. METHODS: We adapted existing commercial EHR products to serve as the point of entry from a simulated hospital and a separate system for tele-ICU support and monitoring of the interfaced data. To train our users we created a modular video-based curriculum to facilitate asynchronous training. Effectiveness of the curriculum was assessed through completion of common ICU documentation tasks in a high-fidelity simulation. Additional endpoints include assessment of EHR navigation, user satisfaction (Net Promoter), system usability (System Usability Scale-SUS), and cognitive load (NASA-TLX). RESULTS: A total of 5 participants achieved a 100% task completion on all domains except ventilator data (91%). Systems demonstrated high degrees of satisfaction (Net Promoter = 65.2), acceptable usability (SUS = 66.5), and acceptable cognitive load (NASA-TLX = 41.5); with higher levels of cognitive load correlating with the number of screens employed. CONCLUSIONS: Clinical usability of a comprehensive and rapidly deployable EHR was acceptable in an intensive care simulation which was preceded by < 1 hour of video education about the EHR. This model should be considered in plans for integrated clinical response with remote and accessory facilities.

A Training Program for Real-Time Ultrasound-Guided Catheterization of the Subclavian Vein.

PURPOSE: To develop and implement a comprehensive program to train providers to place subclavian central venous catheters (CVCs) using real-time ultrasound guidance. STUDY DESIGN: Simulation-based prospective study at an academic medical center. Of 228 anesthesia providers and intensivists eligible to participate, 106 participants voluntarily enrolled. The training program consisted of a didactic module, hands-on instruction and practice using a CVC simulator and a standardized patient. The success of the program was measured by pre and post knowledge tests and direct observation during the hands-on sessions. RESULTS: Of 106 participants who enrolled, 70 successfully completed the program. Out of 20 possible procedure steps, an average of 17.8 ± 2.9 were correctly performed in the simulated environment. The average time to needle insertion, defined by positive aspiration of stained saline, was 3.35 ± 3.02 min and the average time to wire insertion with ultrasound confirmation was 3.85 ± 3.12 min. CONCLUSIONS: Participants learned how to successfully perform ultrasound-guided catheterization of the subclavian vein. Since ultrasound-guided subclavian CVC placement is a useful clinical skill that many practitioners are unfamiliar with, increasing competence and comfort with this procedure is an important goal. Other centers could consider adopting an approach similar to ours to train their providers to perform this technique.

CXC chemokine receptor 4 signaling upon co-activation with stromal cell-derived factor-1α and ubiquitin.

Recently, we reported that extracellular ubiquitin functions as another agonist of CXC chemokine receptor (CXCR)4. Whereas the cognate CXCR4 ligand, stromal cell-derived factor (SDF)-1α, is also a CXCR7 agonist, ubiquitin does not bind to CXCR7. Because both ligands are present in the extracellular environment, co-activation of CXCR4 appears to be physiologically relevant. CXCR4 mediated effects of ubiquitin, however, are not well understood and consequences of co-activation of CXCR4 with both ligands are unknown. Utilizing proximity ligation assays and flow cytometry, we detected CXCR4, but not CXCR7, on the cell surface of THP-1 cells, which suggests that confounding effects of CXCR7 are unlikely. Time course and magnitude of reduction of cell surface CXCR4 expression were comparable after stimulation of THP-1 cells with both ligands. SDF-1α was more efficacious than ubiquitin to mobilize Ca(2+). Co-stimulation of THP-1 cells with both ligands resulted in synergistic effects on Ca(2+) fluxes at suboptimal ligand concentrations. Homologous desensitization of Ca(2+) fluxes was detectable with both ligands. SDF-1α pre-stimulation desensitized ubiquitin induced Ca(2+) fluxes, but not vice versa. Effects of SDF-1α and ubiquitin on cAMP levels, Akt and ERK1/2 phosphorylation and chemotactic responses were additive. The chemotactic activities of ubiquitin and SDF-1α were sensitive to AMD3100, pertussis toxin, U73122, LY94002 and U0126. These data suggest that CXCR4 activation with SDF-1α and ubiquitin results in partially synergistic effects on cellular signaling events and in differential effects on receptor desensitization. The ligand ratio that is present in the extracellular environment may contribute to the regulation of CXCR4 mediated functions.

Evaluation of exhibits from a murder case using the lead isotope method and scanning electron microscopy.

We have used a combination of lead isotopes and scanning electron microscopy to determine the relationships between different exhibits in a murder case. Samples involved lead projectiles removed from the deceased's head and a pillow, lead-rich scrapings and particles (gunshot residues) from spent cartridges and a silencer, and particles from a pillowcase. The lead projectiles had the same isotopic composition. with the lead being derived from the same dominantly geologically old source(s). The lead smear from the silencer had the same isotopic composition as the projectiles, and the lead was probably from the same source. The particles from the spent cartridges had varying elemental compositions ranging from PbO to PbCuZn +/- Ba with or without Si and are consistent with derivation from the primer. The lead isotopic compositions of the particles from the spent cartridges show some variations, but these are markedly different from those of the projectiles, indicating lead from a mixture of geologically old and geologically young lead. The particles from the pillowcase were extremely small (usually <50 microm size) and showed varying isotopic compositions, some consistent with the gunshot residue from the cartridges. As the exhibits had been handled extensively prior to the present investigation, including some being sent to North America, there is a high likelihood that handling was not done in clean room environments and may have been contaminated. In this instance, as we were concerned about contamination, especially of the pillowcase, we felt contamination negated use of the results for assistance in proving the innocence or guilt of the accused. A combination of high-precision lead isotope measurements with scanning electron microscopy provides a powerful tool for forensic investigations if precautions are taken in handling the exhibits.