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Objective: Residents must become proficient in a variety of procedures. The practice of learning procedural skills on patients has come under ethical scrutiny, giving rise to the concept of simulation-based medical education. Resident training in a simulated environment allows skill acquisition without compromising patient safety. We assessed the impact of a simulation-based procedural skills training course on residents' competence in the performance of critical resuscitation procedures. Methods: We solicited self-assessments of the knowledge and clinical skills required to perform resuscitation procedures from a cross-sectional multidisciplinary sample of 28 resident study participants. Participants were then exposed to an intensive 8-hour simulation-based training program, and asked to repeat the self-assessment questionnaires on completion of the course, and again 3 months later. We assessed the validity of the self-assessment questionnaire by evaluating participants' skills acquisition through an Objective Structured Clinical Examination station. Results: We found statistically significant improvements in participants' ratings of both knowledge and clinical skills during the 3 self-assessment periods (p < 0.001). The participants' year of postgraduate training influenced their selfassessment of knowledge (F2,25 = 4.91, p < 0.01) and clinical skills (F2,25 = 10.89, p < 0.001). At the 3-month follow-up, juniorlevel residents showed consistent improvement from their baseline scores, but had regressed from their posttraining measures. Senior-level residents continued to show further increases in their assessments of both clinical skills and knowledge beyond the simulation-based training course. Conclusion: Significant improvement in self-assessed theoretical knowledge and procedural skill competence for residents can be achieved through participation in a simulation-based resuscitation course. Gains in perceived competence appear to be stable over time, with senior learners gaining further confidence at the 3-month follow-up. Our findings support the benefits of simulation-based training for residents. [ABSTRACT FROM AUTHOR]

We identified in this experiment two muon configurations in Lu2O3, the oxygen-bound (O-Mu+) ground state and a metastable (energy barrier 0.7(3) eV) atom-like excited state. These configurations are partially not formed immediately after implantation but somewhat delayed due to the requirement of a lattice rearrangement around the muon. These rearrangement processes occur on a timescale of ns to µs and are thus observable in µSR experiments. A special role plays a fairly long-lived (ns to µs) transition state as an intermediate step in the reaction process.

Abstract Background Ultrasound guidance during central line insertion has significantly reduced complications associated with this procedure and has led to it being incorporated as standard of care in many institutions. However, inadvertent arterial penetration and dilation remains a problem despite ultrasound guidance and can result in significant morbidity and even mortality. Dynamic ultrasound confirmation of guidewire position within the vein prior to dilation may help to prevent and even eliminate this feared complication. Methods A prospectively collected database of central line insertions for one author utilizing this novel technique was retrospectively reviewed for all incidents of arterial dilation over a period from September 2008 to January 2010. Results During the study period 53 central lines were inserted with no incidents of arterial dilation. Conclusions Ultrasound confirmation of guidewire position has the potential to reduce or eliminate the morbidity and mortality of arterial dilation during central line placement.

Abstract Background Pulse oximetry is routinely used to continuously and noninvasively monitor arterial oxygen saturation (SaO2) in critically ill patients. Although pulse oximeter oxygen saturation (SpO2) has been studied in several patient populations, including the critically ill, its accuracy has never been studied in emergency department (ED) patients with severe sepsis and septic shock. Sepsis results in characteristic microcirculatory derangements that could theoretically affect pulse oximeter accuracy. The purposes of the present study were twofold: 1) to determine the accuracy of pulse oximetry relative to SaO2 obtained from ABG in ED patients with severe sepsis and septic shock, and 2) to assess the impact of specific physiologic factors on this accuracy. Methods This analysis consisted of a retrospective cohort of 88 consecutive ED patients with severe sepsis who had a simultaneous arterial blood gas and an SpO2 value recorded. Adult ICU patients that were admitted from any Calgary Health Region adult ED with a pre-specified, sepsis-related admission diagnosis between October 1, 2005 and September 30, 2006, were identified. Accuracy (SpO2 - SaO2) was analyzed by the method of Bland and Altman. The effects of hypoxemia, acidosis, hyperlactatemia, anemia, and the use of vasoactive drugs on bias were determined. Results The cohort consisted of 88 subjects, with a mean age of 57 years (19 - 89). The mean difference (SpO2 - SaO2) was 2.75% and the standard deviation of the differences was 3.1%. Subgroup analysis demonstrated that hypoxemia (SaO2 < 90) significantly affected pulse oximeter accuracy. The mean difference was 4.9% in hypoxemic patients and 1.89% in non-hypoxemic patients (p < 0.004). In 50% (11/22) of cases in which SpO2 was in the 90-93% range the SaO2 was Conclusions Pulse oximetry overestimates ABG-determined SaO2 by a mean of 2.75% in emergency department patients with severe sepsis and septic shock. This overestimation is exacerbated by the presence of hypoxemia. When SaO2 needs to be determined with a high degree of accuracy arterial blood gases are recommended.

Aims: Early identification of patients likely to die after acetaminophen (APAP) poisoning remains challenging. We sought to compare the sensitivity and time to fulfilment (latency) of established prognostic criteria., Methods: Three physician toxicologists independently classified every in-hospital death associated with APAP overdose from eight large Canadian cities over three decades using the Relative Contribution to Fatality scale from the American Association of Poison Control Centres. The sensitivity and latency were calculated for each of the following criteria: King's College Hospital (KCH), Model for End Stage Liver Disease (MELD) ≥33, lactate ≥3.5 mmol/L, phosphate ≥1.2 mmol/L 48+ hours post-ingestion, as well as combinations thereof., Results: A total of 162 in-hospital deaths were classified with respect to APAP as follows: 26 Undoubtedly, 40 Probably, 27 Contributory, 14 Probably not, 25 Clearly not, and 30 Unknown. Cases from the first three classes (combined into n = 93 "APAP deaths") typically presented with supratherapeutic APAP concentrations, hepatotoxicity, acidaemia, coagulopathy and/or encephalopathy, and began antidotal treatment a median of 12 hours (IQR 3.4-30 h) from the end of ingestion. Among all patients deemed "APAP deaths", meeting either KCH or lactate criteria demonstrated the highest sensitivity (94%; 95% CI 86-98%), and the shortest latency from hospital arrival to criterion fulfilment (median 4.2 h; IQR 1.0-16 h). In comparison, the MELD criterion demonstrated a substantially lower sensitivity (55%; 43-66%) and longer latency (52 h; 4.4-∞ h, where "∞" denotes death prior to criterion becoming positive)., Conclusions: Meeting either KCH or serum lactate criteria identifies most patients who die from acetaminophen poisoning at or shortly after hospital presentation., (© 2021 British Pharmacological Society.)

Background: Determining procedural competence requires psychometrically sound assessment tools. A variety of instruments are available to determine procedural performance for central venous catheter (CVC) insertion, but it is not clear which ones should be used in the context of competency-based medical education., Objective: We compared several commonly used instruments to determine which should be preferentially used to assess competence in CVC insertion., Methods: Junior residents completing their first intensive care unit rotation between July 31, 2006, and March 9, 2007, were video-recorded performing CVC insertion on task trainer mannequins. Between June 1, 2016, and September 30, 2016, 3 experienced raters judged procedural competence on the historical video recordings of resident performance using 4 separate tools, including an itemized checklist, Objective Structured Assessment of Technical Skills (OSATS), a critical error assessment tool, and the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE). Generalizability theory (G-theory) was used to compare the performance characteristics among the tools. A decision study predicted the optimal testing environment using the tools., Results: At the time of the original recording, 127 residents rotated through intensive care units at the University of Calgary, Alberta, Canada. Seventy-seven of them (61%) met inclusion criteria, and 55 of those residents (71%) agreed to participate. Results from the generalizability study (G-study) demonstrated that scores from O-SCORE and OSATS were the most dependable. Dependability could be maintained for O-SCORE and OSATS with 2 raters., Conclusions: Our results suggest that global rating scales, such as the OSATS or the O-SCORE tools, should be preferentially utilized for assessment of competence in CVC insertion., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background:: Cheerleading is a specialized athletic activity that can lead to catastrophic injuries. Cheerleading rules are in place to maximize safety of participants. The purpose of this study was to describe catastrophic cheerleading injuries among high school and collegiate-level participants in the United States and to explore whether the 2006-2007 basket toss rule change was effective at reducing the number of catastrophic injuries., Hypothesis:: The 2006-2007 basket toss rule change contributed to a reduction in the number of catastrophic injuries among high school and collegiate cheerleaders., Study Design:: Case series., Level of Evidence:: Level 4., Methods:: Data on catastrophic cheerleading injuries were collected by the National Center for Catastrophic Sport Injury Research from July 2002 to June 2017. Information collected included cheerleader, event, and injury characteristics. The impact of the 2006-2007 rule change banning the basket toss on any hard surfaces was assessed by comparing injury rates and 95% CIs before and after the rule change., Results:: There were 54 catastrophic cheerleading injuries, or 3.6 injuries per year. From July 2002 through June 2017, the injury rate was 2.12 per 1,000,000 cheerleaders (95% CI, 1.56-2.69). Most cheerleaders sustained serious injuries (n = 27; 50%) during practice (n = 37; 69%) to the head (n = 28; 52%) and cervical spine (n = 17; 32%). From July 2002 through June 2017, basket tosses were the stunt that accounted for the highest proportion of injuries (n = 19; 35%). The basket toss injury rate decreased from 1.55 to 0.40 per 1,000,000 cheerleaders among both high school and collegiate cheerleaders after the rule change., Conclusion:: Catastrophic injury rates in cheerleading decreased dramatically after the 2006-2007 rule change banning basket tosses from being performed on any hard surfaces. In particular, there was a nearly 4-fold reduction in the rate of catastrophic basket toss injuries.

Purpose: To study the effect of a peer mentoring group (PMG)., Method: Six junior clinician educator faculty and one senior faculty at the University of Washington Medical Center's Department of Psychiatry formed a PMG in 2006. The PMG had 30 meetings during 2006-2010. Group format, goals, and meeting agendas were determined solely by participants. Feedback about positive and negative outcomes of participation in the PMG was determined by open-ended response to three sets of questions; qualitative analysis was performed by an outside research consultant., Results: Program evaluation revealed benefits and undesirable or unintended outcomes. Reported benefits were increased workplace satisfaction; improved social connection; increased professional productivity and personal growth/development through accountability, collaboration, mutual learning, support, and information sharing; synergy, collaboration, and diversity of thought; increased involvement in professional activities; opportunity for peer discussions in a safe environment; and increased accountability and motivation. Undesirable or unintentional outcomes were exclusivity, lack of hierarchy, scheduling of meetings, absence of an intentional curriculum, diverse and competing interests, personal-professional enmeshment, and occasional loss of focus due to overemphasis on personal matters. Every member of the PMG was retained, and scholarly productivity increased, as did collaboration with other group members., Conclusions: Participants in this PMG experienced qualitative benefits and perceived advantages in career advancement and scholarly productivity. Negative consequences did not deter participation in the PMG or outweigh benefits. The self-sufficient and low-cost structure makes it particularly portable.

Background: Total volume using a standard single inferonasal injection for sub-Tenon's anaesthesia is limited by an increase in intraocular pressure (IOP) and commonly requires the operating surgeon to top-up the block intraoperatively. This study compares the efficacy and safety of a two-quadrant technique that allows the use of a higher volume of local anaesthetic., Methods: 54 patients undergoing vitrectomy were randomised into two groups. The control group (n=27) received a standard 5 ml single inferonasal sub-Tenon injection of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 150 IU hyaluronidase. The study group (n=27) received a 5 ml inferonasal and 5 ml superotemporal injection of the same mixture (10 ml total). The primary outcome measure was the number of intraoperative top-ups required. Secondary outcome measures were intraoperative and postoperative pain scores, IOP, block onset time, ocular akinesia, eyelid akinesia and chemosis., Results: 24 patients required a top-up in the control group. No patients required a top-up in the study group (p<0.001). IOP measurements were similar in both groups. Block onset was shorter, eyelid akinesia was improved and pain scores were also reduced in the study group intraoperatively and at 0-2 h, 4-6 h, 10-14 h and 20-24 h postoperatively., Conclusions: Two-quadrant sub-Tenon's anaesthesia using 10 ml of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 150 IU hyaluronidase seems to be more effective than a single-quadrant technique at reducing intraoperative and postoperative pain during vitrectomy.

Objective: To determine patterns of use of ceftriaxone and cefotaxime (CEFX) in Victorian hospitals and to identify areas for improvement., Design, Patients and Setting: A concurrent, observational evaluation of CEFX use in patients commencing a course of these drugs between 8 and 14 September, 1999, in 51 Victorian hospitals., Main Outcome Measures: Proportion of patients treated with CEFX; indications; duration of use; concordance with recommendations of national antibiotic guidelines (Therapeutic guidelines: antibiotic, 10th edition [AG10])., Results: 671 patients were treated with CEFX. The overall rate of use was 43 patients per 1000 inpatient separations. Treatment of respiratory tract infection accounted for 352 patients (52%) and surgical prophylaxis for 99 patients (15%). Treatment of skin/soft tissue, urinary tract and gastrointestinal tract infections accounted for about 7% of patients each. The median duration of CEFX courses was 3.0 days. The overall rate of concordance with indications recommended in AG10 was 27%. The rate of concordance for empirical treatment of respiratory tract infection was 24%. Of the 195 patients treated empirically with CEFX for community-acquired respiratory tract infection and assessed as non-concordant, 64% did not have radiological evidence of pneumonia, and a further 30% did not fulfill the criteria for severe pneumonia. All courses given for surgical prophylaxis were non-concordant., Conclusions: CEFX is widely used in Victorian hospitals, mostly to treat lower respiratory tract infection and in surgical prophylaxis of infection. The rate of concordance with AG10 is low. Potential areas for intervention include empirical treatment of respiratory tract infection and use in surgical prophylaxis.

Clinical log books were completed by the 1995-1996 clinical clerks at Queen's University, Kingston, Ontario, Canada, during their 2-wk rotation in emergency medicine. To determine the clinical activities of the students and assess the educational effectiveness of our clerkship program, the information recorded in these log books was compared with the results of a survey of the emergency department (ED) staff physicians. This survey asked the physicians to identify five essential clinical presentations and procedural skills that they felt the clerks must observe during their rotation in the ED. To our knowledge, this is the first Canadian report using log books as a quality assurance tool for a clerkship program in emergency medicine. This study has highlighted specific weaknesses in the clinical activities of the clerks and will serve as a valuable resource for future assessments of the emergency medicine rotation at our institution.

We investigated the expression of the cytochrome P450 isozyme, CYP1A1, during the course of tumor development and examined the distribution of the CYP1A1 protein in hyperplastic foci, adenomas and carcinomas. The expression of NADPH-cytochrome P450 reductase, a flavoprotein that mediates the reduction of cytochrome P450, was also determined. Mice were administered urethane (1 mg/g body wt) and were killed at 10, 22 and 52 weeks to coincide with the time at which hyperplastic foci, adenomas and carcinomas were established, respectively. Protein immunoblotting revealed that the antibody for CYP1A1 detected a protein band of approximately M(r) 56,000 in microsomes from mice treated with beta-naphthoflavone. The antibody for NADPH-cytochrome P450 reductase detected a protein band of approximately M(r) 79,000 in microsomes from control mice and mice treated with beta-naphthoflavone. Immunohistochemical studies showed that CYP1A1 was not detected constitutively in the lungs of both non-tumor- and tumor-bearing mice. Treatment with beta-naphthoflavone evoked high induction of CYP1A1 in morphologically normal tissues of all mice, with localization of the protein mainly in endothelial and alveolar type II cells. In contrast, inducibility of CYP1A1 by beta-naphthoflavone was markedly reduced in early hyperplastic foci seen 10 weeks after urethane exposure. At 22 weeks, CYP1A1 was found at low levels in both solid and papillary tumors, whereas at 52 weeks, lung carcinomas were devoid of expression of this protein. However, CYP1A1 inducibility was highly expressed in late hyperplastic foci manifested at 52 weeks. NADPH-cytochrome P450 reductase was expressed in morphologically normal lung tissue of all mice under control conditions and after treatment with beta-naphthoflavone, and was localized mainly in Clara and alveolar type II cells. In contrast, reductase expression in all tumor sites was diminished and closely paralleled that of CYP1A1. These results demonstrated progressive depression of induced CYP1A1 and reductase expression in early hyperplasias, adenomas and carcinomas, suggesting that the co-ordinate regulation of both enzymes is highly conserved during tumor development. Furthermore, these findings suggested diminished capabilities for metabolic activation of potential toxicants and/or carcinogens after neoplastic transformation.

Five hundred one women from Dallas County, Texas who participated in the American Cancer Society 1987 Texas Breast Screening Project were selected because of a self-reported family history of breast cancer (cases). They were matched with 501 randomly selected women from the same county with no family history (controls). Although there was a statistically significant trend with age for an increasing proportion of women to report having undergone mammography, there was no significant difference when comparing mammographic histories of cases with controls after controlling for age (31.5% versus 35.1%, P = 0.33). Significantly more cases (79%) perceived their risk for breast cancer to be moderate or greater compared with controls (54%, P less than 0.0001), but mammographic histories were not different when controlling for perceived risk. Both cases and controls cited lack of physician referral and cost as their reasons for not having undergone mammography. Women at increased risk for breast cancer (because of their family history) are not undergoing regular mammographic screening despite their self-awareness of the increase in their risk.

For characterisation in vitro, four parallel assays were used: the guinea-pig ileum and mouse vas deferens as pharmacological models at 36 degrees C and the inhibition of binding of [3H]-naltrexone, [3H]-leucine-enkephalin and [3H]-methione-enkephalin at 0 degrees C. The Leu65-analogue of beta-andorphin and its fragments (61-65, 61-76 and 61-77) have a lower affinity to the [3H]-naltrexone binding site of mu-receptors than the corresponding Met65-peptides wereheas no such difference was found for the [3H]leucine-enkephalin binding sites or delta-receptors. When the binding of [3H]-methionine-enkephalin or [3H]-leucine-enkephalin was inhibited by cold ligands interacting with delta-, mu-, or kappa-receptors, no evidence was obtained for more than one type of delta-binding site.

1 The activity pattern of analogues of the enkephalins was determined in four parallel assays, the inhibition of the electrically evoked contraction of the guinea-pig ileum and mouse vas deferens at 36 degrees C and the inhibition of [(3)H]-naltrexone and [(3)H]-leucine-enkephalin binding at 0 to 4 degrees C in homogenates of guinea-pig brain.2 The activity pattern was best characterized by the ratio of the potency in the guinea-pig ileum to that in the mouse vas deferens (G.p.i./M.v.d.) and the ratio of the potency in inhibiting [(3)H]-naltrexone binding to that in inhibiting [(3)H]-leucine-enkephalin binding (Nal/Leu).3 The enkephalins had low G.p.i./M.v.d. (0.02 to 0.09) and low Nal/Leu (0.05 to 0.18) ratios whereas the corresponding values for morphine were 7.0 and 7.5.4 Analogues obtained by substituting D-Ala for Gly(2) and D-Met or D-Leu for L-Met(5) or L-Leu(5) showed only minor changes in G.p.i./M.v.d. (0.01 to 0.11) and in Nal/Leu (0.06 to 0.13) ratios.5 Analogues in which resistance to enzymatic degradation was brought about by amidation of the C-terminal carboxylic group or methylation of the amino group of tyrosine or both modifications, had G.p.i./M.v.d. ratios of 1.2 to 5.5 and Nal/Leu ratios of 0.5 to 21. High values (2.1 and 3.4) were found for the potent antinociceptive analogue of Sandoz, Tyr-D-Ala-Gly-NCH(3)Phe-Met(O)-ol.6 In the mouse vas deferens, some of the analogues with high G.p.i./M.v.d. and Nal/Leu ratios were tested for antagonism by naloxone and found to require less than the high concentration needed for the natural enkephalins. C57/BL mice, which have a lowered sensitivity to morphine but a normal response to peptides with low G.p.i./M.v.d. and Nal/Leu ratios, had a lowered sensitivity to analogues with high ratios.7 In the alkaloid-like series of narcotic analgesic drugs, ketobemidone, levorphanol, methadone, etorphine and the antagonist Mr 2266 had lower Nal/Leu ratios (1.0 to 2.8) than morphine, normorphine, naloxone and naltrexone (8 to 12).8 It would appear that compounds with low G.p.i./M.v.d. and Nal/Leu ratios interact mainly with delta-receptors in the brain and peripheral nervous system while compounds with high ratios interact mainly with mu-receptors. For antinociceptive action mu-receptors may be more important than delta-receptors.

The effects of clonidine, UK-14,304, noradrenaline, para-aminoclonidine and phenylephrine were examined on the acid secretory response of the rat isolated gastric mucosa preparation to electrical field stimulation. Clonidine, UK-14,304, noradrenaline and para-aminoclonidine but not phenylephrine (10 microM) reduced the response of the gastric mucosa stimulated at 2.5 Hz; gastric mucosae stimulated at higher frequencies were insensitive to the action of these alpha 2-adrenoceptor agonists. The inhibitory effect of the selective alpha 2-adrenoceptor agonist UK-14,304 was antagonized by idazoxan but not by prazosin. These findings indicate that clonidine and other alpha 2-adrenoceptor agents inhibit the acid secretory response of the rat gastric mucosa to electrical field stimulation by an action at alpha 2-adrenoceptors, which are probably located on cholinergic nerve terminals.

Appropriate modification of 14 beta-methoxy- and 14 beta-ethoxycodeinone (prepared by alkylation of 14 beta-hydroxycodeinone) has generated four alkoxy analogues (3a-d) of naloxone and naltrexone. These agents were pure narcotic antagonists in contradiction to the predictions of the common anionic receptor site hypothesis, postulated to be of importance in the enhanced antagonism of naloxone. The molecular change from allyl to cyclopropylmethyl on the N atom increased selectivity of these antagonists for the mu receptor to the same extent as found for naloxone. Increase in the length of the C14 O-substituent had no effect on receptor selectivity, and either formation in most cases did not significantly alter oral/parenteral ratios of durations of action.

The effect of physostigmine has been studied on cholinesterase in homogenates of chick biventer cervicis muscles and on the contractile responses of the intact muscles to acetylcholine and carbachol. The concentration of physostigmine required to produce the maximum increase in sensitivity to acetylcholine almost completely inhibited the cholinesterase in muscle homogenates. This concentration of physostigmine had no effect on muscle contractures elicited by carbachol. By taking account of the combined effects of acetylcholine diffusion and enzymic hydrolysis, a quantitative theoretical relationship has been derived between the level of cholinesterase activity in cylindrical muscles and the fractional occupancy of the acetylcholine receptors in these muscles in the presence of different concentrations of exogenous acetylcholine. This theory attributes the thousand-fold increase in sensitivity to exogenous acetylcholine produced by anticholinesterases in chick biventer cervicis muscles largely to an alteration in acetylcholine concentration gradient within the muscle and accounts satisfactorily for the shift in the dose-response curve for acetylcholine which occurs after treatment of the muscles with various concentrations of physostigmine.

Opioid peptides were assayed by inhibition of 3H-naloxone and 3H-leu-enkephalin binding in brain homogenates and by depression of contractions of the guinea pig ileum and mouse vas deferens. We conclude that the opioid peptidergic system has agonists of different characteristics which interact with more than one type of receptor.

Peptides based in the stabilised tetrapeptide HTyr-D-Ala-Gly-MePheOH have been synthesised and shown to have substantial opioid activity both in vitro and in vivo. The selectivity of these compounds of different receptor populations has been investigated using both isolated tissue assays and binding studies. Results suggest that the compounds are potent agonists at mu-receptors with little or no affinity for the delta-receptor population. One of the compounds, RX783006 (HTyr-D-Ala-Gly-MePhe-NH(CH2)2OH), has been tritiated to high specific radioactivity and may prove to be a useful probe in the elucidation of the function of the heterogenous opiate receptor population.

A 55-yr old woman with refractory anaemia with excess of blasts in transformation developed prolonged bone marrow hypoplasia following two courses of mitozantrone and cytosine arabinoside. The administration of granulocyte-monocyte colony stimulating factor after two months of pancytopenia led to recovery of normal bone-marrow function, without any morphological evidence of myelodysplasia, which has persisted until the last blood count (6 months +).