White Paper on Early Critical Care Services in Low Resource Settings.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Provider perceptions concerning use of chest x-ray studies in adult blunt trauma assessments.

BACKGROUND: Although they infrequently lead to management changing diagnoses, chest x-rays (CXRs) are the most commonly ordered imaging study in blunt trauma evaluation. OBJECTIVES: To determine: 1) the reasons physicians order chest X-ray studies (CXRs) in blunt trauma assessments; 2) what injuries they expect CXRs to reveal; and 3) whether physicians can accurately predict low likelihood of injury on CXR. METHODS: At a Level I Trauma Center, we asked resident and attending physicians treating adult blunt trauma patients: 1) the primary reason(s) for getting CXRs; 2) what, if any, significant intrathoracic injuries (SITI) they expected CXRs to reveal; and 3) the likelihood of these injuries. An expert panel defined SITI as two or more rib fractures, sternal fracture, pulmonary contusion, pneumothorax, hemothorax, or aortic injury on official CXR readings. RESULTS: There were 484 patient encounters analyzed--65% of participating physicians were residents and 35% were attendings; 16 (3.3%) patients had SITI. The most common reasons for ordering CXRs were: "enough concern for significant injury" (62.9%) and belief that CXR is a "standard part of trauma work-up" (24.8%). Residents were more likely than attendings to cite "standard trauma work-up" (mean difference = 13.5%, p = 0.003). When physicians estimated a < 10% likelihood of SITI on CXR, 2.1% (95% confidence interval [CI] 1.0-4.1%) of patients had SITI; when they predicted a 10-25% likelihood, 5.7% (95% CI 1.2-15.7%) had SITI; and when they predicted a > 25% likelihood, 9.1% (95% CI 3.0-20.0%) had SITI. CONCLUSIONS: Physicians order CXRs in blunt trauma patients because they expect to find injuries and believe that CXRs are part of a "standard" work-up. Providers commonly do not expect CXRs to reveal SITI. When providers estimated low likelihood of SITI, the rate of SITI was very low.

Binding of the Bacillus subtilis LexA protein to the SOS operator.

The Bacillus subtilis LexA protein represses the SOS response to DNA damage by binding as a dimer to the consensus operator sequence 5'-CGAACN(4)GTTCG-3'. To characterize the requirements for LexA binding to SOS operators, we determined the operator bases needed for site-specific binding as well as the LexA amino acids required for operator recognition. Using mobility shift assays to determine equilibrium constants for B.subtilis LexA binding to recA operator mutants, we found that several single base substitutions within the 14 bp recA operator sequence destabilized binding enough to abolish site-specific binding. Our results show that the AT base pairs at the third and fourth positions from the 5' end of a 7 bp half-site are essential and that the preferred binding site for a LexA dimer is 5'-CGAACATATGTTCG-3'. Binding studies with LexA mutants, in which the solvent accessible amino acid residues in the putative DNA binding domain were mutated, indicate that Arg-49 and His-46 are essential for binding and that Lys-53 and Ala-48 are also involved in operator recognition. Guided by our mutational analyses as well as hydroxyl radical footprinting studies of the dinC and recA operators we docked a computer model of B.subtilis LexA on the preferred operator sequence in silico. Our model suggests that binding by a LexA dimer involves bending of the DNA helix within the internal 4 bp of the operator.

Éxito y fracaso de los tratamientos endodonticos realizados por los estudiantes de IX ciclo de la Facultad de Odontología de la Universidad de El Salvador, durante los años 2001 y 2002 / Success and failure of endodontic treatments performed by students of the IX cycle of the Faculty of Dentistry of the University of El Salvador, during the years 2001 and 2002

Este informe presenta los resultados de la investigación realizada al estudiar el porcentaje de éxito y fracaso de los tratamientos de conductos radiculares realizados por los estudiantes de IX ciclo en el área de endodoncia de la Facultad de Odontología de la Universidad de El Salvador durante los años 2001 y 2002. Se mencionan los factores que intervienen en el desarrollo de los tratamientos, y los criterios de éxito y fracaso empleados por la Asociación Americana de Endodoncia: ausencia de dolor, sensibilidad a la percusión y palpación, movilidad, enfermedad periodontal, pieza dental restaurada cumpliendo su función, lámina dura intacta, ligamento periodontal normal, y otros; que se utilizaron como parámetro en esta investigación. Se trabajo con una población de 155 pacientes, para los cuales se administro un instrumento de 26 preguntas y se realizo una evaluación clínica y radiográfica de control, para luego compararlo con las radiografías y datos obtenidos del cuadro clínico archivado en la Facultad de Odontología de la Universidad de El Salvador. Con la información recopilada se elaboraron los cuadros estadísticos que permitieron obtener el porcentaje. Siendo el resultado: éxito 31.43% y fracasos del 68.57 %, con lo cual se concluye que el numero de fracasos supera al porcentaje de éxitos.

This report presents the results of the research carried out by studying the percentage of success and failure of root canal treatments carried out by students of the IX cycle in the area of ​​endodontics of the Faculty of Dentistry of the University of El Salvador during the years 2001 and 2002. The factors that intervene in the development of the treatments, and the success and failure criteria used by the American Endodontic Association are mentioned: absence of pain, sensitivity to percussion and palpation, mobility, periodontal disease, restored tooth fulfilling its function, intact lamina dura, normal periodontal ligament, and others; that were used as a parameter in this investigation. We worked with a population of 155 patients, for whom an instrument of 26 questions was administered and a control clinical and radiographic evaluation was carried out, to then compare it with the radiographs and data obtained from the clinical picture archived in the Faculty of Dentistry of the El Salvador University. With the information collected, the statistical tables were prepared that allowed the percentage to be obtained. The result being: 31.43% success and 68.57% failures, which concludes that the number of failures exceeds the percentage of successes.