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Objective: To validate shear wave elastography (SWE) stiffness measurements for the ulnar collateral ligament (UCL) of the elbow compared to mechanical measurements., Materials and Methods: Eleven fresh frozen human cadaveric upper extremities were evaluated by a musculoskeletal-specialized radiologist to provide SWE measurements used to calculate stiffness at 4 points along the anterior band of the UCL at various load states and flexion angles. Specimens were then dissected and optical markers were placed on the UCL to track displacement during applied force by a load frame, thereby providing measurements to calculate the mechanical stiffness. These two stiffness values were compared by ANOVA for all load states and flexion angles., Results: Measurements of stiffness by SWE for the UCL were three orders of magnitude smaller than the true mechanical testing stiffness and no correlations between SWE and mechanical measurements of stiffness were found at 30, 60 or 90 degrees of elbow flexion (R 2  = 0.004, p = 0.85; R 2  = 0.001, p = 0.92; R 2  = 0.15, p = 0.24 respectively). SWE stiffness was greatest near the insertion of the ligament and lowest in the mid-substance of the ligament (p = 0.0002)., Conclusions: SWE stiffness did not correlate with mechanical measurements. Clinical utility of musculoskeletal SWE may be better defined when biomechanical properties or clinical outcomes can be correlated with SWE measurements. The ultimate clinical utility of SWE in musculoskeletal tissues may be qualitative, as demonstrated by differences throughout the length of the UCL in this study., (© 2023. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Dietary restriction (DR) and hypoxia (low oxygen) extend lifespan in Caenorhabditis elegans through the induction of a convergent downstream longevity gene, fmo-2. Flavin-containing monooxygenases (FMOs) are highly conserved xenobiotic-metabolizing enzymes with a clear role in promoting longevity in nematodes and a plausible similar role in mammals. This makes them an attractive potential target of small molecule drugs to stimulate the health-promoting effects of longevity pathways. Here, we utilize an fmo-2 fluorescent transcriptional reporter in C. elegans to screen a set of 80 compounds previously shown to improve stress resistance in mouse fibroblasts. Our data show that 19 compounds significantly induce fmo-2, and 10 of the compounds induce fmo-2 more than twofold. Interestingly, 9 of the 10 high fmo-2 inducers also extend lifespan in C. elegans. Two of these drugs, mitochondrial respiration chain complex inhibitors, interact with the hypoxia pathway to induce fmo-2, whereas two dopamine receptor type 2 (DRD2) antagonists interact with the DR pathway to induce fmo-2, indicating that dopamine signaling is involved in DR-mediated fmo-2 induction. Together, our data identify nine drugs that each (1) increase stress resistance in mouse fibroblasts, (2) induce fmo-2 in C. elegans, and (3) extend nematode lifespan, some through known longevity pathways. These results define fmo-2 induction as a viable approach to identifying and understanding mechanisms of putative longevity compounds., (© 2024. The Author(s), under exclusive licence to American Aging Association.)

Objectives: We set out to develop a machine learning model capable of distinguishing patients presenting with ischemic stroke from a healthy cohort of subjects. The model relies on a 3-min resting electroencephalogram (EEG) recording from which features can be computed., Materials and Methods: Using a large-scale, retrospective database of EEG recordings and matching clinical reports, we were able to construct a dataset of 1385 healthy subjects and 374 stroke patients. With subjects often producing more than one recording per session, the final dataset consisted of 2401 EEG recordings (63% healthy, 37% stroke)., Results: Using a rich set of features encompassing both the spectral and temporal domains, our model yielded an AUC of 0.95, with a sensitivity and specificity of 93% and 86%, respectively. Allowing for multiple recordings per subject in the training set boosted sensitivity by 7%, attributable to a more balanced dataset., Conclusions: Our work demonstrates strong potential for the use of EEG in conjunction with machine learning methods to distinguish stroke patients from healthy subjects. Our approach provides a solution that is not only timely (3-minutes recording time) but also highly precise and accurate (AUC: 0.95)., Competing Interests: Declaration of competing interest W. Peterson, N. Ramakrishnan, Krag Browder, N. Sanossian, P. Nguyen, and E. Fink are all employees, owners, and/or advisors of Asterion AI, a start-up that uses machine learning to understand the nervous system., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Rhino-orbital cerebral mucormycosis (ROCM) is a rare infection caused by an invasive fungus and found predominantly in immunocompromised patients. The presentation of ROCM ranges from a mild headache, fever, and sinusitis to vision loss, altered mental status, and facial disfigurement secondary to local tissue invasion. ROCM can cause significant morbidity and mortality and requires prompt diagnosis with timely evaluation by surgical and infectious disease specialists. Cases of ROCM have been reported extensively in internal medicine, infectious disease, and otolaryngology literature. However, there are very few reports in emergency medicine literature in the United States., Case Report: A 72-year-old woman presented to the Emergency Department (ED) with altered mental status, 4 days of left-sided facial numbness and weakness, and sudden facial pain, swelling, and erythema. Laboratory analysis was consistent with diabetic ketoacidosis. Noncontrast computed tomography of the head and magnetic resonance imaging of the brain demonstrated findings indicative of invasive fungal infection of the left sinus and orbit with extension to the cavernous sinus and surrounding cranial nerves. She was initiated on broad-spectrum antifungals, but based on the extent of the infection, was not a surgical candidate. She subsequently transitioned to a comfort-based plan of care and died 6 days after initial ED presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition and initiation of treatment can potentially mitigate the devastating outcomes of ROCM, therefore it is critical to be aware of this condition and have a high level of suspicion in susceptible patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method., Methods: We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional expert panel including 15 faculty members from diverse practice environments and geographical regions. The panel voted on the list of competencies through two rounds of a modified Delphi process using a modified Likert scale (1 = not at all important, 5 = very important) to determine levels of agreement for each application-with revisions occurring between the two rounds. High agreement for consensus was set at >80%., Results: Fifteen of 15 panelists completed the first-round survey (100%) that included 359 topics related to EUS. After the first round, 195 applications achieved high agreement, four applications achieved medium agreement, and 164 applications achieved low agreement. After the discussion, we removed three questions and added 13 questions. Fifteen of 15 panelists completed the second round of the survey (100%) with 209 of the 369 applications achieving consensus., Conclusion: Our final list represents expert opinion on EUS competencies for graduating EM residents. We hope to use this consensus list to implement a more consistent EUS curriculum for graduating EM residents and to standardize EUS training across EM residency programs., Competing Interests: JC provides consulting services for Caption Health, Inc. JTN provides consulting services for Philips Healthcare and reports grant money from BMS to conduct research. JB reports grant money from Caption Health, Inc. to conduct research. RBL provides consulting services for Philips Healthcare, Caption Health, Inc., and Butterfly Network, Inc. REL provides consulting services for Echonous. The other authors declare no potential conflict of interest., (© 2022 The Authors. AEM Education and Training published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Interprofessional experiences during medical school are often delivered during pre-clinical years, but less is known about the value of clinical students. Our institution implemented a specialty-specific interprofessiona curriculum during Residency Preparation Courses (RPCs) for senior students including didactics, clinical experiences, and a simulated paging curriculum. Our aim was to determine whether this intervention improved perceptions of interprofesiona roles. We distributed anonymous surveys before (pre-survey) and after (post-survey, collected within 2 weeks of course completion) the RPC to 90 students with questions related to interprofessional roles using a 5-point scale (1 =  strongly disagree , 5 =  strongly agree ). Three months after the start of residency, we sent follow-up surveys inquiring about the usefulness of RPC components (1 =  not at all useful , 5 =  extremely useful ). Response rates were 84.4% pre-survey, 63.3% post-survey, and 41.1% follow-up survey. Post-surveys indicated improvement in self-reported ability in all domains: understanding one's contributions to interprofessional teams (3.9 to 4.4, p < .0001), understanding other team members' contributions (3.9 to 4.4, p < .0001), learning from interprofessional team members (4.2 to 4.6, p = .0002), accounting for interprofessional perspectives (4.2 to 4.6, p < .0001), and co-developing effective care plans (3.9 to 4.4, p < .0001). Follow-up surveys rated clinical experiences as slightly-to-moderately useful (2.3 ± 1.0) and paging curriculum very-to-extremely useful (4.3 ± 1.0). This study demonstrates the value of interprofessional education for advanced students.

Aim: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA., Methods: We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale., Results: Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26)., Conclusion: We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners., Methods: Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned., Results: Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities ( n  Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment., Conclusions: This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.

Background: The novel coronavirus disease was declared a pandemic in March 2020, which necessitated adaptations to medical education. This systematic review synthesises published reports of medical educational developments and innovations that pivot to online learning from workplace-based clinical learning in response to the pandemic. The objectives were to synthesise what adaptations/innovation were implemented (description), their impact (justification), and 'how' and 'why' these were selected (explanation and rationale)., Methods: The authors systematically searched four online databases up to December 21, 2020. Two authors independently screened titles, abstracts and full-texts, performed data extraction, and assessed the risk of bias. Our findings are reported in alignment with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance., Results: Fifty-five articles were included. Most were from North America ( n  = 40), and nearly 70% focused on undergraduate medical education (UGME). Key developments were rapid shifts from workplace-based learning to virtual spaces, including online electives, telesimulation, telehealth, radiology, and pathology image repositories, live-streaming or pre-recorded videos of surgical procedures, stepping up of medical students to support clinical services, remote adaptations for clinical visits, multidisciplinary team meetings and ward rounds. Challenges included lack of personal interactions, lack of standardised telemedicine curricula and need for faculty time, technical resources, and devices. Assessment of risk of bias revealed poor reporting of underpinning theory, resources, setting, educational methods, and content., Conclusions: This review highlights the response of medical educators in deploying adaptations and innovations. Whilst few are new, the complexity, concomitant use of multiple methods and the specific pragmatic choices of educators offers useful insight to clinical teachers who wish to deploy such methods within their own practice. Future works that offer more specific details to allow replication and understanding of conceptual underpinnings are likely to justify an update to this review.

Background: The COVID-19 pandemic spurred an abrupt transition away from in-person educational activities. This systematic review investigated the pivot to online learning for nonclinical undergraduate medical education (UGME) activities and explored descriptions of educational offerings deployed, their impact, and lessons learned., Methods: The authors systematically searched four online databases and conducted a manual electronic search of MedEdPublish up to December 21, 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction and assessed risk of bias. A third author resolved discrepancies. Findings were reported in accordance with the STORIES (STructured apprOach to the Reporting in healthcare education of Evidence Synthesis) statement and BEME guidance., Results: Fifty-six articles were included. The majority ( n  = 41) described the rapid transition of existing offerings to online formats, whereas fewer ( n  = 15) described novel activities. The majority ( n  = 27) included a combination of synchronous and asynchronous components. Didactics ( n  = 40) and small groups ( n  = 26) were the most common instructional methods. Teachers largely integrated technology to replace and amplify rather than transform learning, though learner engagement was often interactive. Thematic analysis revealed unique challenges of online learning, as well as exemplary practices. The quality of study designs and reporting was modest, with underpinning theory at highest risk of bias. Virtually all studies ( n  = 54) assessed reaction/satisfaction, fewer than half ( n  = 23) assessed changes in attitudes, knowledge or skills, and none assessed behavioral, organizational or patient outcomes., Conclusions: UGME educators successfully transitioned face-to-face instructional methods online and implemented novel solutions during the COVID-19 pandemic. Although technology's potential to transform teaching is not yet fully realized, the use of synchronous and asynchronous formats encouraged virtual engagement, while offering flexible, self-directed learning. As we transition from emergency remote learning to a post-pandemic world, educators must underpin new developments with theory, report additional outcomes and provide details that support replication.

Problem: The most effective way to train clinicians to safely don and doff personal protective equipment (PPE) and perform aerosol-generating procedures (AGPs), such as intubations, is unknown when clinician educators are unavailable, as they have been during the COVID-19 pandemic. Proper PPE and airway management techniques are critical to prevent the transmission of respiratory illnesses such as COVID-19., Approach: In March 2020, the authors implemented a structured train-the-trainers curriculum to teach PPE techniques and a modified airway management algorithm for suspected COVID-19 patients. A single emergency medicine physician trainer taught 17 subsequent emergency medicine and critical care physician trainers the proper PPE and airway management techniques. The initial trainer and 7 of the subsequent trainers then instructed 99 other emergency medicine resident and attending physicians using in situ simulation. Trainers and learners completed retrospective pre-post surveys to assess their comfort teaching the material and performing the techniques, respectively., Outcomes: The surveys demonstrated a significant increase in the trainers' comfort in teaching simulation-based education, from 4.00 to 4.53 on a 5-point Likert scale (P < .005), and in teaching the airway management techniques through simulation, from 2.47 to 4.47 (P < .001). There was no difference in the change in comfort level between those learners who were taught by the initial trainer and those who were taught by the subsequent trainers. These results suggest that the subsequent trainers were as effective in teaching the simulation material as the initial trainer., Next Steps: Work is ongoing to investigate clinician- and patient-specific outcomes, including PPE adherence, appropriate AGP performance, complication rate, and learners' skill retention. Future work will focus on implementing similar train-the-trainers strategies for other health professions, specialties, and high-risk or rare procedures., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of American Medical Colleges.)

Background: COVID-19 has fundamentally altered how education is delivered. Gordon et al. previously conducted a review of medical education developments in response to COVID-19; however, the field has rapidly evolved in the ensuing months. This scoping review aims to map the extent, range and nature of subsequent developments, summarizing the expanding evidence base and identifying areas for future research., Methods: The authors followed the five stages of a scoping review outlined by Arskey and O'Malley. Four online databases and MedEdPublish were searched. Two authors independently screened titles, abstracts and full texts. Included articles described developments in medical education deployed in response to COVID-19 and reported outcomes. Data extraction was completed by two authors and synthesized into a variety of maps and charts., Results: One hundred twenty-seven articles were included: 104 were from North America, Asia and Europe; 51 were undergraduate, 41 graduate, 22 continuing medical education, and 13 mixed; 35 were implemented by universities, 75 by academic hospitals, and 17 by organizations or collaborations. The focus of developments included pivoting to online learning ( n  = 58), simulation ( n  = 24), assessment ( n  = 11), well-being ( n  = 8), telehealth ( n  = 5), clinical service reconfigurations ( n  = 4), interviews ( n  = 4), service provision ( n  = 2), faculty development ( n  = 2) and other ( n  = 9). The most common Kirkpatrick outcome reported was Level 1, however, a number of studies reported 2a or 2b. A few described Levels 3, 4a, 4b or other outcomes (e.g. quality improvement)., Conclusions: This scoping review mapped the available literature on developments in medical education in response to COVID-19, summarizing developments and outcomes to serve as a guide for future work. The review highlighted areas of relative strength, as well as several gaps. Numerous articles have been written about remote learning and simulation and these areas are ripe for full systematic reviews. Telehealth, interviews and faculty development were lacking and need urgent attention.

Background: Over the last decade, medical student residency applicants have shown a substantial increase in the number of interviews attended, which is associated with a significant increase in travel. The carbon footprint associated with residency interviews has not been well documented prior to this investigation, and is a critical issue related to climate health., Objective: The purpose of this study is to document the carbon footprint associated with travel to residency interviews of the applicants from a single institution., Methods: Graduating medical students from the University of Michigan Medical School were surveyed in 2020 to gather information regarding travel related to residency interviews. A validated carbon emissions calculator was used to determine the associated carbon footprint., Results: Response rate was 103 of 174 (59%). Average interviews per student across all specialties was 14.39 interviews per student. The overall class average for total carbon footprint per student was calculated as 3.07 metric tons CO 2 , making the class average carbon footprint per interview 0.21 metric tons CO 2 . If we extrapolate the results of our study to all residents, the resulting CO 2 emissions approach 51 665 metric tons CO 2 per year, which is equivalent to the amount of CO 2 produced by 11 162 passenger cars in 1 year., Conclusions: Medical education leaders could help reduce the carbon footprint by encouraging a reduction in number of in-person interviews attended by applicants., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Audience: This ultrasound-guided regional anesthesia elective is designed for emergency medicine residents., Length of Curriculum: The proposed length of this curriculum is over one week., Introduction: Ultrasound-guided regional anesthesia (UGRA) is a useful tool in the emergency department (ED) for managing painful conditions, and many programs have identified that these are useful skills for emergency providers; however, only about 53% of programs report teaching UGRA as part of their core curriculum, and there currently are no widely available or peer reviewed nerve block curricula designed for emergency medicine residents., Educational Goals: To deliver an immersive 1-week elective to provide residents a strong foundation in principles of UGRA and an introduction to 14 nerve block procedures applicable to care provided in the ED., Educational Methods: The educational strategies used in this curriculum include: instructional videos, written and online independent learning materials, one-on-one teaching at the bedside with an emergency ultrasound fellow, simulation of nerve block techniques using a femoral nerve block task trainer, and performance of supervised nerve block procedures on patients in the ED., Research Methods: All residents provided feedback through an online survey after completing the elective., Results: Eight residents completed the elective in the first year of implementation. Following completion of the UGRA curriculum, 8/8 (100%) of residents reported increased level of confidence in performing UGRA. In addition, 8/8 (100%) of residents reported they were "likely" or "very likely" to incorporate UGRA into their future EM practice. All 8 (100%) residents responded they were "very likely" to recommend the elective to other trainees. The elective received high ratings for overall quality with an average rating of 9.4 out of 10 (±0.7)., Discussion: An elective in ultrasound-guided regional anesthesia can be successfully incorporated into an emergency medicine training program. The curriculum was successful in providing focused training in UGRA and resulted in increased resident confidence in performing nerve block procedures., Topics: Ultrasound-guided regional anesthesia, nerve block, resident, elective, pain., (© 2021 Tucker, et al.)

Objectives: Ultrasound-guided regional anesthesia (UGRA) can be a powerful tool in the treatment of painful conditions commonly encountered in emergency medicine (EM) practice. UGRA can benefit patients while avoiding the risks of procedural sedation and opioid-based systemic analgesia. Despite these advantages, many EM trainees do not receive focused education in UGRA and there is no published curriculum specifically for EM physicians. The objective of this study was to identify the components of a UGRA curriculum for EM physicians., Methods: A list of potential curriculum elements was developed through an extensive literature review. An expert panel was convened that included 13 ultrasound faculty members from 12 institutions and from a variety of practice environments and diverse geographical regions. The panel voted on curriculum elements through two rounds of a modified Delphi process., Results: The panelists voted on 178 total elements, 110 background knowledge elements, and 68 individual UGRA techniques. A high level of agreement was achieved for 65 background knowledge elements from the categories: benefits to providers and patients, indications, contraindications, risks, ultrasound skills, procedural skills, sterile technique, local anesthetics, and educational resources. Ten UGRA techniques achieved consensus: interscalene brachial plexus, supraclavicular brachial plexus, radial nerve, median nerve, ulnar nerve, serratus anterior plane, fascia iliaca, femoral nerve, popliteal sciatic nerve, and posterior tibial nerve blocks., Conclusions: The defined curriculum represents ultrasound expert opinion on a curriculum for training practicing EM physicians. This curriculum can be used to guide the development and implementation of more robust UGRA education for both residents and independent providers., (© 2020 by the Society for Academic Emergency Medicine.)

Introduction: Scholarship and academic networking are essential for promotion and productivity. To develop education scholarship, the Council of Emergency Medicine Directors (CORD) and Clerkship Directors of Emergency Medicine (CDEM) created an annual Special Issue in Educational Research and Practice of the Western Journal of Emergency Medicine. The objective of this study was to evaluate the network created by the special Issue, and explore changes within the network over time., Methods: Researchers used bibliometric data from Web of Science to create a social network analysis of institutions publishing in the first four years of the special issue using UCINET software. We analyzed whole-network and node-level metrics to describe variations and changes within the network., Results: One hundred and three (56%) Accreditation Council for Graduate Medical Education-accredited emergency medicine programs were involved in 136 articles. The majority of institutions published in one or two issues. Nearly 25% published in three or four issues. The network analysis demonstrated that the mean number of connections per institution increased over the four years (mean of 5.34; standard deviation [SD] 1.27). Mean degree centralization was low at 0.28 (SD 0.05). Network density was low (mean of 0.09; SD 0.01) with little change across four issues. Five institutions scored consistently high in betweenness centrality, demonstrating a role as connectors between institutions within the network and the potential to connect new members to the network., Conclusion: Network-wide metrics describe a consistently low-density network with decreasing degree centralization over four years. A small number of institutions within the network were persistently key players in the network. These data indicate that, aside from core institutions that publish together, the network is not widely connected. There is evidence that new institutions are coming into the network, but they are not necessarily connected to the core publishing groups. There may be opportunities to intentionally increase connections across the network and create new connections between traditionally high-performing institutions and newer members of the network. Through informal discussions with authors from high-performing institutions, there are specific behaviors that departments may use to promote education scholarship and forge these new connections.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic presents unique challenges to frontline healthcare workers. In order to safely care for patients new processes, such as a plan for the airway management of a patient with COVID-19, must be implemented and disseminated in a rapid fashion. The use of in-situ simulation has been used to assist in latent problem identification as part of a Plan-Do-Study-Act cycle. Additionally, simulation is an effective means for training teams to perform high-risk procedures before engaging in the actual procedure. This educational advance seeks to use and study in-situ simulation as a means to rapidly implement a process for airway management in patients with COVID-19., Methods: Using an airway algorithm developed by the authors, we designed an in-situ simulation scenario to train physicians, nurses, and respiratory therapists in best practices for airway management of patients with COVID-19. Physician participants were surveyed using a five-point Likert scale with regard to their comfort level with various aspects of the airway algorithm both before and after the simulation in a retrospective fashion. Additionally, we obtained feedback from all participants and used it to refine the airway algorithm., Results: Over a two-week period, 93 physicians participated in the simulation. We received 81 responses to the survey (87%), which showed that the average level of comfort with personal protective equipment procedures increased significantly from 2.94 (95% confidence interval, 2.71-3.17) to 4.36 (4.24-4.48), a difference of 1.42 (1.20-1.63, p < 0.001). There was a significant increase in average comfort level in understanding the physician role with scores increasing from 3.51 (3.26-3.77) to 4.55 (2.71-3.17), a difference of 1.04 (0.82-1.25, p < 0.001). There was also increased comfort in performing procedural tasks such as intubation, from 3.08 (2.80-3.35) to 4.38 (4.23-4.52) after the simulation, a difference of 1.30 points (1.06-1.54, p < 0.001). Feedback from the participants also led to refinement of the airway algorithm., Conclusion: We successfully implemented a new airway management guideline for patients with suspected COVID-19. In-situ simulation is an essential tool for both dissemination and onboarding, as well as process improvement, in the context of an epidemic or pandemic.

Background: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk., Methods: Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline)., Results: Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort., Conclusions: Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.

Introduction: Forming effective networks is important for personal productivity and career development. Although critical for success, these networks are not well understood. The objective of this study was to usze a social network analysis tool to demonstrate the growth of institutional publication networks for education researchers and show how a single institution has expanded its publication network over time., Methods: Publications from a single institution's medical education research group (MERG) were pulled since its inception in 2010 to 2019 using Web of Science to collect publication information. Using VOSViewer software, we formed and plotted a network sociogram comparing the first five years to the most recent 4.25 years to compare the institutions of authors from peer reviewed manuscripts published by this group., Results: We found 104 peer-reviewed research articles, editorials, abstracts, and reviews for the MERG authors between 2010 and 2019 involving 134 unique institutions. During 2010-2014, there were 26 publications involving 56 institutions. From 2015-2019, there were 78 publications involving 116 unique institutions., Conclusion: This brief report correlates successful research productivity in medical education with the presence of increased inter-institutional collaborations as demonstrated by network sociograms. Programs to intentionally expand collaborative networks may prove to be an important element of facilitating successful careers in medical education scholarship.

Introduction: Leading change effectively is critical to advancing medical education. Residency didactics often require change in order to meet stakeholder's needs. Kotter's change management model (KCMM) is an 8-step method for implementing change that can be applied to educational initiatives. This innovation improved an emergency medicine residency didactics curriculum through application of KCMM., Methods: An initiative to improve residency didactics curriculum was titled the "Didactics Revolution" and implemented according to KCMM: establish a sense of urgency, form a powerful guiding coalition, create a vision, communicate the vision, empower others to act on the vision, plan for and create short-term wins, consolidate improvements and produce still more change, and institutionalize new approaches. Data from the Annual Program Review was utilized to assess the impact of the KCMM strategy., Results: The percentage of residents who agreed or strongly agreed that lectures provide a valuable learning experience increased from 39.1% in the year prior to 88.0% in the year during the implementation (p < .001), and remained relatively high at 73.5% in the year following. The percentage of residents who agreed or strongly agreed that they felt well-prepared for the written boards increased from 60.9% in the year prior to 92.0% in the year during the implementation (p = .01) and remained high at 73.5% in the year following., Conclusion: Residency didactics can be improved through the use of KCMM, a change management model originally developed in the corporate context.

Advances in point-of-care ultrasound technology have allowed for the extension of emergency medicine ultrasound beyond the walls of the emergency department. Emergency medical system providers may benefit from the use of ultrasound. It has previously been shown that with a brief introductory course, novices can obtain and correctly interpret focused ultrasound examinations. The purpose of this study was to design a theory-driven point-of-care ultrasound curriculum to assess and develop ultrasound skill in prehospital providers. The resultant curriculum outlined in this paper encompasses a large array of skills that may be useful for different prehospital services to use to develop curriculum for their own needs., (Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Background: Although dantrolene effectively treats malignant hyperthermia (MH), discrepant recommendations exist concerning dantrolene availability. Whereas Malignant Hyperthermia Association of the United States guidelines state dantrolene must be available within 10 min of the decision to treat MH wherever volatile anesthetics or succinylcholine are administered, a Society for Ambulatory Anesthesia protocol permits Class B ambulatory facilities to stock succinylcholine for airway rescue without dantrolene. The authors investigated (1) succinylcholine use rates, including for airway rescue, in anesthetizing/sedating locations; (2) whether succinylcholine without volatile anesthetics triggers MH warranting dantrolene; and (3) the relationship between dantrolene administration and MH morbidity/mortality., Methods: The authors performed focused analyses of the Multicenter Perioperative Outcomes Group (2005 through 2016), North American MH Registry (2013 through 2016), and Anesthesia Closed Claims Project (1970 through 2014) databases, as well as a systematic literature review (1987 through 2017). The authors used difficult mask ventilation (grades III and IV) as a surrogate for airway rescue. MH experts judged dantrolene treatment. For MH morbidity/mortality analyses, the authors included U.S. and Canadian cases that were fulminant or scored 20 or higher on the clinical grading scale and in which volatile anesthetics or succinylcholine were given., Results: Among 6,368,356 queried outcomes cases, 246,904 (3.9%) received succinylcholine without volatile agents. Succinylcholine was used in 46% (n = 710) of grade IV mask ventilation cases (median dose, 100 mg, 1.2 mg/kg). Succinylcholine without volatile anesthetics triggered 24 MH cases, 13 requiring dantrolene. Among 310 anesthetic-triggered MH cases, morbidity was 20 to 37%. Treatment delay increased complications every 10 min, reaching 100% with a 50-min delay. Overall mortality was 1 to 10%; 15 U.S. patients died, including 4 after anesthetics in freestanding facilities., Conclusions: Providers use succinylcholine commonly, including during difficult mask ventilation. Succinylcholine administered without volatile anesthetics may trigger MH events requiring dantrolene. Delayed dantrolene treatment increases the likelihood of MH complications. The data reported herein support stocking dantrolene wherever succinylcholine or volatile anesthetics may be used.

In busy emergency departments (EDs), it can be difficult for faculty to teach students amid pressure to provide patient care and conduct research. As a result, medical student teaching may be an afterthought rather than a priority, and there is a lack of focus on how students spend their time during clinical shifts in the ED. Students want to contribute to departmental workflow, but can be hampered by systems limitations and lack of clinical knowledge. One solution is for faculty and medical students to partner to add value to patient care in the ED. However, faculty and students must be wary of the distinction between activities that add value and "scutwork," tasks that involve little learning and do not require medical expertise. In this perspective, the student, resident, and faculty authors discuss learner and educator perspectives for how medical students can be productive contributors to patient care in the ED without being subjected to scutwork. They also recommend ideas for productive student activities that promote learning, contrasted with examples of scutwork to avoid. Definitions of value-added activities and scutwork depend on the learner's experience level and interests and are subject to debate. However, if medical students can be engaged in learning while also providing meaningful contributions to patient care, students, educators, and patients stand to benefit.

This educational download will help readers turn their work into scholarship with 5 straight forward tips. When doing educational work-ask questions. Be sure to have a strong educational foundation for teaching, assessment, and evaluation. Work in teams. Use colleagues to help promote educational work. And finally, manage the work flow to ensure completion.

Background: Relatively little is understood about which factors influence students' choice of specialty and when learners ultimately make this decision., Objective: The objective is to understand how experiences of medical students relate to the timing of selection of Emergency Medicine (EM) as a specialty. Of specific interest were factors such as how earlier and more positive specialty exposure may impact the decision-making process of medical students., Methods: A cross-sectional survey study of EM bound 4th year US medical students (MD and DO) was performed exploring when and why students choose EM as their specialty. An electronic survey was distributed in March 2015 to all medical students who applied to an EM residency at 4 programs representing different geographical regions. Descriptive analyses and multinomial logistic regressions were performed., Results: 793/1372 (58%) responded. Over half had EM experience prior to medical school. When students selected EM varied: 13.9% prior to, 50.4% during, and 35.7% after their M3 year. Early exposure, presence of an EM residency program, previous employment in the ED, experience as a pre-hospital provider, and completion of an M3 EM clerkship were associated with earlier selection. Delayed exposure to EM was associated with later selection of EM., Conclusions: Early exposure and prior life experiences were associated with choosing EM earlier in medical school. The third year was identified as the most common time for definitively choosing the specialty.

Background: The clinical learning environment helps to shape the professional identity of medical students. This process begins from existing personal identity and is influenced by various factors, including clinical experiences and clinical learning environment., Objective: The purpose of this study was to examine medical students' reflections as a way to identify and better characterize the modern struggles that medical students face, in order to inform the development of professional identity., Methods: Students rotating in their emergency medicine clerkship wrote reflections on dilemmas that highlighted common struggles of becoming a doctor. Qualitative analysis was performed to determine common themes from the essays. The research team coded 173 reflections and identified themes and major domains., Results: The first domain was Patient-Provider Conflict, including challenging patient (34%), difficult communication (25%), competing priorities between patients' interest and trainees need to learn (19%), and bias (13%). The second domain was Provider-Specific Issues, such as the "gray zone," in which there is not a clear standard of practice (29%), end-of-life care (14%), emotional struggle (6%), and fear of litigation (5%). The final domain was Systems Issues, such as cost of care (12%) and role of the emergency department (6%)., Conclusions: The reflections point to a wide variety of challenges that students confront in practice that will contribute to how they develop into physicians., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A warm anomaly in the upper ocean, colloquially named "the Blob," appeared in the Gulf of Alaska during the calm winter of 2013-2014, spread across the northern North Pacific (NP) Ocean, and shifted eastward and onto the Oregon shelf. At least 14 species of copepods occurred which had never been observed in shelf/slope waters off Oregon, some of which are known to have NP Gyre affinities, indicating that the source waters of the coastal "Blob" were likely of both offshore (from the west) and subtropical/tropical origin. The anomalously warm conditions were reduced during strong upwelling in spring 2015 but returned when upwelling weakened in July 2015 and transitioned to downwelling in fall 2015. The extended period of warm conditions resulted in prolonged effects on the ecosystem off central Oregon, lasting at least through 2016. Impacts to the lower trophic levels were unprecedented and include a novel plankton community composition resulting from increased copepod, diatom, and dinoflagellate species richness and increased abundance of dinoflagellates. Additionally, the multiyear warm anomalies were associated with reduced biomass of copepods and euphausiids, high abundance of larvaceans and doliolids (indictors of oligotrophic ocean conditions), and a toxic diatom bloom ( Pseudo-nitzschia ) throughout the California Current in 2015, thereby changing the composition of the food web that is relied upon by many commercially and ecologically important species.

This article presents system performance studies for the Discovery MI PET/CT system, a new time-of-flight system based on silicon photomultipliers. System performance and clinical imaging were compared between this next-generation system and other commercially available PET/CT and PET/MR systems, as well as between different reconstruction algorithms. Methods: Spatial resolution, sensitivity, noise-equivalent counting rate, scatter fraction, counting rate accuracy, and image quality were characterized with the National Electrical Manufacturers Association NU-2 2012 standards. Energy resolution and coincidence time resolution were measured. Tests were conducted independently on two Discovery MI scanners installed at Stanford University and Uppsala University, and the results were averaged. Back-to-back patient scans were also performed between the Discovery MI, Discovery 690 PET/CT, and SIGNA PET/MR systems. Clinical images were reconstructed using both ordered-subset expectation maximization and Q.Clear (block-sequential regularized expectation maximization with point-spread function modeling) and were examined qualitatively. Results: The averaged full widths at half maximum (FWHMs) of the radial/tangential/axial spatial resolution reconstructed with filtered backprojection at 1, 10, and 20 cm from the system center were, respectively, 4.10/4.19/4.48 mm, 5.47/4.49/6.01 mm, and 7.53/4.90/6.10 mm. The averaged sensitivity was 13.7 cps/kBq at the center of the field of view. The averaged peak noise-equivalent counting rate was 193.4 kcps at 21.9 kBq/mL, with a scatter fraction of 40.6%. The averaged contrast recovery coefficients for the image-quality phantom were 53.7, 64.0, 73.1, 82.7, 86.8, and 90.7 for the 10-, 13-, 17-, 22-, 28-, and 37-mm-diameter spheres, respectively. The average photopeak energy resolution was 9.40% FWHM, and the average coincidence time resolution was 375.4 ps FWHM. Clinical image comparisons between the PET/CT systems demonstrated the high quality of the Discovery MI. Comparisons between the Discovery MI and SIGNA showed a similar spatial resolution and overall imaging performance. Lastly, the results indicated significantly enhanced image quality and contrast-to-noise performance for Q.Clear, compared with ordered-subset expectation maximization. Conclusion: Excellent performance was achieved with the Discovery MI, including 375 ps FWHM coincidence time resolution and sensitivity of 14 cps/kBq. Comparisons between reconstruction algorithms and other multimodal silicon photomultiplier and non-silicon photomultiplier PET detector system designs indicated that performance can be substantially enhanced with this next-generation system., (© 2017 by the Society of Nuclear Medicine and Molecular Imaging.)

Domoic acid is a potent neurotoxin produced by certain marine microalgae that can accumulate in the foodweb, posing a health threat to human seafood consumers and wildlife in coastal regions worldwide. Evidence of climatic regulation of domoic acid in shellfish over the past 20 y in the Northern California Current regime is shown. The timing of elevated domoic acid is strongly related to warm phases of the Pacific Decadal Oscillation and the Oceanic Niño Index, an indicator of El Niño events. Ocean conditions in the northeast Pacific that are associated with warm phases of these indices, including changes in prevailing currents and advection of anomalously warm water masses onto the continental shelf, are hypothesized to contribute to increases in this toxin. We present an applied domoic acid risk assessment model for the US West Coast based on combined climatic and local variables. Evidence of regional- to basin-scale controls on domoic acid has not previously been presented. Our findings have implications in coastal zones worldwide that are affected by this toxin and are particularly relevant given the increased frequency of anomalously warm ocean conditions., Competing Interests: The authors declare no conflict of interest.

In spring/summer 2015, a toxic bloom by the diatom Pseudo-nitzschia (PN) occurred along the west coast of the United States which led to closures of the harvest of razor clams and Dungeness crabs. Twice monthly observations of temperature, salinity, nutrients, chlorophyll and phytoplankton species composition allowed us to track oceanographic conditions preceding and during the development of the bloom. PN cells were first detected during late winter 2015. A PN bloom was initiated following the onset of coastal upwelling in mid-April; subsequent peaks in May and June were sustained by episodic upwelling events and reached magnitudes of 105 cells/L and 106 cells/L, 40% and 90% of the total diatom abundance, respectively. The bloom temporarily crashed in July due to a lack of upwelling, but PN cells increased again in August due to a resumption of upwelling, albeit with lower magnitude. Macronutrient conditions prior to this bloom likely played a critical role in triggering the bloom and its toxicity (particularly silicic acid limitation stress). Nutrient stress preceding the toxic bloom was related to two oceanographic events: an anomalously warm and thick water mass that occupied the northern North Pacific from September 2014 through 2015 leading to a highly-stratified water column, and the drawdown of nitrate and silicic acid during an unusually intense winter phytoplankton bloom in February and early March 2015., Competing Interests: The authors have declared that no competing interests exist.

Resource managers at the state, federal, and tribal levels make decisions on a weekly to quarterly basis, and fishers operate on a similar timeframe. To determine the potential of a support tool for these efforts, a seasonal forecast system is experimented with here. JISAO's Seasonal Coastal Ocean Prediction of the Ecosystem (J-SCOPE) features dynamical downscaling of regional ocean conditions in Washington and Oregon waters using a combination of a high-resolution regional model with biogeochemistry and forecasts from NOAA's Climate Forecast System (CFS). Model performance and predictability were examined for sea surface temperature (SST), bottom temperature, bottom oxygen, pH, and aragonite saturation state through model hindcasts, reforecast, and forecast comparisons with observations. Results indicate J-SCOPE forecasts have measurable skill on seasonal timescales. Experiments suggest that seasonal forecasting of ocean conditions important for fisheries is possible with the right combination of components. Those components include regional predictability on seasonal timescales of the physical environment from a large-scale model, a high-resolution regional model with biogeochemistry that simulates seasonal conditions in hindcasts, a relationship with local stakeholders, and a real-time observational network. Multiple efforts and approaches in different regions would advance knowledge to provide additional tools to fishers and other stakeholders.

Introduction: This study investigates the impact of the Doximity rankings on the rank list choices made by residency applicants in emergency medicine (EM)., Methods: We sent an 11-item survey by email to all students who applied to EM residency programs at four different institutions representing diverse geographical regions. Students were asked questions about their perception of Doximity rankings and how it may have impacted their rank list decisions., Results: Response rate was 58% of 1,372 opened electronic surveys. This study found that a majority of medical students applying to residency in EM were aware of the Doximity rankings prior to submitting rank lists (67%). One-quarter of these applicants changed the number of programs and ranks of those programs when completing their rank list based on the Doximity rankings (26%). Though the absolute number of programs changed on the rank lists was small, the results demonstrate that the EM Doximity rankings impact applicant decision-making in ranking residency programs., Conclusion: While applicants do not find the Doximity rankings to be important compared to other factors in the application process, the Doximity rankings result in a small change in residency applicant ranking behavior. This unvalidated ranking, based principally on reputational data rather than objective outcome criteria, thus has the potential to be detrimental to students, programs, and the public. We feel it important for specialties to develop consensus around measurable training outcomes and provide freely accessible metrics for candidate education.

The zooplankton of the northern California Current are typically characterized by an abundance of lipid-rich copepods that support rapid growth and survival of ecologically, commercially, and recreationally valued fish, birds, and mammals. Disruption of this food chain and reduced ecosystem productivity are often associated with climatic variability such as El Niño events. We examined the variability in timing, magnitude, and duration of positive temperature anomalies and changes in copepod species composition in the northern California Current in relation to 10 tropical El Niño events. Measurable impacts on mesozooplankton of the northern California Current were observed during seven of 10 of these events. The occurrence of anomalously warm water and the response of the copepod community was rapid (lag of zero to 2 months) following the initiation of canonical Eastern Pacific (EP) events, but delayed (lag of 2-8 months) following 'Modoki' Central Pacific (CP) events. The variable lags in the timing of a physical and biological response led to impacts in the northern California Current peaking in winter during EP events and in the spring during CP events. The magnitude and duration of the temperature and copepod anomalies were strongly and positively related to the magnitude and duration of El Niño events, but were also sensitive to the phase of the lower frequency Pacific Decadal Oscillation. When fisheries managers and biological oceanographers are faced with the prospect of a future El Niño event, prudent management and observation will require consideration of the background oceanographic conditions, the type of event, and both the magnitude and duration of the event when assessing the potential physical and biological impacts on the northern California Current., (© 2015 John Wiley & Sons Ltd.)

Reported trends in the mean and variability of coastal upwelling in eastern boundary currents have raised concerns about the future of these highly productive and biodiverse marine ecosystems. However, the instrumental records on which these estimates are based are insufficiently long to determine whether such trends exceed preindustrial limits. In the California Current, a 576-year reconstruction of climate variables associated with winter upwelling indicates that variability increased over the latter 20th century to levels equaled only twice during the past 600 years. This modern trend in variance may be unique, because it appears to be driven by an unprecedented succession of extreme, downwelling-favorable, winter climate conditions that profoundly reduce productivity for marine predators of commercial and conservation interest., (Copyright © 2014, American Association for the Advancement of Science.)

Objectives: Medical education is a continuum from medical school through residency to unsupervised clinical practice. There has been a movement toward competency-based medical education prompted by the Accreditation Council for Graduate Medical Education (ACGME) using milestones to assess competence. While implementation of milestones for residents sets specific standards for transition to internship, there exists a need for the development of competency-based instruments to assess medical students as they progress toward internship. The objective of this study was to develop competency-based milestones for fourth-year medical students completing their emergency medicine (EM) clerkships (regardless of whether the students were planning on entering EM) using a rigorous method to attain validity evidence., Methods: A literature review was performed to develop a list of potential milestones. An expert panel, which included a medical student and 23 faculty members (four program directors, 16 clerkship directors, and five assistant deans) from 19 different institutions, came to consensus on these milestones through two rounds of a modified Delphi protocol. The Delphi technique builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires., Results: Of the initial 39 milestones, 12 were removed at the end of round 1 due to low agreement on importance of the milestone or because of redundancy with other milestones. An additional 12 milestones were revised to improve clarity or eliminate redundancy, and one was added based on expert panelists' suggestions. Of the 28 milestones moving to round 2, consensus with a high level of agreement was achieved for 24. These were mapped to the ACGME EM residency milestone competency domains, as well as the Association of American Medical Colleges (AAMC) core entrustable professional activities for entering residency to improve content validity., Conclusions: This study found consensus support by experts for a list of 24 milestones relevant to the assessment of fourth-year medical student performance by the completion of their EM clerkships. The findings are useful for development of a valid method for assessing medical student performance as students approach residency., (© 2014 by the Society for Academic Emergency Medicine.)

Research on regulatory mechanisms in biological populations often focuses on environmental covariates. An integrated approach that combines environmental indices with organismal-level information can provide additional insight on regulatory mechanisms. Survival of spring/summer Snake River Chinook salmon (Oncorhynchus tshawytscha) is consistently low whereas some adjacent populations with similar life histories experience greater survival. It is not known if populations with differential survival respond similarly during early marine residence, a critical period in the life history. Ocean collections, genetic stock identification, and otolith analyses were combined to evaluate the growth-mortality and match-mismatch hypotheses during early marine residence of spring/summer Snake River Chinook salmon. Interannual variation in juvenile attributes, including size at marine entry and marine growth rate, was compared with estimates of survival and physical and biological metrics. Multiple linear regression and multi-model inference were used to evaluate the relative importance of biological and physical metrics in explaining interannual variation in survival. There was relatively weak support for the match-mismatch hypothesis and stronger evidence for the growth-mortality hypothesis. Marine growth and size at capture were strongly, positively related to survival, a finding similar to spring Chinook salmon from the Mid-Upper Columbia River. In hindcast models, basin-scale indices (Pacific Decadal Oscillation (PDO) and the North Pacific Gyre Oscillation (NPGO)) and biological indices (juvenile salmon catch-per-unit-effort (CPUE) and a copepod community index (CCI)) accounted for substantial and similar portions of variation in survival for juvenile emigration years 1998-2008 (R2>0.70). However, in forecast models for emigration years 2009-2011, there was an increasing discrepancy between predictions based on the PDO (50-448% of observed value) compared with those based on the NPGO (68-212%) or biological indices (CPUE and CCI: 83-172%). Overall, the PDO index was remarkably informative in earlier years but other basin-scale and biological indices provided more accurate indications of survival in recent years.

Most modeling and statistical approaches encourage simplicity, yet ecological processes are often complex, as they are influenced by numerous dynamic environmental and biological factors. Pacific salmon abundance has been highly variable over the last few decades and most forecasting models have proven inadequate, primarily because of a lack of understanding of the processes affecting variability in survival. Better methods and data for predicting the abundance of returning adults are therefore required to effectively manage the species. We combined 31 distinct indicators of the marine environment collected over an 11-year period into a multivariate analysis to summarize and predict adult spring Chinook salmon returns to the Columbia River in 2012. In addition to forecasts, this tool quantifies the strength of the relationship between various ecological indicators and salmon returns, allowing interpretation of ecosystem processes. The relative importance of indicators varied, but a few trends emerged. Adult returns of spring Chinook salmon were best described using indicators of bottom-up ecological processes such as composition and abundance of zooplankton and fish prey as well as measures of individual fish, such as growth and condition. Local indicators of temperature or coastal upwelling did not contribute as much as large-scale indicators of temperature variability, matching the spatial scale over which salmon spend the majority of their ocean residence. Results suggest that effective management of Pacific salmon requires multiple types of data and that no single indicator can represent the complex early-ocean ecology of salmon.

Euphausiid krill play a critical role in coastal and oceanic food webs, linking primary producers to upper trophic levels. In addition, some species support commercial fisheries worldwide. Despite their ecological importance, the genetics of these important species remain poorly described. To improve our understanding of the genetics of these ecological links, we sequenced the mitochondrial genomes of two species of North Pacific krill, Euphausia pacifica and Thysanoessa raschii, using long-range PCR and 454 GS Junior next-generation sequencing technology. The E. pacifica mitogenome (14,692 + base pairs (bp)) encodes 13 protein-coding genes (PCGs), two ribosomal RNA (rRNA) genes, and at least 22 transfer RNA (tRNA) genes. The T. raschii mitogenome (14,240 + bp) encodes 13 PCGs, two rRNA genes, and at least 19 tRNA genes. The gene order in both species is similar to that of E. superba. Comparisons between Bering Sea and Yellow Sea E. pacifica revealed a total of 644 variable sites. The most variable protein-coding gene were atp8 (7.55 %, 12 of 159 sites variable), nad4 (6.35 %, 85 variable sites) and nad6 (6.32 %, 33 variable sites). Phylogenetic analyses to assess the phylogenetic position of the Euphausiacea, using the concatenated nucleic acid sequences of E. pacifica and T. raschii along with 46 previously published malacostracan mitogenomes, support the monophyly of the order Decapoda and indicate that the Euphausiacea share a common ancestor with the Decapoda. Future research should utilize this sequence data to explore the population genetics and molecular ecology of these species.

The Antarctic krill (Euphausia superba Dana 1852) is widely distributed throughout the Southern Ocean, where it provides a key link between primary producers and upper trophic levels and supports a major commercial fishery. Despite its ecological and commercial importance, genetic population structure of the Antarctic krill remains poorly described. In an attempt to illuminate genetic markers for future population and phylogenetic analysis, five E. superba mitogenomes, from samples collected west of the Antarctic Peninsula, were sequenced using new 454 next-generation sequencing techniques. The sequences, of lengths between 13,310 and 13,326 base pairs, were then analyzed in the context of two previously-published near-complete sequences. Sequences revealed relatively well-conserved partial mitochondrial genomes which included complete sequences for 11 of 13 protein-coding genes, 16 of 23 tRNAs, and the large ribosomal subunit. Partial sequences were also recovered for cox1 and the small ribosomal subunit. Sequence analysis suggested that the cox2, nad5, and nad6 genes would be the best candidates for future population genetics analyses, due to their high number of variable sites. Future work to reveal the noncoding control region remains.

Background: Catheter-related bacteremia (CRB) is a frequent complication of tunneled dialysis catheters, and Enterococcus is a common infecting organism. CRB may be treated by instilling an antibiotic lock into the catheter lumen in conjunction with systemic antibiotics. The efficacy of this approach in Enterococcus bacteremia is unknown., Design: Quality improvement report., Setting & Participants: 64 catheter-dependent hemodialysis outpatients with vancomycin-sensitive Enterococcus bacteremia treated with a uniform antibiotic lock protocol. Clinical outcomes were tracked prospectively. QUALITY IMPROVEMENT PLANS: Patients received intravenous vancomycin for 3 weeks in conjunction with a vancomycin lock instilled into both catheter lumens after each dialysis session., Measures: Treatment failure was defined as persistent fever 48 hours after initiation of antibiotic therapy or recurrent Enterococcus bacteremia within 90 days. A clinical cure was defined as fever resolution without recurrent bacteremia. Major infection-related complications within 6 months were documented., Results: Treatment failure occurred in 25 patients (39%) because of persistent fever in 10 and recurrent bacteremia in 15. Treatment success occurred in 39 patients (61%). A serious complication of Enterococcus CRB occurred in 4 of 64 patients (6%); endocarditis in 1 and osteomyelitis in 3. The frequency of serious complications was 16% (4 of 25 patients) in those with treatment failure compared with 0% (0 of 39 patients) in those with treatment success (P = 0.01)., Limitations: This was a single-center study. We did not measure serum vancomycin., Conclusions: An antibiotic lock protocol permits catheter salvage in 61% of hemodialysis patients with Enterococcus CRB. Serious complications occur in 6% of patients and are more common in those with treatment failure.

Background and Objectives: Failure to mature (primary failure) of new fistulas remains a major obstacle to increasing the proportion of dialysis patients with fistulas. This failure rate is higher in women than in men, higher in older than in younger patients, and higher in forearm than in upper arm fistulas. These disparities in the frequency of failure to mature may be due in part to marginal vessels in the high-risk groups and should be reduced by routine preoperative vascular mapping., Design, Setting, Participants, & Measurements: A prospective, computerized database was queried retrospectively to evaluate the frequency of primary fistula failure in 205 hemodialysis patients for whom preoperative mapping was obtained. The association between clinical characteristics and risk for primary fistula failure was analyzed by univariate and multiple variable regression analysis., Results: The overall primary fistula failure rate was 40% (82 of 205 patients). On multiple variable logistic regression, three clinical factors were associated with an increased risk for failure to mature among patients who underwent preoperative vascular mapping: Female gender, age > or =65 yr, and forearm location. The primary fistula failure rate varied from 22% in younger men with an upper arm fistula to 78% in older women with a forearm fistula. Dynamic preoperative vascular measurements (change in peak systolic velocity and resistive index after tight fist clenching) did not differ between patients with mature and immature forearm fistulas., Conclusion: Disparities in fistula maturation persist despite the use of routine preoperative vascular mapping.

People with disabilities are profoundly affected by what is built around and for them, yet far too often they are not consulted during the various phases of a product's life cycle. People with disabilities need to be strong self-advocates and demand relevance to ensure that researchers ask the right questions and that engineers and designers develop products that will meet their needs. This article discusses the need for consumer involvement in all aspects of the design process, from initial concept to research and development and to influencing technology transfer and marketing.

Summertime wind stress along the coast of the northwestern United States typically exhibits intraseasonal oscillations (ISOs) with periods from approximately 15 to 40 days, as well as fluctuations on the 2- to 6-day "weather-band" and 1-day diurnal time scales. Coastal upwelling of cool, nutrient-rich water is driven by extended periods of equatorward alongshore winds, and we show that the approximately 20-day ISOs in alongshore wind stress dominated the upwelling process during summer 2001 off Oregon. These wind stress ISOs resulted from north-south positional ISOs of the atmospheric jet stream (JS). Upper-ocean temperature, phytoplankton, and zooplankton varied principally on the approximately 20-day time scale as well, and these correlated with the ISOs in alongshore wind stress and JS position, even though there also were weather-band stress fluctuations of comparable magnitude. Such wind stress ISOs are typical along Oregon in the summer upwelling season, occurring in 10 of 12 years examined, including 2001. We present a previously unreported direct connection from the atmospheric JS to oceanic primary and secondary production on the intraseasonal time scale and show the leading importance of ISOs in driving this coastal upwelling ecosystem during a typical summer.

Phoretic stages of the exuviotrophic apostome Gymnodinioides pacifica were examined using transmission and scanning electron microscopy (TEM and SEM). TEM revealed that the mature cyst wall possesses 2 or 3 layers differing by the presence or absence of the third inner layer. This inner layer may represent a different form of the middle wall material. The inner cyst layer is approximately 0.15 microm thick and has striations with a periodicity of approximately 19 nm. The middle cyst layer has a variable thickness and the outer dense layer is approximately 0.1 microm thick. The 3 layered cyst wall had a thickness of 0.3-0.7 microm and averaged 0.5 microm. Advanced phoront stages were enclosed by fully formed cyst walls or by cyst walls thinned to approximately 0.1 microm, as the phoronts prepared to excyst prior to host ecdysis. Additionally, we report the fine structure of the rosette, trichocysts, nuclei, food plaquettes, oral fiber, and other cytoplasmic inclusions. SEM revealed an outer cyst wall layer connected to the secreted peduncle material, which was observed to extend over a wide (15 microm) area on the host setae. Cysts were usually attached at their posterior ends or, less frequently, along their side.

Objective: Ménière's disease in an only hearing ear is rare. Our objective is to define the current practice patterns for this problem., Subjects: Clinically active members of the American Otological Society and the American Neurotology Society., Main Outcome Measure: Survey responses., Results: Three hundred fifty-four surveys were sent out, and 165 were returned (48%). Ninety-nine percent recommended dietary modification as first line. Only 39% recommended oral corticosteroids. Second-line treatments were, in order of significance, the Meniett device (Medtronic ENT, Jacksonville, FL, USA), intratympanic corticosteroids, endolymphatic mastoid shunt, intratympanic gentamicin, and endolymphatic sac vein decompression. Interestingly, 71.5% of respondents would operate on an only hearing ear provided the appropriate circumstances., Conclusion: We have documented current practice patterns for treatment. Second-line treatments vary, but the Meniett is recommended most frequently, and further recommendations may not logically progress from least to most invasive. Many respondents eventually offer surgery.

Objectives: Our aims were to introduce temporal bone encephalocele (TBE) to the differential diagnosis of persistent middle ear effusion, cerebrospinal fluid otorrhea, or chronic otitis media in obese adults and to demonstrate the basic pathophysiologic principles of morbid obesity as it may lead to the cascade of increased intra-abdominal pressure, increased central venous pressure, benign increased intracranial pressure, and TBE., Methods: A retrospective review of the medical records was performed to determine the location, nature, and etiology of the encephaloceles identified at our institution from 1989 to 2005. Body mass index was calculated from the patient height and weight data., Results: Eight patients with spontaneous, idiopathic TBE were identified. Body mass index values ranged from 32.0 to 67.5 kg/m(2) with a mean of 48.6 kg/m(2). All patients identified with a spontaneous, idiopathic TBE were obese., Conclusion: TBE is associated with morbid obesity in our population and should be considered in the differential diagnosis when evaluating mastoid and middle ear disease in the morbidly obese.

Palladium-catalyzed coupling of an aryl siloxane and an allylic carbonate proceeded in good yield to give an adduct that was converted to an analogue of (+/-)-7-deoxypancratistatin.

An apostome ciliate, Collinia oregonensis n. sp., is reported inhabiting the cephalothorax and abdomen of 3 euphausiid species from the Oregon-Washington coast: Euphausia pacifica Hansen, 1911, Thysanoessa spinifera Holmes, 1900, and Thysanoessa gregaria G.O. Sars, 1883. This ciliate is the 7th species described for the genus Collinia and the 2nd species known to infect euphausiids. Disease progression and ciliate morphology are described using (1) modified protargol stain, (2) hematoxylin counterstained with Fast Green, and (3) Scanning Electron Microscopy (SEM). All endoparasitic developmental stages (trophont, tomont, tomitogenesis, protomite, and tomite) of C. oregonensis are astomatous and possess between 14 and 22 kineties. C. oregonensis is smaller than C. beringensis Capriulo & Small, 1986, which infects the euphausiid Thysanoessa inermis Krøyer, 1846 in the Bering Sea and which possesses between 24 and 80 kineties. The ciliate is a parasitoid because it must kill the host to complete its life cycle. Infections and mortalities in multiple host species likely reflect the virulent nature of the ciliate. Adult euphausiids infected with this parasitoid possess a swollen and bright orange cephalothorax. C. oregonensis feeds and proliferates inside euphausiids, producing fulminating infections that rupture the cephalothorax and release large numbers of tomites into the surrounding water. After several hours in the free swimming stage under shipboard conditions in the present study, the tomites adhered to each other, forming filaments. Infection rates ranged between 3 and 20% within individual euphausiid aggregations, but infected aggregations were randomly and sparingly distributed. Infected euphausiids were found at 6.7% of 316 stations sampled during 3 summer cruises. No infected euphausiids were collected in winter. Because E. pacifica and T. spinifera account for about 90% of the euphausiid standing stock in the northern California Current System, this parasitoid ciliate may have a significant impact on euphausiid population abundance, distribution and secondary productivity.

A new species of apostome ciliate, Gymnodinioides pacifica n. sp. from the euphausiid Euphausia pacifica is described. The ciliated protozoan encysts on the setae of the appendages, telson and antennae. It excysts and enters the exoskeleton of the host after moulting, where it feeds on exuvial fluid. The phoront and trophont stages of this ciliate are described. The ciliature of the trophont has the following characteristics that distinguish it from the other species of Gymnodinioides: (1) a short kinety 9a (ciliary row 9a or K9a), approximately half of the length of falciform field 8, that extends from the anterior end of the cell posteriorly to the level of K1, (2) a straight K5a, perpendicular to K5b, K6, and K7, and (3) two distinct bands of kineties, K9b-K5b and K4-K1. In addition to those on the host E. pacifica, phoront cysts of similar shape were observed on Thysanoessa spinifera, T. gregaria, T. inspinata, T. longipes, and Nematoscelis difficilis. High prevalence rates were recorded (83%) for these apostome cysts on E. pacifica and T. spinifera during summer collections from the Oregon and Washington coasts. Additionally, we report other apostome ciliate symbionts of euphausiids, including Phtorophrya sp., which preys on apostomes in the genus Gymnodinioides.