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Emergency physicians (EP) frequently resuscitate and manage critically ill patients. Resuscitation of the crashing obese patient presents a unique challenge for even the most skilled physician. Changes in anatomy, metabolic demand, cardiopulmonary reserve, ventilation, circulation, and pharmacokinetics require special consideration. This article focuses on critical components in the resuscitation of the crashing obese patient in the emergency department, namely intubation, mechanical ventilation, circulatory resuscitation, and pharmacotherapy. To minimize morbidity and mortality, it is imperative that the EP be familiar with the pearls and pitfalls discussed within this article.

A 22-year-old man presented to the emergency department with facial swelling, rash, and fatigue. Hehad a past medical history of pericarditis and pericardial effusion. His evaluation showed anemia and thrombocytopenia. He was admitted for intravenous administration of steroids, plasmapheresis, and workup of his anemia and thrombocytopenia. He was ultimately diagnosed with Evans syndrome as a presenting feature of systemic lupus erythematosus. Plasmapheresis was stopped but administration of steroids continued. His blood counts improved, and the facial swelling and rash subsided. Evans syndrome is an immunologic conundrum that requires early recognition and treatment.

Live virus vaccine (LVV) purification, employing chromatography, can be challenged by low binding capacities and elution yields. Alternatively, processes relying solely on enzymatic digestion steps and size‐based membrane separations can be limited by suboptimal reduction of process related impurities and poorly scalable unit operations. Here, we demonstrate that the combination of flowthrough mode chromatography and an ultrafiltration/diafiltration (UF/DF) unit operation delivers a purification process for two different LVV candidates, V590 and Measles, expressed in adherent Vero cells. For V590, chromatography with mixed mode cation exchange resins returned final product yields of ∼50% and logarithmic reduction values (LRVs) of 1.7–>3.4 and 2.5–3.0 for host cell DNA (hcDNA) and host cell proteins (HCPs), respectively. For Measles, chromatography with mixed mode anion exchange resins returned final product yields of ∼50% and LRVs of 1.6 and 2.2 for hcDNA and HCPs, respectively. For both V590 and Measles processing, the employed resins cleared a key HCP, fibronectin, which could foul the UF/DF unit operation, and thusly enabling it to further reduce HCPs and to formulate the final LVV products. This integrated purification process utilizes the complementary action of the two unit operations and its applicability across LVVs supports its consideration for their processing. [ABSTRACT FROM AUTHOR]

Extranuclear localization of long noncoding RNAs (lncRNAs) is poorly understood. Based on machine learning evaluations, we propose a lncRNA-mitochondrial interaction pathway where polynucleotide phosphorylase (PNPase), through domains that provide specificity for primary sequence and secondary structure, binds nuclear-encoded lncRNAs to facilitate mitochondrial import. Using FVB/NJ mouse and human cardiac tissues, RNA from isolated subcellular compartments (cytoplasmic and mitochondrial) and cross-linked immunoprecipitate (CLIP) with PNPase within the mitochondrion were sequenced on the Illumina HiSeq and MiSeq, respectively. lncRNA sequence and structure were evaluated through supervised [classification and regression trees (CART) and support vector machines (SVM)] machine learning algorithms. In HL-1 cells, quantitative PCR of PNPase CLIP knockout mutants (KH and S1) was performed. In vitro fluorescence assays assessed PNPase RNA binding capacity and verified with PNPase CLIP. One hundred twelve (mouse) and 1,548 (human) lncRNAs were identified in the mitochondrion with Malat1 being the most abundant. Most noncoding RNAs binding PNPase were lncRNAs, including Malat1. lncRNA fragments bound to PNPase compared against randomly generated sequences of similar length showed stratification with SVM and CART algorithms. The lncRNAs bound to PNPase were used to create a criterion for binding, with experimental validation revealing increased binding affinity of RNA designed to bind PNPase compared to control RNA. The binding of lncRNAs to PNPase was decreased through the knockout of RNA binding domains KH and S1. In conclusion, sequence and secondary structural features identified by machine learning enhance the likelihood of nuclear-encoded lncRNAs binding to PNPase and undergoing import into the mitochondrion. NEW & NOTEWORTHY: Long noncoding RNAs (lncRNAs) are relatively novel RNAs with increasingly prominent roles in regulating genetic expression, mainly in the nucleus but more recently in regions such as the mitochondrion. This study explores how lncRNAs interact with polynucleotide phosphorylase (PNPase), a protein that regulates RNA import into the mitochondrion. Machine learning identified several RNA structural features that improved lncRNA binding to PNPase, which may be useful in targeting RNA therapeutics to the mitochondrion. [ABSTRACT FROM AUTHOR]

The introduction of highly automated driving systems is expected to significantly change in-vehicle interactions, creating opportunities for the design of novel use cases and interactions for occupants. In this study, we sought to identify and extract these novel use cases and determine preliminary auditory display recommendations for these novel situations. We developed and generated use cases for level 4 automated vehicles through an expert workshop (N = 17) and online focus group interviews (N = 12). Most of the use cases we generated were then tested, apart from meditation, and user opinions were collected in a driving simulator study (N = 20). Results indicated participants were interested in functions that support their experience with both driving and non-driving related interactions in highly automated vehicles. Three categories of use cases for level 4 automated vehicles were developed: driving automation use cases, immersion use cases, and in-vehicle notification use cases. For the driving simulator study, we tested three display modalities for interaction with drivers: visual alert only, non-speech with visual, and speech with visual. In terms of situation awareness (SA), the non-speech with visual display was associated with significantly better SA for the use case consisting of a planned increase in automation level than the speech-with visual display. This study will provide guidance on sonification design to advance user experiences in highly automated vehicles. [ABSTRACT FROM AUTHOR]

Introduction: There is scant literature regarding the optimal resident physician staffing model of academic emergency departments (ED) that maximizes learning opportunities. A department of emergency medicine at a large inner-city academic hospital initiated a team-based staffing model. Its pre-interventional staffing model consisted of residents and attending physicians being separately assigned patients, resulting in residents working with two different faculty providers in the same shift. This study aimed to determine if the post-interventional team-based system, in which residents were paired with a single attending on each shift, would result in improved residents’ learning and clinical experiences as manifested by resident evaluations and the number of patients seen.Methods: This retrospective before-and-after study at an academic ED with an annual volume of 52,000 patients examined the mean differences in five-point Likert-scale evaluations completed by residents assessing their ED rotation experiences in both the original and team-based staffing models. The residents were queried on their perceptions of feeling part of the team, decision-making autonomy, clinical experience, amount of supervision, quality of teaching, and overall rotational experience. We also analyzed the number of patients seen per hour by residents. Paired sample t-tests were performed. Residents who were in the program in the year preceding and proceeding the intervention were eligible for inclusion.Results: 34 of 38 eligible residents were included (4 excluded for lack of evaluations in either the pre- or post-intervention period).  There was a statistically significant improvement in resident perception of the quality and amount of teaching, 4.03 to 4.27 (mean difference=0.24, p=0.03). There were non-statistically significant trends toward improved mean scores for all other queries. Residents also saw more patients following the initiation of the team-based model, 1.24 to 1.56 patients per hour (mean difference=0.32, p=0.0005).Conclusion: Adopting a team-based physician staffing model is associated with improved resident perceptions of quality and amount of teaching. Residents also experience a greater number of patient evaluations in a team-based model. [West J Emerg Med. 2014;15(6):-0]

Introduction: Our goal was to evaluate patients’ threshold for waiting in an emergency department(ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness towait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status.Methods: We conducted this survey-based study from March to July 2010 at an urban academicmedical center. After triage, patients were given a multiple-choice questionnaire, designed toascertain how long they would wait for medical care. We collected data including age, gender, race,insurance status, and triage acuity level. We looked at the association between willingness to waitand these variables, using stratified analysis and logistic regression.Results: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventyone(51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and110 (32%) would wait indefinitely. No association was found between willingness to wait and race,gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended tobe older than 25, have higher acuity, and prefer the study site ED.Conclusion: Many patients have a defined, limited period that they are willing to wait for emergencycare. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED withoutbeing seen. This result suggests that efforts to reduce the percentage of patients who LWBS mustfactor in time limits. [West J Emerg Med. 2012;13(6):463-467]

Erythema gyratum repens (EGR) is a rare, and characteristic, paraneoplastic rash associated with a variety of malignancies, most notably lung, esophageal, and breast cancers. This case report details the appearance, epidemiology, diagnosis, and treatment of EGR. Prompt identification of EGR is essential, as the rash often precedes the diagnosis of malignancy by several months. Urgent patient referral to evaluate for malignancy is crucial, as this may lead to decreased morbidity and mortality. [West J Emerg Med. 2011;12(4):556–558.]