Effectiveness of the Introduction to Critical Care in Emergency Medicine Curriculum's Implementation Among Trainees Interested in Intensive Care.

BACKGROUND: Emergency physicians and trainees provide the initial care for critically ill patients. In times of emergency department boarding, this care may extend beyond the first few hours. To meet the needs of this population, a standardized novel critical care curriculum targeting third- and fourth-year medical students was developed. OBJECTIVES: We hypothesized that the institution of such a curriculum is feasible and will provide an increased understanding of the underlying critical care principles within this learner population. METHODS: We developed a 2-month-long critical care curriculum (February-April) and carried out the course twice from 2022-2023. Our pilot study deployed this curriculum to medical students interested in critical care through the American Academy of Emergency Medicine/Resident and Student Association. The primary outcome included was the overall composite score comparison of the pre- and post-course evaluations, with a higher score indicating that the student improved their comprehension. Secondary outcomes included the individual factors of the pre- and post-course surveys. RESULTS: Fifty-one trainees completed the pilot course, including 11/51 (21.6%) third-year medical students and 40/51 (78.4%) fourth-year medical students. Overall, 39 had "no experience" in critical care and 12 indicated that they had "previous experience." The students' baseline pre-course from the pooled 2022 and 2023 Introduction to Critical Care in Emergency Medicine (ICCEM) curriculum data was 3 (interquartile range 4-3) and their post-course score was 9 (interquartile range 9-9), p-value 0.015 for the 51/54 students who completed the course. CONCLUSIONS: The novel curriculum was found to be effective during its implementation in third- and fourth-year medical students. As such, it indicated that a critical care fundamentals course improves confidence in these topics for students with and without prior experience. Further work is necessary to understand the generalizability and knowledge retention of the proposed pilot curriculum.

Pulmonary function in patients with transfusion-dependent thalassemia and its associations with iron overload.

In patients with transfusion-dependent thalassemia (TDT), pulmonary function impairment has been reported but data are conflicting. Moreover, it remains unclear whether pulmonary dysfunction is associated with iron overload. This study aimed to evaluate the pulmonary function in patients with TDT and to investigate the associations between pulmonary dysfunction and iron overload. It was a retrospective observational study. 101 patients with TDT were recruited for lung function tests. The most recent ferritin levels (pmol/L) and the magnetic resonance imaging (MRI) measurements of the myocardial and liver iron status, as measured by heart and liver T2* relaxation time (millisecond, ms) respectively, were retrieved from the computerized medical records. Only data within 12 months from the lung function measurement were included in the analysis. The serum ferritin, and the cardiac and liver T2* relaxation time were the surrogate indexes of body iron content. The threshold of abnormality in lung function was defined as under 80% of the predicted value. 101 subjects were recruited with a mean age of 25.1 years (standard deviation (SD) 7.9 years). Thirty-eight (38%) and five (5%) demonstrated restrictive and obstructive lung function deficits, respectively. A weak correlation of FVC %Predicted and TLC %Predicted with MRI myocardial T2* relaxation time (rho = 0.32, p = 0.03 and rho = 0.33, p = 0.03 respectively) was observed. By logistic regression, MRI cardiac T2* relaxation time was negatively associated with restrictive lung function deficit (B - 0.06; SE 0.03; Odds ratio 0.94; 95% confidence interval (CI) 0.89-0.99; p = 0.023) after adjusting for age, sex and body mass index. Restrictive pulmonary function deficit was commonly observed in patients with TDT, and the severity potentially correlates with myocardial iron content. Monitoring of lung function in this group of patients, particularly for those with iron overload, is important.

Heavy metal extraction from an artificially contaminated sandy soil under EDDS deficiency: significance of humic acid and chelant mixture.

Biodegradable EDDS ([S,S]-ethylenediaminedisuccinic acid) has been suggested for enhancing heavy metal extraction from contaminated soils. Recent studies showed that Zn and Pb are less effectively extracted due to metal exchange and re-adsorption onto the soil surfaces, especially for EDDS-deficiency conditions. This study therefore investigated the influence of dissolved organic matter and the co-presence of EDTA (ethylene-diamine-tetraacetic acid) on metal extraction from an artificially contaminated sandy soil under deficient amount of chelants in batch kinetics experiments. The addition of 10 and 20mgL(-1) of humic acid as dissolved organic matter (DOC) suppressed metal extraction by EDDS, probably resulting from the competition of adsorbed humic acid for heavy metals and adsorption of metal-humate complexes onto the soil surfaces. The effects were most significant for Pb because of greater extent of metal exchange of PbEDDS and high affinity towards organic matter. Thus, one should be cautious when there is a high content of organic matter in soils or groundwater. On the other hand, compared to individual additions of EDDS or EDTA, the equimolar EDDS and EDTA mixture exhibited significantly higher Pb extraction without notable Pb re-adsorption. The synergistic performance of the EDDS and EDTA mixture probably resulted from the change of chemical speciation and thus less competition among Cu, Zn and Pb for each chelant. These findings suggest further investigation into an optimum chemistry of the chelant mixture taking into account the effectiveness and associated environmental impact.

Influence of EDDS-to-metal molar ratio, solution pH, and soil-to-solution ratio on metal extraction under EDDS deficiency.

In situ biodegradable EDDS ([S,S]-stereoisomer of ethylenediaminedisuccinic acid) applications at low concentration may present conditions where applied EDDS is insufficient relative to sorbed metals in soils. This study investigated the influence of EDDS-to-metal molar ratios (MR), solution pH and soil-to-solution ratio on metal extraction under EDDS deficiency (i.e., MR<1). Batch kinetics experiments showed that Pb and Zn extraction exhibited different kinetic behaviors at MR 0.35-0.75, while Cu extraction was comparable. At MR 0.75 or below, newly extracted Pb was re-adsorbed onto the soil surfaces. Similar re-adsorption phenomenon, to a lower extent, was observed for newly extracted Zn at MR 0.5 or below, whereas this appeared to be marginal at MR 0.75, reflecting Zn extraction was less affected by EDDS deficiency than Pb extraction. Moreover, Pb extraction at an alkaline condition was preferable under EDDS deficiency because at MR 0.5 it was 30% higher at pH 8 and 9 than pH 5.5 and 7. The influence of varying soil-to-solution ratios (1:50-1:5) at MR 0.5 was marginal compared with that of MR and solution pH. These findings indicated that Pb extraction by deficient EDDS would be more difficult to accomplish compared to Cu and Zn extraction.

Obstructive sleep apnea is independently associated with insulin resistance.

Epidemiological studies have implicated obstructive sleep apnea (OSA) as an independent comorbid factor in cardiovascular and cerebrovascular diseases. It is postulated that recurrent episodes of occlusion of upper airways during sleep result in pathophysiological changes that may predispose to vascular diseases. Insulin resistance is a known risk factor for atherosclerosis, and we postulate that OSA represents a stress that promotes insulin resistance, hence atherogenesis. This study investigated the relationship between sleep-disordered breathing and insulin resistance, indicated by fasting serum insulin level and insulin resistance index based on the homeostasis model assessment method (HOMA-IR). A total of 270 consecutive subjects (197 male) who were referred for polysomnography and who did not have known diabetes mellitus were included, and 185 were documented to have OSA defined as an apnea-hypopnea index (AHI) > or =5. OSA subjects were more insulin resistant, as indicated by higher levels of fasting serum insulin (p = 0.001) and HOMA-IR (p < 0.001); they were also older and more obese. Stepwise multiple linear regression analysis showed that obesity was the major determinant of insulin resistance but sleep-disordered breathing parameters (AHI and minimum oxygen saturation) were also independent determinants of insulin resistance (fasting insulin: AHI, p = 0.02, minimum O(2), p = 0.041; HOMA-IR: AHI, p = 0.044, minimum O(2), p = 0.022); this association between OSA and insulin resistance was seen in both obese and nonobese subjects. Each additional apnea or hypopnea per sleep hour increased the fasting insulin level and HOMA-IR by about 0.5%. Further analysis of the relationship of insulin resistance and hypertension confirmed that insulin resistance was a significant factor for hypertension in this cohort. Our findings suggest that OSA is independently associated with insulin resistance, and its role in the atherogenic potential of sleep disordered breathing is worthy of further exploration.

Analgesics. Opioids, adjuvants, and others.

The purpose of this article is to summarize the main categories of pain-relieving medications. The authors review a number of analgesic preparations and treatments, with special emphasis on advantages, precautions, limitations, and various routes of administration.