Disaster Preparedness Training for Emergency Medicine Residents Using a Tabletop Exercise.

Introduction: Emergency medicine (EM) physicians serve at the frontline of disasters in our communities. The 2016 Model of Clinical Practice according to the American Board of EM identifies disaster management as an integral task of EM physicians. We described a low-cost and feasible tabletop exercise to implement such training for EM residents. Methods: The exercise took place during 2 hours of resident didactic time. A lecture introduced the incident command system (ICS) and triage concepts, followed by a tabletop scenario with a map of a disaster scene or emergency department. Facilitators presented situational prompts of tasks for residents to address during the exercise. These exposed residents to challenges in disaster scenarios, such as surge and limited resources. The exercise concluded with a debrief and short lecture reviewing scenario-specific topics and challenges. Residents completed an online pre- and postexercise assessment, evaluating knowledge and perceptions of disaster scenario management. Results: Eighteen residents participated in this exercise. The response rates to the pre- and postsurvey were 76% and 72% respectively. Using a Mann Whitney U test, no statistically significant difference was demonstrated on the medical knowledge component of the survey. There was, however, a statistically significant increase in perceived confidence of the residents' ability to manage disaster incidents. Discussion: We developed a simple exercise that is an easily adaptable and practical option for introduction to disaster preparedness training. These concepts are difficult to teach and assess among learners, however it remains an important component of education for EM physicians-in-training.

Caring for Infectious Disease in the Prehospital Setting: A Qualitative Analysis of EMS Providers Experiences and Suggestions for Improvement.

Objective: The purpose of this study was to examine the attitudes and behaviors of emergency medical technicians (EMTs) and Paramedics when faced with the decision to care for patients with suspected Ebola Virus Disease (EVD) and to illicit suggestions for improvement of infectious disease (ID) preparedness. Methods: A convenience sample of 22 EMT/Paramedics were recruited from an emergency department at one of the designated Ebola centers. Each provider participated in one of three on-site focus groups. Participants answered questions about how they gained their knowledge, felt about caring for EVD patients, made decisions about caring for EVD patients, and suggestions for improvement of ID preparedness. Focus groups were recorded, transcribed, and coded using inductive content analysis. Results: Analysis revealed five prominent themes: reactions to scare, education/training, danger, decision making, and suggestions for future responses. Overall, first responders were excited to be a part of the response to EVD. They were more comfortable caring for EVD patients if they received adequate education and transparency from the administration. This resulted in a decreased perceived danger of the disease and decreased hesitancy when caring for EVD patients. However, those that expressed the most hesitancy also expressed the most emotional distress. Suggestions for improvement of ID preparedness included continuing education, tiered training models, peer training models, collaboration between emergency medical services (EMS) systems, better communication between departments, and the development of an infectious disease response team. Conclusions: Although first responders were excited to be a part of the response to EVD, this did not come without hesitation and emotional distress. Some of these concerns may be mitigated by first providing a clear definition of "duty to care," followed by interventions such as the development of clear and consistent ID preparedness training and interventions that address the emotional distress experienced by these providers.

Intra-articular treatment of knee osteoarthritis: from anti-inflammatories to products of regenerative medicine.

OBJECTIVES: Knee osteoarthritis (OA) is a debilitating condition that may ultimately require total knee arthroplasty (TKA). Non-operative treatments are bracing, oral analgesics, physical therapy, and intra-articular knee injection (IAKI). The objective of this paper is to provide a systematic literature review regarding intra-articular treatment of knee OA and insight into promising new products of regenerative medicine that may eventually have a substantial effect on treatment. METHODS: A literature search was executed using Medline, Cochrane, and Embase with keywords "knee osteoarthritis" and "injection." Specifically, 45 articles that discussed intra-articular knee injection using corticosteroids, hyaluronic acid, analgesics, local anesthetics, and newer products of regenerative medicine, such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSC), were analyzed. Of these, eleven were level 1, three were level 2, twelve were level 3, two were level 4, and seventeen were level 5 evidence. Papers included animal models. RESULTS: Local anesthetics have potential side effects and may only be effective for a few hours. Morphine and ketorolac may provide significant pain relief for 24 hours. Corticosteroids may give patients weeks to months of effective analgesia, but complications may occur, such as systemic hyperglycemia, septic arthritis, and joint degradation . Hyaluronic acid is a natural component of synovial fluid, but efficacy with respect to analgesia is controversial. Platelet-rich plasma formulations, autologous conditioned serum, autologous protein solution, and mesenchymal stem cell injections contain anti-inflammatory molecules and have been proposed to attenuate joint destruction or potentially remodel the joint. CONCLUSIONS: Currently, knee OA treatment does not address the progressively inflammatory environment of the joint. More investigation is needed regarding products of regenerative medicine, but they may ultimately have profound implications in the way knee OA is managed.

Successful treatment of stent knot in the proximal ureter using ureteroscopy and holmium laser.

Knotted ureteral stent is rare yet tedious complication that might represent a treatment challenge to the endourologist. Only twelve cases of knotted stent have been reported. Different management options have been reported, including simple traction, ureteroscopy, percutaneous removal, and open surgery. In this paper, we present the successful untying of the knot using ureteroscopy with holmium laser.

Perinatal factors, growth and development, and osteosarcoma risk.

Osteosarcoma incidence patterns suggest an aetiologic role for perinatal factors, and growth and development. Osteosarcoma patients (n = 158) and controls with benign orthopaedic conditions (n = 141) under age 40 were recruited from US orthopaedic surgery departments. Exposures were ascertained by interview, birth, and growth records. Age- and sex-adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. Current height and age- and sex-specific height percentiles were not associated with osteosarcoma risk. Male cases, however, appeared to have an earlier adolescent growth period, and earlier attainment of final height (OR = 7.1; 95% CI = 1.6-50 for <19 vs 19+ years), whereas earlier puberty appeared protective with ORs of 0.41 (95% CI 0.18-0.89) and 0.68 (95% CI 0.31-1.5) for developing facial and pubic hair, respectively. High birth weight was associated with an elevated osteosarcoma risk (OR = 3.9; CI = 1.7-10 for 4000 g vs 3000-3500 g), although there was no trend in risk with increasing weight. These data provide some evidence that osteosarcoma is related to size at birth and in early adolescence, while earlier puberty in male subjects may be protective.

The lytB gene of Escherichia coli is essential and specifies a product needed for isoprenoid biosynthesis.

LytB and GcpE, because they are codistributed with other pathway enzymes, have been predicted to catalyze unknown steps in the nonmevalonate pathway for isoprenoid biosynthesis. We constructed a conditional Escherichia coli lytB mutant and found that LytB is essential for survival and that depletion of LytB results in cell lysis, which is consistent with a role for this protein in isoprenoid biosynthesis. Alcohols which can be converted to pathway intermediates beyond the hypothesized LytB step(s) support limited growth of E. coli lytB mutants. An informatic analysis of protein structure suggested that GcpE is a globular protein of the TIM barrel class and that LytB is also a globular protein. Possible biochemical roles for LytB and GcpE are suggested.

A single-ring mitochondrial chaperonin (Hsp60-Hsp10) can substitute for GroEL-GroES in vivo.

Chaperonins participate in the facilitated folding of a variety of proteins in vivo. To see whether the same spectrum of target proteins can be productively folded by the double-ring prokaryotic chaperonin GroEL-GroES and its single-ring human mitochondrial homolog, Hsp60-Hsp10, we expressed the latter in an Escherichia coli strain engineered so that the groE operon is under strict regulatory control. We found that expression of Hsp60-Hsp10 restores viability to cells that no longer express GroEL-GroES, formally demonstrating that Hsp60-Hsp10 can carry out all essential in vivo functions of GroEL-GroES.

Only the N-terminal domain of FtsK functions in cell division.

Deletion of ftsK results in the inhibition of cell division, but this inhibition can be reversed by a plasmid carrying only the first approximately 17% of ftsK. The division block can be suppressed in most mutants by deletion of dacA, which codes for the D-alanine:D-alanine carboxypeptidase PBP5, or in all mutants by overexpression of ftsN. Overexpression of ftsK inhibits cell division and the formation of FtsZ rings. This division block is not due to the induction of either the SOS or the heat shock regulons.

The gender difference on the Mental Rotations test is not due to performance factors.

Men score higher than women on the Mental Rotations test (MRT), and the magnitude of this gender difference is the largest of that on any spatial test. Goldstein, Haldane, and Mitchell (1990) reported finding that the gender difference on the MRT disappears when "performance factors" are controlled--specifically, when subjects are allowed sufficient time to attempt all items on the test or when a scoring procedure that controls for the number of items attempted is used. The present experiment also explored whether eliminating these performance factors results in a disappearance of the gender difference on the test. Male and female college students were allowed a short time period or unlimited time on the MRT. The tests were scored according to three different procedures. The results showed no evidence that the gender difference on the MRT was affected by the scoring method or the time limit. Regardless of the scoring procedure, men scored higher than women, and the magnitude of the gender difference persisted undiminished when subjects completed all items on the test. Thus there was no evidence that performance factors produced the gender difference on the MRT. These results are consistent with the results of other investigators who have attempted to replicate Goldstein et al.'s findings.

Regulation of plasmid R1 replication: PcnB and RNase E expedite the decay of the antisense RNA, CopA.

The replication frequency of plasmid R1 is controlled by an unstable antisense RNA, CopA, which, by binding to its complementary target, blocks translation of the replication rate-limiting protein RepA. Since the degree of inhibition is directly correlated with the intracellular concentration of CopA, factors affecting CopA turnover can also alter plasmid copy number. We show here that PcnB (PAPl-a poly(A)polymerase of Escherichia coli) is such a factor. Previous studies have shown that the copy number of ColE1 is decreased in pcnB mutant strains because the stability of the RNase E processed form of RNAI, the antisense RNA regulator of ColE1 replication, is increased. We find that, analogously, the twofold reduction in R1 copy number caused by a pcnB lesion is associated with a corresponding increase in the stability of the RNase E-generated 3' cleavage product of CopA. These results suggest that CopA decay is initiated by RNase E cleavage and that PcnB is involved in the subsequent rapid decay of the 3' CopA stem-loop segment. We also find that, as predicted, under conditions in which CopA synthesis is unaffected, pcnB mutation reduces RepA translation and increases CopA stability to the same extent.

Autoregulation of the Escherichia coli replication initiator protein, DnaA, is indirect.

The expression of dnaA is autoregulated, in that transcription of the gene increases when DnaA is inactivated (and initiation of replication prevented) and decreases when DnaA is supplied in excess. However, the inactivation of DnaA does not necessarily lead to increased DnaA production, as dnaA(Ts; temperature sensitive) strains which are integratively suppressed by derivatives of the plasmid R1 do not show temperature-induced derepression. Several possible explanations for this unanticipated behaviour were considered and ruled out. We suggest here that the completion of a critical step in initiation may prevent dnaA derepression: although DnaA would be required to complete this step at oriC, DnaA(Ts) would be sufficient at the R1 origin. Autoregulation of dnaA has been attributed to the binding of DnaA at a consensus binding site in the dnaA promoter region. We show here, using reporter systems, that this DnaA-binding site is not required for the autoregulatory response. We find, further, that replacement of the chromosomal dnaA gene with one containing a mutated binding site causes no demonstrable phenotypic change: cells with the mutant gene show no disadvantage in competition with dnaA+ cells.

The coupling between ftsZ transcription and initiation of DNA replication is not mediated by the DnaA-boxes upstream of ftsZ or by DnaA.

The DnaA protein of Escherichia coli is a multi-functional protein which, In addition to promoting initiation of replication, can regulate the initiation or termination of transcription of a variety of genes. It acts by binding to DNA at a defined sequence, termed a DnaA-box. Three candidate DnaA-boxes which occur within the essential cell-division genes, ftsQ and ftsA, have been hypothesized to mediate the response of the downstream ftsZ gene to intracellular levels of DnaA, and thus to couple the processes of initiation and cell division. We show here that, although transcription from promoters upstream of ftsZ is increased when initiation of chromosome replication is blocked by DnaA inactivation, this response is not mediated by the DnaA-boxes near these promoters, nor is it specific to DnaA. We show, furthermore, that mutational inactivation of the putative DnaA-binding sites in the fts region of the chromosome does not lead to impaired growth or reduced survival of cells.

The tail of a chaperonin: the C-terminal region of Escherichia coli GroEL protein.

The active form of the HSP60 molecular chaperone of Escherichia coli, GroEL, is a pair of seven-membered rings. We have used site-directed mutagenesis to construct forms of the 547-amino-acid monomer truncated at the C-terminus. We show here that forms that are 520 amino acids long or longer are close to being fully functional. Removing one further amino acid, however, results in a protein, GroEL519, which retains little function. This truncated form is metabolically stable but is not recovered from the cell in particle form. When synthesized at high levels, it prevents the normal assembly of GroEL547 present in the same cell. When synthesized at low levels, it can be included, probably at low molar ratios, in particles formed by assembly-competent forms of GroEL. This can be seen as partial complementation of the temperature-sensitive mutant groEL44. We conclude that amino acid 520 is crucial for particle assembly. GroEL516 has in vivo properties similar to those of GroEL516 has in vivo properties similar to those of GroEL519, but the still shorter form, GroEL504, appears to be inactive.

Building TQM into nursing management.

Total quality management (TQM) is a management philosophy that addresses problems currently faced by health care, specifically reducing costs while improving quality of services. As hospital administrators embrace this new management style, nurse executives and managers will be challenged to implement TQM. Building TQM into nursing management will improve quality and reduce costs while meeting the needs of health care customers.

Psychosocial performance of family physicians.

This study surveyed 30 residency-trained family physicians all currently in practice to determine the nature of their psychosocial interactions with patients. In general, respondents were satisfied with the quality of their psychosocial training in residency and generally evaluated their competency on a range of psychosocial skills as adequate to excellent. Physician psychosocial competency was most strongly related to residency, but not to postresidency, behavioral science training or to psychosocial screening practices. Frequency of performing psychosocial behaviors was also related to behavioral science training, as well as to length of time in practice. Neither frequency nor self-perceived competency related to physician age, gender, patient volume, or type of practice.

PcnB is required for the rapid degradation of RNAI, the antisense RNA that controls the copy number of ColE1-related plasmids.

The replication of ColE1-related plasmids is controlled by an unstable antisense RNA, RNAI, which can interfere with the successful processing of the RNAII primer of replication. We show here that a host protein, PcnB, supports replication by promoting the decay of RNAI. In bacterial strains deleted for PcnB a stable, active form of RNAI, RNAI*, which appears to be identical to the product of 5'-end processing by RNAase E, accumulates. This leads to a reduction in plasmid copy number. We show, using a GST-PcnB fusion protein, that PcnB does not interfere with RNAI/RNAII binding in vitro. The fusion protein, like PcnB, has polyadenylating activity and is able to polyadenylate RNAI (and also another antisense RNA, CopA) in vitro.