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Audience: The targeted audience for this simulation is Emergency Medicine (EM) residents. Medicalstudents, advanced practice providers, and staff physicians could all also find educational merit in thisscenario.Background: Cardiovascular disease is the leading cause of death in the United States according to the CDC.1Coronary artery disease caused 375,000 deaths 2021 alone, and about 5% of all adult patients have a priorhistory of coronary artery disease.2 Furthermore, chest pain itself is a common chief complaint encounteredin the ED, with nearly 8 million visits annually occurring throughout the United States, with 10-20% of thosepatients ultimately being diagnosed with an acute coronary syndrome3, including ST-elevation myocardialinfarction (STEMI). Given this, it is essential that EM residents are well prepared to care for all patientspresenting with chest pain, regardless of the acute care or emergency setting.Throughout their training, most EM residents typically learn and evaluate patients at a large tertiary orquaternary medical center with 24-hour catheterization laboratory availability. For patients presenting withelectrocardiogram (EKG) findings consistent with STEMI, the standard of care is for the patient to undergocardiac catheterization and stent placement within 90 minutes of arrival. Unfortunately, only half of patientsliving in rural areas have a cardiac catheterization-capable facility available to them within a 60-minutedriving radius, making it difficult for those patients to undergo cardiac catheterization within the desired timeframe.4 These patients remain candidates for thrombolytic therapy, but given infrequent opportunities tolearn about and deploy thrombolytic agents during residency training, graduating EM residents may beunfamiliar with indications, dosing, and contraindications before they begin practice. Furthermore, the recent EM workforce data suggests that although there may be an oversupply of 8,000 emergency physiciansby 2030, robust practice opportunities for emergency physicians remain in rural settings.5 Althoughhistorically EM graduates have not selected rural areas for practice, with only approximately 8% ofemergency physicians practicing in rural areas,6 it is likely that given the opportunities present and perceivedsaturation in many non-rural settings, more EM graduates will pursue practice in a rural setting. With thesechanging practice dynamics in mind, this simulation provides the opportunity for residents and medicalstudents to experience the management of a STEMI in the rural setting, with a focus upon the indications,contraindications, dosing, and disposition of a patient receiving thrombolytics.Educational Objectives: By the end of this simulation, learners will be able to:1. Diagnose ST elevation myocardial infarction accurately and initiate thrombolysis in the rural settingwithout timely access to cardiac catheterization.2. Engage the simulated patient in a shared decision-making conversation, clearly outlying the benefitsand risks of thrombolysis.3. Identify the indications and contraindications for thrombolysis in ST elevation myocardial infarction.4. Arrange for transfer to a tertiary care center following completion of thrombolysis.Educational Methods: This scenario is a simulated encounter in a rural emergency department settingrequiring the diagnosis of a STEMI, a discussion with the patient regarding the risks and benefits ofthrombolysis prior to administration, administration of thrombolysis, and transfer of patient to a higher levelof care.Research Methods: The educational content of this simulation as a teaching instrument was evaluated bythe learner utilizing an internally developed survey after case completion. This survey was reviewed forprecision of language and assessment of learning objectives by our simulation faculty and other members ofour West Virginia University Emergency Medicine Department of Medical Education. The learner was askedto specify any prior experience with rural STEMI management as well as quantify via a five-point Likert Scale,where 1 = very uncomfortable and 5 = very comfortable, their level of comfort with thrombolysis before andafter the scenario as well as their comfort with having a shared decision-making conversation with patientswith regards to thrombolysis. Learners were also asked to rank the helpfulness of this simulation in preparingthem for administering thrombolytics for STEMI in a rural setting on a five-point Likert scale, where 1 = nothelpful and 5 =very helpful. An open response section was also provided to allow learners the opportunity tocomment directly on any aspect of the simulation.Results: Data was collected anonymously from 16 PGY1-3 resident learners via surveys with a 100% responserate. Overall, the feedback received regarding the simulation was positive. There was a low average comfortlevel with administering thrombolytics and having a shared decision-making conversation regardingadministering thrombolytics. There was a high average rating of the helpfulness of this simulation in preparing residents for this conversation as well as managing STEMIs in a rural setting. Subjective commentsregarding the simulation were universally positive.Discussion: The management of STEMI in the rural emergency department differs significantly from theenvironment in which many EM residents train. As a leading cause of death in the United States, STEMImanagement is a vital component of EM resident education. Although the concept of thrombolysis in the rural setting is discussed, the opportunity for real-world experience in its execution is often limited despitemany graduates ultimately working in rural emergency departments. This simulation sought to provide arealistic patient encounter to promote familiarity and comfort in the identification, patient discussion andexecution of thrombolysis in the treatment of a STEMI. The educational content was shown to be effectivevia learner survey completion.

K‐changes are observed as step‐like increases in the thundercloud electric fields. The K‐changes occur in the late part of intra‐cloud lightning or during negative cloud‐to‐ground lightning between return strokes. It has been shown that the processes leading to K‐changes initiate in the decayed part of a positive leader channel and propagate toward the flash origin. They are often accompanied by microsecond‐scale electric field pulses. We introduce a new model to simulate processes leading to the K‐changes in cloud‐to‐ground lightning. Our method is based on the full solution of Maxwell's equations coupled to Poisson's equation for the thundercloud charge structure. To model the K‐changes, we gradually increase the decayed channel conductivity. The modeled current wavefront propagates due to the K‐processes downward along a vertical channel and completely attenuates before reaching the ground. We derive the evolution of the linear charge densities and the scalar electric potential along the channel leading to K‐changes. We model electrostatic step‐like changes in the measured electric field together with the approximate rates and amplitudes of the microsecond scale pulses. Step‐like changes increase their amplitudes with the length of the simulated channel and with a higher conductivity of the channel. The microsecond‐scale pulse waveshapes depend mainly on the propagation velocity of the current wave, and the time scale of the conductivity increase. We show that our modeled waveforms are in a good agreement with observations conducted in Florida. Plain Language Summary: K‐changes are the step‐like increases in the measured electric fields in the late part of an intra‐cloud lightning and between return strokes in cloud‐to‐ground lightning. The K‐changes are often accompanied by microsecond‐scale electric field pulses. We have developed a new model to simulate the K‐changes in cloud‐to‐ground lightning. We solve electrodynamic equations to model these processes and we are able to reproduce the observed electric field waveforms recorded in Florida by a flat‐plane antenna. We model how the current wave propagates along the vertical channel and attenuates before reaching the ground. We show how the charges are distributed along the simulated channel and we model why in some cases the breakdown occurs at the positive end of the channel after the recoil leader propagates several hundreds of meters along a decayed channel. Key Points: We model for the first time the simultaneous occurrence of step‐like changes and microsecond‐scale pulses related to K‐changesThe waveshape of the microsecond‐scale pulses depends mainly on the current front propagation velocity and the conductivity rise timeThe modeled amplitudes and repetition rates are in a good agreement with observations [ABSTRACT FROM AUTHOR]

The disestablishment clause of the U.S. Constitution has led educators in the United States to establish guidelines about addressing religion in the classroom. As a basic rule, districts have allowed teaching about religion without encouraging or supporting a particular religion. This article suggests that patriotism and patriotic expressions are, in fact, religious and that encouraging or supporting patriotism may be tantamount to establishing a state religion in the classroom.

This article originated from a single question: do the restrictions that various accrediting agencies place on teacher educators limit, or entirely eliminate, academic freedom? Considering that question makes it apparent the problem is much broader than academic freedom. The issue has two foci: personal identity and the impact of market influences, and the attendant model of rationality, on education. The argument here, however, is that restricting teacher educators' academic freedom really signifies a deeper and more-systemic problem facing society today. Although academic freedom's history is elusive, the nineteenth-century introduction of the freedom to teach and learn has allowed academicians the freedom to teach what they think appropriate using whatever pedagogical methodology they prefer. The assault on academic freedom is only a symptom of a deeper and more-insidious problem in higher education in general and teacher education in particular. As teacher educators construct syllabi, they no longer act as arbiters, based on expertise and competency, of the content and methodology of their courses and programs. Instead teacher educators must meet standards imposed by the various accrediting agencies. The implication is clear: accrediting agencies can deprive institutions, faculty, and students of academic freedom by attacking the individual's self-identity.

The adverse effects of stress on brain and behavior have long been known and well-studied, with abundant evidence linking stress to, among other things, mood and anxiety disorders. Likewise, many have investigated potential treatments for stress-related mood and anxiety phenotypes and demonstrated good response to standard antidepressant medications like selective serotonin reuptake inhibitors (SSRIs), as well as environmental manipulations like exercise or enrichment. However, the extent to which stress and various treatments act on overlapping pathways in the brain is less well understood. Here, we used a widely studied social defeat stress paradigm to induce a robust depression- and anxiety-like phenotype and chronic corticosterone elevation that persisted for at least 4 weeks in wild type male mice. When mice were treated with either the SSRI fluoxetine or an enriched environment, both led to similar behavioral recovery from social defeat. We then focused on the amygdala and assessed the effects of social defeat, fluoxetine, and enrichment on 168 genes broadly related to synaptic plasticity or oxidative stress. We found 24 differentially expressed genes in response to social defeat stress. Interestingly, fluoxetine led to broad normalization of the stress-induced expression pattern while enrichment led to expression changes in a separate set of genes. Together, this study provides additional insight into the chronic effects of social defeat stress on behavior and gene expression in the amygdala. The findings also suggest that, for a subset of genes assessed, fluoxetine and environmental enrichment have strikingly divergent effects on expression in the amygdala, despite leading to similar behavioral outcomes.

This case addresses the critical topic in education of developing students' skills and capabilities associated with enterprise-level business intelligence systems and associated internal control concerns. The experiences of using a business intelligence,task-based activity in an interdisciplinary curriculum model are presented and discussed. Pedagogically, the task-based activity enhances perceived learning for both accounting and IS disciplines indomain (internal controls and IS development), communication (comprehension and creation), and critical thinking skills. Additionally, students appreciate the realism and active learning associated with the task-based activity delivered in an interdisciplinary curriculum model. The design of the task-based activity as a teaching resource allows other instructors, based on their requirements, to develop a lesson plan around using the activity as written, or focusing on the any of the many aspects of controls or technology presented.

Healthcare workers (HCWs) are at increased risk of infection from SARS-CoV-2 and other disease pathogens, which take a disproportionate toll on HCWs, with substantial cost to health systems. Improved infection prevention and control (IPC) programmes can protect HCWs, especially in resource-limited settings where the health workforce is scarcest, and ensure patient safety and continuity of essential health services. In response to the COVID-19 pandemic, we collaborated with ministries of health and development partners to implement an emergency initiative for HCWs at the primary health facility level in 22 African countries. Between April 2020 and January 2021, the initiative trained 42 058 front-line HCWs from 8444 health facilities, supported longitudinal supervision and monitoring visits guided by a standardised monitoring tool, and provided resources including personal protective equipment (PPE). We documented significant short-term improvements in IPC performance, but gaps remain. Suspected HCW infections peaked at 41.5% among HCWs screened at monitored facilities in July 2020 during the first wave of the pandemic in Africa. Disease-specific emergency responses are not the optimal approach. Comprehensive, sustainable IPC programmes are needed. IPC needs to be incorporated into all HCW training programmes and combined with supportive supervision and mentorship. Strengthened data systems on IPC are needed to guide improvements at the health facility level and to inform policy development at the national level, along with investments in infrastructure and sustainable supplies of PPE. Multimodal strategies to improve IPC are critical to make health facilities safer and to protect HCWs and the communities they serve.