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Introduction: Emergency medicine (EM) residency programs have variable approaches to educating residents on recognizing and managing healthcare disparities. We hypothesized that our curriculum with resident-presented lectures would increase residents’ sense of cultural humility and ability to identify vulnerable populations. Methods: At a single-site, four-year EM residency program with 16 residents per year, we designed a curriculum intervention from 2019-2021 where all second-year residents selected one healthcare disparity topic and gave a 15-minute presentation overviewing the disparity, describing local resources, and facilitating a group discussion. We conducted a prospective observational study to assess the impact of the curriculum by electronically surveying all current residents before and after the curriculum intervention. We measured attitudes on cultural humility and ability to identify healthcare disparities among a variety of patient characteristics (race, gender, weight, insurance, sexual orientation, language, ability, etc). Statistical comparisons of mean responses were calculated using the Mann-Whitney U test for ordinal data. Results: A total of 32 residents gave presentations that covered a broad range of vulnerable patient populations including those that identify as Black, migrant farm workers, transgender, and deaf. The overall survey response was 38/64 (59.4%) pre-intervention and 43/64 (67.2%) post-intervention. Improvements were seen in resident self-reported cultural humility as measured by their responsibility to learn (mean responses of 4.73 vs 4.17; P < 0.001) and responsibility to be aware of different cultures (mean responses of 4.89 vs 4.42; P < 0.001). Residents reported an increased awareness that patients are treated differently in the healthcare system based on their race (P < 0.001) and gender (P < 0.001). All other domains queried, although not statistically significant, demonstrated a similar t rend. Conclusion: This study demonstrates increased resident willingness to engage in cultural humility and the feasibility of resident near-peer teaching on a breadth of vulnerable patient populations seen in their clinical environment. Future studies may query the impact this curriculum has on resident clinical decision-making.

Background Emergency physicians (EPs) perform critical actions while operating with diagnostic uncertainty. Point-of-care ultrasound (POCUS) is useful in evaluation of dyspneic patients. In prior studies, POCUS is often performed by ultrasound (US) teams without patient care responsibilities. Objectives This study evaluates the effectiveness of POCUS in narrowing diagnostic uncertainty in dyspneic patients when performed by treating EPs vs. separate US teams. Methods This multicenter, prospective noninferiority cohort study investigated the effect of a POCUS performing team in patient encounters for dyspnea. Before-and-after surveys assessing medical decision-making were administered to attending physicians. Primary outcome was change in most likely diagnosis after POCUS. This was assessed for noninferiority between encounters where the primary or US team performed POCUS. Secondary outcomes included change in differential diagnosis, confidence in diagnosis, interventions considered, and image quality. Results There were 156 patient encounters analyzed. In the primary team group, most likely diagnosis changed in 40% (95% confidence interval 28–52%) of encounters vs. 32% (95% confidence interval 22–41%) in the US team group. This was noninferior using an a priori specified margin of 20% (p Conclusion POCUS performed by primary teams was noninferior to POCUS performed by US teams for changing the most likely diagnosis, and equivalent when considering mean reduction in number of diagnoses. POCUS performed by treating EPs reduces cognitive burden in dyspneic patients.

BACKGROUND: Vascular access is a critical component of emergency department (ED) care. Ultrasound guided placement of peripheral intravenous (USIV) catheters is increasingly common. However, USIV are thought to suffer from reduced durability and higher complication rates. Extended dwell catheters (EDC) are long peripheral IVs placed under combined ultrasound and wire guidance. The goal of this study is to compare dwell times and complication rates of EDC to standard peripheral USIV. METHODS: We performed a retrospective cohort study at a tertiary care adult ED comparing IV placements during a 17-month period (8/1/2018 – 12/31/2019), stratified by standard USIV versus EDC. The primary outcome was catheter dwell time and secondary outcomes included need for inpatient vascular access team (VAST) consultation, peripherally inserted central catheter (PICC) insertions, and radiocontrast extravasations. Multivariable Cox regression time-to-event analyses were used to evaluate dwell times, adjusting for age, gender, BMI and end-stage renal disease. RESULTS: 359 EDC and 4190 standard USIV were included for analysis. Most USIV (95.6%) and EDC (98.3%) were placed by ED technicians trained in ultrasound vascular access. EDC median dwell time (5.9 days [95%CI: 5.1–6.7]) exceeded standard USIV (3.8 days [95% CI: 3.6–4.0]). Patients with EDC placed in the ED required less VAST consultation (0.84 vs 0.99 charges/encounter), had similar rates of PICC line use (8.0% vs 8.4% of encounters) and had no radiocontrast extravasation events. Multivariable Cox regression demonstrated survival benefit (longer dwell time) favoring EDC (HR 0.70 [95%CI 0.60–0.81]). CONCLUSION: Use of EDC results in longer dwell time and reduces subsequent use of vascular access resources, while maintaining low complication rates. EDC demonstrate superior durability which may justify their selection over standard USIV in some patients.

Purpose Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients. Methods Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle. Results Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications.

Gastric cancer remains a deadly cancer with poor outcomes in the United States. There is a need for screening strategies for gastric cancer in the U.S. population. With progressive Helicobacter pylori–mediated inflammation of the gastric mucosa, pepsinogen I levels decrease and the pepsinogen I/II ratio decreases. Pepsinogen test positivity (PG+) has been evaluated as a promising screening test among Asian and European populations; however, its utility in multiethnic U.S. populations is poorly described. In this case-control study nested within the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, In and colleagues evaluate the discrimination of PG+ in serum collected from individuals prior to the development of gastric cancer. The authors find that PG+ individuals were at nearly 10-fold increased risk for developing gastric cancer, and this effect remained robust after adjusting for Helicobacter pylori status, family history, education, smoking, and obesity. In subgroup analysis, the predictive ability of the test was particularly robust for noncardia gastric cancers, and nonpredictive of cardia gastric cancers. Serum pepsinogen testing holds promise as a noninvasive screening strategy to triage individuals at heightened risk for gastric cancer, and may help to improve early diagnosis in the United States. See related article by In et al., p. 1426

TPS2694 Background: Folate-receptor 1 (FOLR1) and prostate specific membrane antigen (PSMA) are overexpressed on tumor and angiogenic endothelial cells in solid tumors, including prostate cancer, renal cell cancer and lung cancer. CBP-1018 is a first-in-class bi-ligand drug conjugate targeting to both FOLR1 and PSMA, with a tubulin inhibitor payload, monomethyl auristatin E (MMAE). We herein introduce its first-in-human study which is designed based on the significant anti-tumor potency and acceptable safety profile in nonclinical studies. Methods: This study is a phase Ⅰa/Ⅰb, multicenter, open-label study enrolling patients with advanced solid tumor relapsed after previous standard therapies. The primary objective is to assess CBP-1018 safety, tolerability, dose limiting toxicity and maximum tolerated dose. Preliminary efficacy including objective response rate, duration of response and progression-free survival will be observed. Pharmacokinetics, immunogenicity and biomarkers will be also evaluated. This study includes 2 parts: Ⅰa (Dose Escalation) and Ⅰb (Dose Expansion). CBP-1018 is administrated iv Q2W (4 weeks/cycle) in Ⅰa, with accelerated titration at lower doses (0.03 mg/kg and 0.06 mg/kg) and an i3+3 design at following doses (0.08 mg/kg, 0.10 mg/kg, 0.12 mg/kg and 0.14mg/kg, etc.). Subjects will be enrolled in 4 cohorts in Ⅰb: metastatic castration resistant prostate cancer, advanced renal cell cancer, advanced lung squamous cell cancer, and other advanced solid tumors. Efficacy will be assessed every 8 weeks (±7days) according to RECIST 1.1, PCWG3 and PSA assessment (only for prostate cancer). Treatment will be continued untill disease progression or intolerable toxicity. Enrollment has been started in Nov. 2021 and is ongoing. Clinical trial information: NCT04928612.

3000 Background: Folate receptor α (FRα) and vanilloid subfamily member 6 of transient receptor potential channels (TRPV6) are overexpressed in many solid tumors hence could be promising therapeutic targets. CBP-1008 is a first-in-class bi-specific ligand drug targeting FRα and TRPV6 carrying monomethyl auristatin E (MMAE) as payload. Here we report the first-in-human, multicenter, phase Ia/Ib study designed to explore the safety, pharmacokinetics and efficacy of CBP-1008 in advanced solid tumors. Methods: CBP-1008 was administered by intravenous infusion. Phase Ia study included a dose-escalation period initiated by accelerated titration (0.015, 0.03mg/kg d1,15; q28d) and then switched to 3+3 scheme (0.12, 0.15, 0.17, 0.18mg/kg d1,15; q28d) and a dose expansion period. Phase Ib clinical expansion study included 3 cohorts, platinum-resistant ovarian cancer (OC), metastatic triple negative breast cancer (TNBC) and other solid tumors. The primary objective was to assess the safety and preliminary efficacy. Results: As of January 13, 2022, 106 patients received at least one dose of study drug were enrolled (phase Ia: n = 30; phase Ib: n = 76) and received median 3 prior regimens. Included tumor species were OC (n = 52), TNBC (n = 20), ER+/Her2+ breast cancer (BC) (n = 16), lung cancer (n = 3), pancreatic cancer (n = 2) and others (n = 13). In phase Ia study, DLTs were observed in 3 patients (0.12, 0.15, 0.18mg/kg, n = 1 each), including grade 4 hypophosphatemia, neutropenia, febrile neutropenia, and grade 3 hyperglycemia, alanine aminotransferase (ALT). MTD was not yet reached. Majority of adverse events were mild to moderate. The most common grade 3/4 treatment-emerging adverse events (TEAEs) were neutropenia (37.7%), AST elevation (6.6%), ALT elevation (5.7%), hyperglycemia (2.8%), hypohemoglobinemia (2.8%) and nausea (1.9%). Drug-related death was not observed. A total of 69 patients at dose of 0.15mg/kg or above were evaluable for efficacy assessment. There were 11 patients achieved partial response (PR) (OC n = 8, ER+/Her2+ BC n = 2, TNBC n = 1) and 30 patients achieved stable disease (SD). In 32 advanced platinum-resistant OC patients with FRα and/or TRPV6-positive expression, 6 PR and 16 SD were observed. Moreover, 6/18 PR (33.3%) and 8/18 SD (44.4%) were observed in enriched OC patients who showed high score of FRα/TRPV6 receptor. Conclusions: The preliminary results showed that CBP-1008 has manageable safety profile. Antitumor activity was observed in patients with FRα/TRPV6 receptor expression, especially in platinum-resistant OC cohort with high score of the two receptors. Clinical trial information: NCT04740398.

Author(s): Tucker, Ryan; Huang, Robert; Peterson, William; Munzer, Brendan; Thiessen, Molly

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.

Introduction The average number of applications per allopathic applicant to emergency medicine (EM) residency programs in the United States (US) has increased significantly since 2014. This increase in applications has caused a significant burden on both programs and applicants. Our goal in this study was to investigate the drivers of this application increase so as to inform strategies to mitigate the surge. Methods An expert panel designed an anonymous, web-based survey, which was distributed to US allopathic senior applicants in the 2017-2018 EM match cycle via the Council of Residency Directors in Emergency Medicine and the Emergency Medicine Residents Association listservs for completion between the rank list certification deadline and release of match results. The survey collected descriptive statistics and factors affecting application decisions. Results A total of 532 of 1748 (30.4%) US allopathic seniors responded to the survey. Of these respondents, 47.3% felt they had applied to too many programs, 11.8% felt they had applied to too few, and 57.7% felt that their perception of their own competitiveness increased their number of applications. Application behavior of peers going into EM was identified as the largest external factor driving an increase in applications (61.1%), followed by US Medical Licensing Exam scores (46.9%) - the latter was most pronounced in applicants who self-perceived as "less competitive." The most significant limiter of application numbers was the cost of using the Electronic Residency Application Service (34.3%). Conclusion A substantial group of EM applicants identified that they were over-applying to residencies. The largest driver of this process was individual applicant response to the behavior of their peers who were also going into EM. Understanding these motivations may help inform solutions to overapplication.

Background This study aims to compare the increased time needed to perform advanced focused cardiac measurements in the emergency department, including diastolic heart failure evaluation via E/E′, and cardiac output with LVOT/VTI. Patients with pertinent cardiopulmonary symptoms in the emergency department had a focused cardiac ultrasound performed by the emergency department ultrasound team. The ability to obtain basic cardiac windows, evaluate for effusion, systolic ejection fraction, and right-sided heart pressures were recorded. Advanced measurements, along with time to obtain all images and the training level of the provider, were recorded. Results Fifty-three patients were enrolled. Basic focused cardiac windows were able to be obtained in 80% of patients. The average 4-window focused cardiac ultrasound took 4 min and 49 s to perform. Diastolic measurements were able to be obtained in 51% of patients, taking an average of 3 min and 17 s. Cardiac output measurements were able to be obtained in 53% of patients, taking an average of 3 min and 8 s. Conclusion The ability to obtain these images improved with increasing level of training. Performing both cardiac output and diastolic measurements increased the time with bedside ultrasound by 6 min and 25 s, and were able to be obtained in slightly over half of all ED patients.

Ocular complaints prompt a significant number of emergency department (ED) visits, and they can range from benign to sight-threatening. Detailed fundoscopic examination is difficult, even for experienced providers. Point-of-care ultrasound (POCUS) is increasingly utilized in the ED for numerous applications, including ocular evaluation. We present a case in which ocular POCUS was used to diagnose a submacular hemorrhage in a patient who presented with acute painless loss of vision. Ocular POCUS can be readily employed to assess for myriad clinically significant pathologies.

Live-tweeting during educational presentations is typically learner-generated and can lead to misquoted information. Presenter curated tweets have not been well described. We created Presenter Initiated and Generated Live Educational Tweets (PIGLETs) with the goal to broaden the reach of educational conferences. We hypothesized that using PIGLETs would increase the reach and exposure of our material. We developed a prospective single-arm intervention study performed during the “Not Another Boring Lecture” workshops presented at two national conferences in 2015. Presenters tweeted PIGLETs linked to unique hashtags #NotAnotherBoringLecture and #InnovateMedEd. Analytic software was used to measure the following outcomes: (1) number of tweets published by presenters versus learners, (2) reach (users exposed to content containing the hashtag), and (3) exposure (total number of times content was delivered). One hundred and twenty-six participants attended the workshops. A total of 636 tweets (including retweets) were sent by presenters containing the study hashtags, compared with 162 sent by learners. #NotAnotherBoringLecture reached 47,200 users and generated 136,400 impressions; #InnovateMedEd reached 36,400 users and generated 79,100 impressions. PIGLETs allowed presenters to reach a significant number of learners, as well as control the content delivered through Twitter. PIGLETs can be used to augment educational sessions beyond the physical confines of the classroom.

We propose a method for detecting bipartite entanglement in a many-body mixed state based on estimating moments of the partially transposed density matrix. The estimates are obtained by performing local random measurements on the state, followed by postprocessing using the classical shadows framework. Our method can be applied to any quantum system with single-qubit control. We provide a detailed analysis of the required number of experimental runs, and demonstrate the protocol using existing experimental data [Brydges et al., Science 364, 260 (2019)]., Research in Innsbruck is supported by the European Union's Horizon 2020 research and innovation programme under Grant Agreement No. 817482 (PASQuanS) and No. 731473 (QuantERA via QTFLAG), and by the Simons Collaboration on Ultra-Quantum Matter, which is a grant from the Simons Foundation (651440, P. Z.). B. K. acknowledges financial support from the Austrian Academy of Sciences via the Innovation Fund 'Research, Science and Society', the SFB BeyondC (Grant No. F7107- N38), and the Austrian Science Fund (FWF) Grant DKALM: W1259-N27. Research at Caltech is supported by the Kortschak Scholars Program, the U.S. Department of Energy (DE-SC0020290), the U.S. Army Research Office (W911NF-18-1-0103), and the U.S. National Science Foundation (PHY-1733907). The Institute for Quantum Information and Matter is an NSF Physics Frontiers Center. Research in Trieste is partly supported by European Research Council (Grants No. 758329 and No. 771536) and by the Italian Ministry of Education under the FARE programme. B. V. acknowledges funding from the Austrian Science Foundation (FWF, P. 32597N).

Author(s): Haas, Mary R. C.; Munzer, Brendan W.; Santen, Sally A.; Hopson, Laura R.; Haas, Nathan L.; Overbeek, Daniel; Peterson, William J.; Cranford, James A.; Huang, Robert D. | Abstract: 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 l .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.

Ocular complaints prompt a significant number of emergency department (ED) visits, and they can range from benign to sight-threatening. Detailed fundoscopic examination is difficult, even for experienced providers. Point-of-care ultrasound (POCUS) is increasingly utilized in the ED for numerous applications, including ocular evaluation. We present a case in which ocular POCUS was used to diagnose a submacular hemorrhage in a patient who presented with acute painless loss of vision. Ocular POCUS can be readily employed to assess for myriad clinically significant pathologies.

Infrared vision system uses infrared lens to collect radiation and focus the object onto the detector. Information such as pixel and temperature distribution could be captured and displayed as images. Infrared optics are the “eyes” of the vision system. The need of broadband, compact, low cost are driven by increasing commercial applications such as UAV, autonomous driving and smart phone. This paper presents our latest development in infrared optics design for broadband application and optics manufacturing based on Chalcogenide glasses for potential mass production. New optics design makes a single lens to achieve dual wavelength band (MWIR and LWIR) switchable. The aspheric lens and diffractive optical element (DOE) configuration are investigated to realize the broadband and compact lens design. In LWIR regime, several detector manufacturers have demonstrated both cooled and uncooled technologies with pixel size down to 12μm. It sets new standard for size, weight, power and performance in terms of resolution. Chalcogenide material is gradually taking over Germanium in broad IR regime. It performs especially well in the 8 to 12μm range, because of its lowest absorption and dispersion in LWIR. The low dn/dT of the Chalcogenide makes lens athermalization much simpler by removing required mechanical compensation complexity. The Chalcogenide series of glasses can be processed by molding. As compare to the polished/machined glass lens which take more than 1 hour for each piece, the molding process time will be reduced to 5 mins.

3077 Background: CBP-1008 is a first-in-class bi-specific ligand drug conjugate targeting folate receptor α (FRα) and vanilloid subfamily member 6 of transient receptor potential channels (TRPV6) with a high potency tublin inhibitor payload, monomethyl auristatin E (MMAE). A first-in-human, multicenter, phase I study of CBP-1008 (NCT 04740398) is ongoing, and we herein report the preliminary result of part A which is to evaluate the safety, tolerability, pharmacokinetics, and antitumor activity of CBP-1008 in solid tumors. Methods: Dose escalation commenced in single-patient cohorts for the first 2 planned dose levels and then followed by a standard 3 + 3 scheme. CBP-1008 was administered as intravenous infusion at escalating doses (0.015, 0.03, 0.12, 0.15, and 0.18 mg/kg). The primary endpoints were to determine the safety and maximum tolerated dose (MTD). Adverse events (AEs) and dose-limiting toxicities (DLTs) were evaluated. Results: Eighteen patients with advanced solid tumors who had failed multiple systemic treatment regimens were enrolled. The diseases include colorectal cancer (n = 7), breast cancer (n = 5), non-small cell lung cancer (n = 2), ovarian cancer (n = 2), adrenocortical carcinoma (n = 1), and follicular dendritic cell sarcoma (n = 1). The DLTs observed included grade 4 hypophosphatemia (0.15 mg/kg), grade 4 neutropenia (0.12, 0.15, and 0.18 mg/kg), grade 4 febrile neutropenia (FN) (0.18 mg/kg), grade 3 hyperglycemia (0.15 mg/kg), and grade 3 alanine aminotransferase (ALT) elevation (0.18 mg/kg). The most common all grade AEs suspected to be drug-related were fever (83.3%, totally limited to grade 1-2), aspartate aminotransferase (AST) elevation (72.2%, 5.6% evaluated as grade 3-4), leukopenia (66.7%, 27.8% as grade 3-4), neutropenia (66.7%, 38.9% as grade 3-4) and hypohemoglobinemia (55.6%, 5.6% as grade 3-4), with no drug-related deaths. MTD is estimated between 0.15 mg/kg and 0.18 mg/kg Q2W. Best overall response was partial response (PR) in 1 patient at 0.18 mg/kg and 4 patients (22.2%) achieved stable disease (SD). Responses occurred in patients with FRα and/or TRPV6 -positive expression advanced solid tumors. Conclusions: CBP-1008 has demonstrated acceptable safety profile. Tumor response correlating with dosing and FRα/TRPV6 receptor expression levels has been well observed. Clinical trial information: 04740398.

Objective Our objectives were 2-fold: to describe the creation of a flight nurse (FN) ultrasound (US) program and to evaluate whether critical care US performed by nonphysician providers in the prehospital setting can clarify patient assessment. Methods Twenty FNs completed a didactic and hands-on US curriculum focusing on critical care modalities. FNs displayed competency by successful completion of an objective-structured clinical examination. Portable US devices were used during patient transports when deemed clinically indicated by the FN. If US was subsequently performed, the FN was asked if US use prompted a change in assessment. Associations were evaluated with chi-square and bivariate logistic regression analyses. Results FNs reported US use during 102 (12.3%) patient transports, of which intensive care unit (ICU) to ICU (58.8%) constituted the majority of cases followed by emergency department (ED) to ED (28.4%), ED to ICU (4.9%), and scene to ED (2.9%). FNs agreed or strongly agreed that US use clarified the cause of patient symptoms in 67.4% of transports. Conclusion FNs were more likely to perform US when they expressed lower confidence in their initial patient assessment. FNs reported that US helped to clarify patient assessments.

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.

Introduction Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography. Methods We performed a literature search and report clinical experience to provide an introduction to CEUS and describe its current applications for point-of-care indications. Results The uses of CEUS include several applications highly relevant for emergency medicine, such as solid-organ injuries, actively bleeding hematomas, or abdominal aortic aneurysms. Compared with CT as the preeminent advanced imaging modality in the emergency department, CEUS is low cost, radiation sparing, repeatable, and readily available. It does not require sedation, preprocedural laboratory assessment, or transportation to the radiology suite. Conclusions CEUS is a promising imaging technique for point-of-care applications in pediatric and adult patients and can be applied for patients with allergy to CT contrast medium or with impaired renal function. More high-quality CEUS research focusing on accuracy, patient safety, health care costs, and throughput times is needed to validate its use in emergency and critical care settings.

Ultrasound assessment of the respiratory-induced change in size of the inferior vena cava is a useful technique in the evaluation and management of critically ill patients. We have developed an automated technique based on the Kanade-Lucas-Tomasi feature tracker and pyramidal segmentation to continuously track the diameter of the inferior vena cava during ultrasound. To test the accuracy of this automated process, the inferior vena cava of 47 spontaneously breathing patients were measured by trained ultrasound physicians and compared against the results obtained via the automated tracking. Good agreement between the techniques was found, with intra-class correlation coefficients for maximum vessel diameter, minimum diameter and caval index of 0.897, 0.967 and 0.975, respectively. More than 95% of the difference between physicians and automated measurements agreed to within 10% of the inferior vena cava collapse. Furthermore a phenomenon of cardiac collapsibility index variability was observed and reported. The accuracy and precision of this algorithmic technique provide a foundation for future automated measures for critical care ultrasound.

We believe that the strongest residencies feature trainees of diverse personalities and backgrounds. We believe that true understanding and excellence in patient care are nurtured by these differences, and we firmly disagree with any actions that, intentionally or not, diminish our field's diversity. Attempting to predict future potential from a psychometric present may be shade to growth for the diverse physicians that EM hopes to attract. If applicant metrics are not adequate or valid, we must reevaluate their utility and inclusion. However, we recommend that a more thorough explanation of the need for the SVI pilot study be shared, with consideration to the possibility that other markers of an applicant's portfolio may already satisfy this need. We question the utility of an additional measure that increases burden and potential bias on medical students who have no ability to decline participation or participate in design. Until the validity of the SVI's ability to predict future performance is determined, mandatory participation and reporting to residency programs should not be implemented.

Assessment of volume status in critically ill patients poses a challenge to clinicians. Measuring changes in the inferior vena cava (IVC) diameter using ultrasound is becoming a standard tool to assess volume status. Ultrasound requires physicians with significant training and specialized expensive equipment. It would be of significant value to be able to obtain this measurement continuously without physician presence. We hypothesize that dynamic changes in limb's bioimpedance in response to respiration could be used to predict changes in IVC. Forty-six subjects were tested a hemodialysis session. Impedance was measured via electrodes placed on the arm. Simultaneously, the IVC diameter was assessed by ultrasound. Subjects were asked to breathe spontaneously and perform respiratory maneuvers using a respiratory training device. Impedance (dz) was determined and compared with change in IVC diameter (dIVC; r = 0.76, p < 0.0001). There was significant relationship between dz and dIVC (p< 0.0001). Receiver-operator curves for dz at thresholds of dIVC (20% to70%) demonstrated high predictive power with areas under the curves (0.87-0.99, p < 0.0001). This evaluation suggests that real-time dynamic changes in limb impedance are capable of tracking a wide range of dynamic dIVC. This technique might be a suitable surrogate for monitoring real-time changes in dIVC to assess intravascular volume status.

Toxoplasma gondii is an obligate intracellular parasite of all vertebrates, including man. Successful invasion and replication requires the synchronized release of parasite proteins, many of which require proteolytic processing. Unlike most parasites, T. gondii has a limited number of Clan CA, family C1 cysteine proteinases with one cathepsin B (TgCPB), one cathepsin L (TgCPL) and three cathepsin Cs (TgCPC1, 2, 3). Previously, we characterized toxopain, the only cathepsin B enzyme, which localizes to the rhoptry organelle. Two cathepsin Cs are trafficked through dense granules to the parasitophorous vacuole where they degrade peptides. We now report the cloning, expression, and modeling of the sole cathepsin L gene and the identification of two new endogenous inhibitors. TgCPL differs from human cathepsin L with a pH optimum of 6.5 and its substrate preference for leucine (vs. phenylalanine) in the P2 position. This distinct preference is explained by homology modeling, which reveals a non-canonical aspartic acid (Asp 216) at the base of the predicted active site S2 pocket, which limits substrate access. To further our understanding of the regulation of cathepsins in T. gondii, we identified two genes encoding endogenous cysteine proteinase inhibitors (ICPs or toxostatins), which are active against both TgCPB and TgCPL in the nanomolar range. Over expression of toxostatin-1 significantly decreased overall cysteine proteinase activity in parasite lysates, but had no detectable effect on invasion or intracellular multiplication. These findings provide important insights into the proteolytic cascades of T. gondii and their endogenous control.

Centers for Disease Control guidelines for schistosomiasis and strongyloidiasis in Sudanese and Somali refugees are not widely implemented. Given limited prevalence data, we conducted a seroprevalence study of schistosomiasis, strongyloidiasis, and loiasis in Sudanese refugees across diverse ages. Sudanese refugees, ages 4-78, were recruited via community organizations. Half of the patients (86/172), were seropositive for schistosomiasis (46/171; 26.9%), strongyloidiasis (56/172; 33%), or both (16/171; 9.4%). No Loa loa infections were detected. Infection rates were similar in adults and children except that no schistosomiasis was detected in children < 4 years of age at the time of immigration to the United States. The high prevalence of schistosomiasis and strongyloidiasis in a community-based sample of Sudanese confirms the urgency for compliance with CDC refugee health guidelines. We detected no co-infection with Loa loa using the most sensitive serologic techniques, allowing use of ivermectin, the most effective treatment of strongyloidiasis.

Leishmania species are obligate intracellular protozoan parasites that cause a broad spectrum of clinical diseases in mammalian hosts. The most frequently used approach to quantify parasites in murine model systems is based on thickness measurements of the footpad or ear after experimental infection. To overcome the limitations of this method, we used a Leishmania mutant episomally transfected with enhanced green fluorescent protein, enabling in vivo real-time whole-body fluorescence imaging, to follow the progression of Leishmania infection in parasitized tissues. Fluorescence correlated with the number of Leishmania parasites in the tissue and demonstrated the real-time efficacy of a therapeutic vaccine. This approach provides several substantial advantages over currently available animal model systems for the in vivo study of immunopathogenesis, prevention, and therapy of leishmaniasis. These include improvements in sensitivity and the ability to acquire real-time data on progression and spread of the infection.

Over the past few years, clouds have become an important terms in different domains. ITRI (Industrial Technology Research Institute) CCMA is one of Cloud developers especially on IaaS, called ITRI Cloud OS. ITRI Cloud OS is a comprehensive data center software stack. Inside this system, server virtualization, network virtualization, and storage virtualization are included to make Cloud OS serves virtual machines. Security is an important issue which is one of Cloud OS components. In this paper we represent security from different viewpoints in the system. Cloud OS could be deployed either as a public or private cloud. To host large number of VMs, horizontal scale up is a requirement. Security implementation should be adapted to support such an environment. ITRI Cloud OS could easily accommodate new VMs by adding new computing resources. In order to make cloud OS a secure environment, how we implement security protection and service level guarantee are discussed in this paper. Security protection means VMs are under protections through different mechanism and service level agreement (SLA). That is VMs running inside Cloud OS could have service guarantee even when resource is limited. To provide security protections, the following properties are built inside Cloud OS: multi-tenant support with tenant isolation including network as well as user data volume isolations; role-based distributed L3/L4 firewall, and automatic firewall setting in Cloud OS for enterprise firewall device; Distributed WAF protection; ARP spoofing; and DDoS mitigating system. In this paper, we present our security component's algorithms, system models, performance analysis, and performance evaluation results. To support SLA, we provide a distributed traffic shaping architecture. Through SLA policy setting, VMs can achieve guaranteed network bandwidth. We will present our distributed traffic shaping performance evaluation results which demonstrate the efficiency of Cloud OS.

The proteoglycan versican is implicated in several atherogenic events, including stimulation of vascular smooth muscle cell (VSMC) growth and migration, retention of lipoproteins, and promotion of thrombogenesis. A high content of intimal versican also correlates with a low content of elastin, suggesting an inhibitory role for versican in elastogenesis. To determine whether reduced production of versican can be used to enhance elastogenesis, we transduced Fischer rat VSMC (FRSMC) with a versican antisense sequence using the retroviral vector LXSN. Stable expression of versican antisense (LVaSN) significantly reduced versican production, induced a flattened morphology, reduced cell proliferation and migration, increased tropoelastin synthesis, increased elastin binding protein (S-Gal/EBP), and increased deposition of elastic fibers in long-term cultures. Add-back of chondroitin sulfate chains, or versican, decreased S-Gal/EBP and elastic fiber formation. LVaSN cells seeded into balloon catheter-injured rat carotid arteries formed neointimae containing low levels versican, increased amounts of S-Gal/EBP, and increased elastin deposits 7 days postinjury. At 4 weeks, neointimae formed from LVaSN cells were highly structured and contained multiple layers of elastic fibers and lamellae. These results indicate a central role for versican and its constituent chondroitin sulfate chains in controlling cell phenotype, elastogenesis, and intimal structure.

Data centers use about 2% of the electricity in the United States; a typical data center has 100 to 200 times the energy use intensity of a commercial building. Data centers present tremendous opportunities--energy use can be reduced as much as 80% between inefficient and efficient data centers. Data center efficiency measures generally fall into the following categories: power infrastructure (e.g., more efficient uninterruptible power supplies, power distribution units); cooling (e.g., free cooling, variable-speed drives, temperature and humidity set points); airflow management (e.g., hot aisle/cold aisle, containment, grommets); and information technology efficiency (e.g., server virtualization, efficient servers, efficient data storage).

Histologic studies have demonstrated both a decrease in size and loss in number of type II muscle fibers with increasing age. Although these age-related histologic changes are believed to result in decreased strength and functional capacity, age-related changes in muscle force dynamics have not been clearly elucidated. Using vibromyographic (VMG) techniques, we recorded muscle activity of the soleus in 40 healthy adult volunteers spanning the age range of 20-82 years to test whether changes in postural muscle dynamics, in the frequency range of 0.1-50 Hz, were also associated with age. Although muscle dynamics below 15 Hz do not change with aging, the 30-50 Hz frequency components of the VMG were found to change significantly with advancing age (r = -.619, p = .0001). This was observed in both sexes independently. The observed age-related changes in muscle force dynamics demonstrate distinct physiologic alterations in muscle fiber activity. Further research will be required to fully elucidate the relationship between age-related changes in muscle fiber activity and other age-related conditions such as postural instability and osteoporosis.

Chronic inflammation in vascular disease affects the organization of the extracellular matrix (ECM) in such a way as to promote the events associated with atherosclerosis and restenosis. Versican and hyaluronan are two ECM components that are affected by inflammation and, in turn, affect the inflammatory response. Inflammatory growth factors such as TGF-β1 and PDGF stimulate the production of versican and hyaluronan by arterial smooth muscle cells (ASMCs). These ECM components accumulate in vascular disease and promote the proliferation and migration of ASMCs, contributing to intimal hyperplasia. Hyaluronan also serves as attachment ligand for inflammatory cells and may be partly responsible for leukocyte retention as part of the early inflammatory response. Inflammation also leads to destruction of the ECM and failure of the ECM to remodel. Elastic fibers are absent in atherosclerotic and restenotic lesions and controlled expression of a versican variant, V3, in ASMCs restores the ability of these cells to form elastic fibers. ECM assembly is critical to vascular healing and the prevention of vascular disease.

Although radioiodinated interleukin 2 (IL-2) has been used to define the binding characteristics of the cytokine to the alpha chain of the receptor complex, we have found that unsubstituted IL-2 behaves differently. Whereas previous investigations with radioiodinated IL-2 have shown binding to the alpha chain with a Kd of 10 nM, we show that unsubstituted IL-2 binds to the alpha chain but does not reach saturation between 100 and 1000 nM. The explanation for the discrepancy between the analysis of radioiodinated and unsubstituted cytokine involves the propensity of unsubstituted IL-2 for self-association, a property that is abrogated by radioiodination. The functional relevance of our findings is indicated by the different capacities of unsubstituted and iodinated cytokine to induce prolonged proliferation of human T lymphocytes.

The effect of 6-diazo-5-oxo-L-norleucine (L-DON), a glutamine analog, on RSV replication was studied. At a concentration of 0.01 mM L-DON, 99% of RSV replication in treated CV-1 cells was inhibited. At this concentration of L-DON, the level of cellular protein synthesis was identical to untreated control cells. Trypan blue staining revealed that all the cells remained viable even at concentrations of L-DON as high as 10 mM. In addition, L-DON added as late as 24 h post infection can effectively suppress viral replication. Analysis of viral mRNA levels by Northern blot revealed that secondary transcription and subsequent steps in the virus life cycle were inhibited. Immunoprecipitation of viral proteins from drug treated or untreated cultures showed that synthesis of all viral proteins was drastically reduced by L-DON, with a slightly greater inhibition of viral glycoproteins. Furthermore, immunofluorescent staining showed that drug treated cells expressed both F and N proteins and that F was inserted into the membrane as the native F protein.