Effect of serial night shifts on the cognitive, psychomotor, and moral performance of residents in the department of Emergency Medicine.

OBJECTIVES: The objective was to study the effect of serial night shifts on the cognitive, psychomotor, and moral performance of emergency medicine residents of an academic Emergency Medicine Department. METHODS: This prospective case-crossover study compared emergency medicine residents' sleep time, subjective sleepiness, cognitive function, moral judgment, and psychomotor skills after 5 consecutive days versus night shifts using sleep diaries, activity monitors, and multiple performance tests. Paired t-tests and Wilcoxon signed-rank tests were used to analyze data based on normality. Correlation analysis was done using Spearman's correlation test. Subgroup analysis was also performed to find any difference based on gender and year of residency. RESULTS: Twenty-seven emergency medicine residents participated (13 males, 48.1%). The distribution across residency years was as follows: 44.4% in their first year, 25.9% in their second year, and 29.6% in their third year. Following five consecutive night shifts, total sleep duration decreased significantly from 338.1 ± 67.8 to 307.4 ± 71.0 min (p < 0.001), while subjective sleepiness scores increased from 9.6 ± 3.3 to 13.6 ± 4.6. Psychomotor performance and reaction times did not significantly differ between night and day shifts. However, working memory declined, assessed by self-paced three-back test scores (median [IQR] 517.1 [471.9-546.7] vs. 457.6 [334.4-508.8]; p = 0.034) and interference test scores (445.5 ± 59.9 vs. 407.2 ± 56.8; p < 0.001), along with moral judgment (median [IQR] 19 [18-28] vs. 15 [11-21]; p = 0.010) after serial night shifts. No correlations existed between performance measures nor differences based on gender or residency year. CONCLUSIONS: Residents sleep less following night versus day shifts, reporting the highest sleepiness levels after 5 consecutive nights. Despite this, psychomotor performance and reaction times did not significantly differ. However, considerable reductions occurred in moral judgment, working memory, and interference test performance after serial night shifts.

Outcome of early emergency intubation and early emergency dialysis in deliberate self-harm with formic acid in a tertiary care center in South India: A retrospective cohort study.

OBJECTIVE: The objective is to evaluate the outcome of early emergency intubation and early dialysis in formic acid (FA) poisoning and to determine the clinical features associated with its mortality. METHODS: It is a retrospective cohort study of 78 patients who presented to the emergency medicine department from July 2008 to June 2015 with alleged history and clinical features of FA poisoning. The outcome of early intubation and early dialysis was studied in terms of 7-day and 30-day mortality. The outcome was compared in severe and not severe groups separately. Severity was graded according to Med-Tu chart used for corrosive poisoning. RESULTS: In the severe group (n = 53), early dialysis was done in 15 patients. There was 53% (n = 8) 30-day mortality. In the group where early dialysis was not done there was a significant increase in mortality 92.1% (n = 35). This was statistically significant with a P = 0.003. In a similar fashion 7-day mortality was analyzed in the severe group where mortality was higher when early dialysis was not done. In not severe group early dialysis has minimally decreased the mortality. Early intubation in severe group did not demonstrate any mortality benefit. Patients who were intubated early and not intubated early had equally high mortality. In not severe group, intubation could not make any significant difference in mortality. CONCLUSION: In this retrospective study, we observed that early dialysis in the severe group has a better outcome in terms of 7-day and 30-day mortality.

Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial.

OBJECTIVES: The primary objective was to compare the analgesic efficacy of ultrasound-guided erector spinae plane block (ESPB) with a sham procedure in adult patients presenting with rib fractures to the emergency department (ED). METHODS: A randomized controlled trial was conducted at an academic ED over a 17-month period. Forty-six adults with confirmed rib fractures and numeric rating score (NRS) greater than 4 were randomized to one of two treatment arms: ultrasound-guided ESPB group or placebo (sham procedure). Intravenous opioids were prescribed as rescue analgesia when self-reported pain scores were ≥4. The primary outcome measure, pain intensity reduction, was derived using the 11-point NRS at six time points over 12 h. Secondary outcome measures included the amount of rescue analgesia, in morphine equivalents, and the occurrence of adverse events. Two-way repeated-measures ANOVA was used to compare the trend in NRSs across the two arms. The association between the complications and intervention was explored using the Fisher's exact test. RESULTS: Forty-six patients (23 in each arm) completed the study. There was no difference between treatment groups with respect to age, sex, vital signs, preenrollment analgesia, or baseline pain intensity. In comparing pain intensity during the study period, NRS scores at 30, 60, and 120 min were significantly lower in the ESPB group (p < 0.001) during rest and deep inspiration. Moreover, patients in the ESPB group received lesser rescue analgesia than those in the sham group (10 mg, IQR 2.5 vs. 20 mg, IQR 5 mg; p ≤ 0.01). There was no difference in adverse events between groups. CONCLUSIONS: Ultrasound-guided ESPB resulted in significantly reduced pain intensity over the study period and reduced amount of rescue analgesia and had no discernible difference in adverse events when compared with a sham.

The ABCDE (Avoid Shaming/Personal Opinions, Build a Rapport, Choose a Communication Approach, Develop a Debriefing Content, Ensure the Ergonomics of Debriefing) Approach: A Simplified Model for Debriefing During Simulation in Emergency Medicine.

Several debriefing models have been described in the literature. However, all these debriefing models are designed in the general medical education format. Hence, for people involved in patient care and clinical teaching, sometimes it may become tedious and difficult to incorporate these models. In the following article, we describe a simplified model for debriefing using the well-known mnemonic ABCDE. The ABCDE approach is expanded as follows: A - Avoid Shaming/Personal Opinions, B - Build a Rapport, C - Choose a Communication Approach, D - Develop a Debriefing Content, and E - Ensure the Ergonomics of Debriefing. The unique thing about this model is that it provides a debriefing approach as a whole rather than only the delivery. It deals with human factors, educational factors, and ergonomics of debriefing, unlike other debriefing models. This approach can be used for debriefing by simulation educators in the field of emergency medicine and also by educators in other specialties.

The Morel-Lavallée lesionLavalleeLavelle.

BACKGROUND: Trauma patients present to the emergency department with various injuries. Few injuries can be easily missed during the evaluation of polytrauma patients. We report one such rare injury in a trauma patient. CASE REPORT: We report the case of a 67-year-old man who presented to the emergency department with an alleged history of trauma. He reported severe pain in the lower abdomen, right hip, and right thigh. An x-ray study did not reveal any bony injury, and an extended focused assessment with sonography in trauma was also negative. Point-of-care ultrasound of his right thigh revealed the presence of a Morel-Lavallée lesion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Morel-Lavallée lesions are post-traumatic, closed, degloving injuries that go unnoticed in many polytrauma patients. Emergency physicians should be mindful of this lesion because delay in diagnosis can result in significant complications.

A Rare Case of Limb-Threatening Injury Secondary to Extrinsic Vascular Compression Following Crocodile Bite.

Crocodile bites lead to fatal and nonfatal outcomes in humans. Mugger crocodiles (Crocodylus palustris) and saltwater crocodiles (Crocodylus porosus) are common in India. Most crocodile bites can cause severe injuries, especially to the extremities, due to the substantial bite force of the crocodile, which typically leads to extensive tissue damage, fractures, amputations, and vascular injuries. We report the case of a crocodile bite victim who presented with features of acute limb ischemia, was found to have vascular thrombosis of the common femoral artery, and was experiencing complete compression of the femoral vein due to external vascular compression by a hematoma. We discuss various injury mechanisms sustained in crocodile bites and the roles of point-of-care ultrasound and continuous tomography angiography, which could help identify these injuries. After thrombectomy and hematoma evacuation the patient recovered and was discharged without any physical dysfunction.

ATP-competitive inhibitors modulate the substrate binding cooperativity of a kinase by altering its conformational entropy.

ATP-competitive inhibitors are currently the largest class of clinically approved drugs for protein kinases. By targeting the ATP-binding pocket, these compounds block the catalytic activity, preventing substrate phosphorylation. A problem with these drugs, however, is that inhibited kinases may still recognize and bind downstream substrates, acting as scaffolds or binding hubs for signaling partners. Here, using protein kinase A as a model system, we show that chemically different ATP-competitive inhibitors modulate the substrate binding cooperativity by tuning the conformational entropy of the kinase and shifting the populations of its conformationally excited states. Since we found that binding cooperativity and conformational entropy of the enzyme are correlated, we propose a new paradigm for the discovery of ATP-competitive inhibitors, which is based on their ability to modulate the allosteric coupling between nucleotide and substrate-binding sites.

Effectiveness of "Resuscitation Cover All" in Minimizing COVID-19 Transmission to Health-Care Workers during Cardiopulmonary Resuscitation.

Introduction: Coronavirus disease 2019 (COVID-19) is a highly contagious disease transmitted by contact, droplets, and aerosols. Front line health-care workers (HCWs), particularly emergency physicians and acute care providers, are vulnerable to being exposed while treating their sick patients. Despite appropriate personal protective equipment use, HCW gets infected, suggesting the need for multiple layers of protection such as barrier devices. Methods: We aimed to determine the effectiveness of our novel "Resuscitation Cover All"(RCA) in reducing the exposure of HCW to simulated respiratory particles and its feasibility during cardio pulmonary resuscitation (CPR). This was a pilot simulation-based study. Five CPR simulation sessions were performed in Standard and RCA protocols, individually. Exposures through contact, droplets, and aerosols were simulated using a standardized volume of liquid detergent. Under Wood's lamp illumination, exposures of participants were compared between the protocols. Rate and depth of chest compressions, time taken to intubate, interruptions in CPR, and first-pass success were analyzed. Results: Overall mean exposure in standard protocol was 4950.4 ± 1461.6 (95%confidence interval [CI]:3135.7-6765.2) sq.pixels and RCA protocol was 2203.6 ± 1499.0 (95%CI: 342.4-4064.9) sq.pixels (P = 0.019). In standard, chest compressor had the highest exposure of 3066.6 ± 1419.2 (95%CI: 2051.3-4081.9) sq.pixels followed by defibrillator assistant 1166.4 ± 767.4 (95%CI: 617.4-1715.4) sq.pixels. Chest compressor of RCA had reduced exposure compared to that of standard (P < 0.001). Hands were the most frequently exposed body part. Airway manager of RCA had no exposure over head and neck in any session. No significant difference in CPR performance metrics was observed. Conclusion: This pilot simulation-based study shows that the novel RCA device could minimize the exposure of HCW to simulated respiratory particles during CPR. Also, it might not alter the high-quality CPR performance metrics. We need more real-life evidence.

Tracheo Esophageal Prosthesis Insertion Under Endoscopic Guidance and Local Anaesthesia- Feasibility and Outcome.

OBJECTIVES: Voice rehabilitation after laryngectomy is by tracheo esophageal puncture (TEP) and prosthesis insertion. Secondary TEP is very difficult due to neck fibrosis. Puncture under local anaesthesia with endoscopy guidance is a feasible option. METHODS: Retrospective review of all laryngectomy patients from March 2009 till March 2019 was done and the methods of voice rehabilitation were assessed. The patients undergoing the procedure were classified according to the timing of insertion and type as primary insertion under general anaesthesia (Group P), secondary insertion under local anaesthesia (Group L), secondary insertion under general anaesthesia (Group G). The speech outcome and the procedure outcome were compared. RESULTS: There were 148 patients who underwent laryngectomy, of which groups P, G, L were 12, 12 and 11. The rate of successful insertion was 100% in primary, 91.6% in secondary in general anaesthesia and 91% in secondary under local anaesthesia. All secondary TEP were done after surgery and radiotherapy. Complications related to the insertion techniques were minimal. Speech outcome were similar on intelligibility rating scale and longevity was not affected by the method. CONCLUSION: TEP in local anaesthesia is feasible and has comparable outcome with TEP in general anaesthesia. Financial burden was very much less in group L compared to the other two groups.

Is Disrupted Nucleotide-Substrate Cooperativity a Common Trait for Cushing's Syndrome Driving Mutations of Protein Kinase A?

Somatic mutations in the PRKACA gene encoding the catalytic α subunit of protein kinase A (PKA-C) are responsible for cortisol-producing adrenocortical adenomas. These benign neoplasms contribute to the development of Cushing's syndrome. The majority of these mutations occur at the interface between the two lobes of PKA-C and interfere with the enzyme's ability to recognize substrates and regulatory (R) subunits, leading to aberrant phosphorylation patterns and activation. Rarely, patients with similar phenotypes carry an allosteric mutation, E31V, located at the C-terminal end of the αA-helix and adjacent to the αC-helix, but structurally distinct from the PKA-C/R subunit interface mutations. Using a combination of solution NMR, thermodynamics, kinetic assays, and molecular dynamics simulations, we show that the E31V allosteric mutation disrupts central communication nodes between the N- and C- lobes of the enzyme as well as nucleotide-substrate binding cooperativity, a hallmark for kinases' substrate fidelity and regulation. For both orthosteric (L205R and W196R) and allosteric (E31V) Cushing's syndrome mutants, the loss of binding cooperativity is proportional to the density of the intramolecular allosteric network. This structure-activity relationship suggests a possible common mechanism for Cushing's syndrome driving mutations in which decreased nucleotide/substrate binding cooperativity is linked to loss in substrate fidelity and dysfunctional regulation.

Streptococcus dysgalactiae Subspecies dysgalactiae Infection Presenting With Septic Shock.

Streptococcus dysgalactiae has two main subspecies: Streptococcus dysgalactiae subspecies dysgalactiae (SDSD) and Streptococcus dysgalactiae subspecies equisimilis (SDSE). Although there are various case reports of SDSE causing clinical infection in humans, very few reports of SDSD causing human infections have been reported in the literature. As of date, there are only five case reports of infection with SDSD and all five patients survived the infection. We report a case of a 40-year-old male who presented with features of right upper limb cellulitis and went into septic shock. This report is unique as it presents the first report of SDSD causing fulminant sepsis in humans. Elevation of total fraction of creatinine kinase was also seen in our patient which could be due to myositis or rhabdomyolysis.

Superior Mesenteric Arterial and Venous Thrombosis in COVID-19.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) commonly present with fever, constitutional symptoms, and respiratory symptoms. However, atypical presentations are also well known. Though isolated mesenteric arterial occlusion associated with COVID-19 has been reported in literature, combined superior mesenteric arterial and venous thrombosis is rare. We report a case of combined superior mesenteric arterial and venous occlusion associated with COVID-19 infection. CASE REPORT: We report a case of a 45-year-old man who was a health care worker who presented to the emergency department with severe abdominal pain. The clinical examination was unremarkable, but imaging revealed acute mesenteric ischemia caused by superior mesenteric artery and superior mesenteric vein occlusion. Imaging of the chest was suggestive of COVID-19 infection, which was later confirmed with reverse transcription polymerase chain reaction of his nasopharyngeal swab. To date, only 1 case of combined superior mesenteric artery and superior mesenteric vein thrombosis caused by COVID-19 has been reported. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: During the COVID-19 pandemic it is important to keep mesenteric ischemia in the differential diagnosis of unexplained abdominal pain. Routinely adding high-resolution computed tomography of the chest to abdominal imaging should be considered in patients with acute abdomen because it can help to identify COVID-19 immediately. © 2020 Elsevier Inc.

Multi-state recognition pathway of the intrinsically disordered protein kinase inhibitor by protein kinase A.

In the nucleus, the spatiotemporal regulation of the catalytic subunit of cAMP-dependent protein kinase A (PKA-C) is orchestrated by an intrinsically disordered protein kinase inhibitor, PKI, which recruits the CRM1/RanGTP nuclear exporting complex. How the PKA-C/PKI complex assembles and recognizes CRM1/RanGTP is not well understood. Using NMR, SAXS, fluorescence, metadynamics, and Markov model analysis, we determined the multi-state recognition pathway for PKI. After a fast binding step in which PKA-C selects PKI's most competent conformations, PKI folds upon binding through a slow conformational rearrangement within the enzyme's binding pocket. The high-affinity and pseudo-substrate regions of PKI become more structured and the transient interactions with the kinase augment the helical content of the nuclear export sequence, which is then poised to recruit the CRM1/RanGTP complex for nuclear translocation. The multistate binding mechanism featured by PKA-C/PKI complex represents a paradigm on how disordered, ancillary proteins (or protein domains) are able to operate multiple functions such as inhibiting the kinase while recruiting other regulatory proteins for nuclear export.

T2* weighted Deconvolution of NMR Spectra: Application to 2D Homonuclear MAS Solid-State NMR of Membrane Proteins.

2D homonuclear NMR spectroscopy is an essential technique to characterize small and large molecules, such as organic compounds, metabolites, and biomacromolecules at atomic resolution. However, for complex samples 2D homonuclear spectra display poor resolution, making spectral assignment very cumbersome. Here, we propose a new method that exploits the differential T2* relaxation times of individual resonances and resolves the 2D NMR peaks into pseudo-3D spectra, where time is the 3rd dimension. T2* weIghted DEconvolution or TIDE analyzes individual free induction decays (FIDs) and dissects them into sub-FIDs that are transformed into pseudo-3D spectra combining Fourier transformation and covariance NMR. TIDE achieves higher resolution and sensitivity for NMR spectra than classical covariance NMR reducing offset-dependent artifacts. We demonstrate the performance of TIDE for magic angle spinning (MAS) [13C,13C]-DARR NMR spectra of single- and multi-span membrane proteins embedded in lipid bilayers. Since TIDE is applicable to all type of homonuclear correlation experiments for liquid and solid samples, we anticipate that it will be a general method for processing NMR data of biomacromolecules, complex mixtures of metabolites as well as material samples.

Globally correlated conformational entropy underlies positive and negative cooperativity in a kinase's enzymatic cycle.

Enzymes accelerate the rate of chemical transformations by reducing the activation barriers of uncatalyzed reactions. For signaling enzymes, substrate recognition, binding, and product release are often rate-determining steps in which enthalpy-entropy compensation plays a crucial role. While the nature of enthalpic interactions can be inferred from structural data, the molecular origin and role of entropy in enzyme catalysis remains poorly understood. Using thermocalorimetry, NMR, and MD simulations, we studied the conformational landscape of the catalytic subunit of cAMP-dependent protein kinase A, a ubiquitous phosphoryl transferase involved in a myriad of cellular processes. Along the enzymatic cycle, the kinase exhibits positive and negative cooperativity for substrate and nucleotide binding and product release. We found that globally coordinated changes of conformational entropy activated by ligand binding, together with synchronous and asynchronous breathing motions of the enzyme, underlie allosteric cooperativity along the kinase's cycle.