Optimizing global health experiences in emergency medicine residency programs: A consensus statement from the Council of Emergency Medicine Residency Directors 2011 Academic Assembly global health specialty track

BACKGROUND: An increasing number of emergency medicine (EM) residency training programs have residents interested in participating in clinical rotations in other countries. However, the policies that each individual training program applies to this process are different. To our knowledge, little has been done in the standardization of these experiences to help EM residency programs with the evaluation, administration and implementation of a successful global health clinical elective experience. The objective of this project was to assess the current status of EM global health electives at residency training programs and to establish recommendations from educators in EM on the best methodology to implement successful global health electives. METHODS: During the 2011 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly, participants met to address this issue in a mediated discussion session and working group. Session participants examined data previously obtained via the CORD online listserve, discussed best practices in global health applications, evaluations and partnerships, and explored possible solutions to some of the challenges. In addition a survey was sent to CORD members prior to the 2011 Academic Assembly to evaluate the resources and processes for EM residents’ global experiences. RESULTS: Recommendations included creating a global health working group within the organization, optimizing a clearinghouse of elective opportunities for residents and standardizing elective application materials, site evaluations and resident assessment/feedback methods. The survey showed that 71.4% of respondents have global health partnerships and electives. However, only 36.7% of programs require pre-departure training, and only 20% have formal competency requirements for these global health electives. CONCLUSIONS: A large number of EM training programs have global health experiences available, but these electives and the trainees may benefit from additional institutional support and formalized structure

A model for emergency medicine education in post-conflict Liberia

AbstractThe specialty of emergency medicine (EM) remains largely underdeveloped in many parts of the world including Africa. Within West Africa the Liberian health care system was presented with incredible challenges in the immediate post conflict years. One significant challenge facing the country was the paucity of health care providers. In 2006, only 122 physicians were practising in Liberia (one for every 26,782 citizens), only 87 of them Liberian national physicians. The public health indicators in post conflict Liberia suffered as a result of the overburdened system. Many indicators placed Liberia as having the worst health survivability in the world. Significantly, morbidity and mortality associated with unaddressed emergent presentations remained high.This article describes a unique paradigm for addressing the deficit in human capacity for emergency health care in the Republic of Liberia. This system was designed and supported by a consortium of academic medical centres in the United States working in conjunction with a local non-governmental organisation, Health Education and Relief Through Teaching (HEARTT). Since 2007, the consortium has delivered virtually uninterrupted emergency medical care and medical education at the largest teaching hospital in Liberia. The Liberian programme objectives included supervising and directing emergency medical care, providing a model for curriculum development, building capacity for medical education, and improving systems-based EM practice. The collaboration of multiple academic institutions in bringing emergency medical services and academic EM teaching to a post-conflict setting remains a unique model for introducing the development of acute care in a developing country

Parkinson's disease biomarkers: perspective from the NINDS Parkinson's Disease Biomarkers Program

Biomarkers for Parkinson's disease (PD) diagnosis, prognostication and clinical trial cohort selection are an urgent need. While many promising markers have been discovered through the National Institute of Neurological Disorders and Stroke Parkinson's Disease Biomarker Program (PDBP) and other mechanisms, no single PD marker or set of markers are ready for clinical use. Here we discuss the current state of biomarker discovery for platforms relevant to PDBP. We discuss the role of the PDBP in PD biomarker identification and present guidelines to facilitate their development. These guidelines include: harmonizing procedures for biofluid acquisition and clinical assessments, replication of the most promising biomarkers, support and encouragement of publications that report negative findings, longitudinal follow-up of current cohorts including the PDBP, testing of wearable technologies to capture readouts between study visits and development of recently diagnosed (de novo) cohorts to foster identification of the earliest markers of disease onset

Intestinal toxicity to CTLA-4 blockade driven by IL-6 and myeloid infiltration

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A Role for TLR4 in Clostridium difficile Infection and the Recognition of Surface Layer Proteins

Clostridium difficile is the etiological agent of antibiotic-associated diarrhoea (AAD) and pseudomembranous colitis in humans. The role of the surface layer proteins (SLPs) in this disease has not yet been fully explored. The aim of this study was to investigate a role for SLPs in the recognition of C. difficile and the subsequent activation of the immune system. Bone marrow derived dendritic cells (DCs) exposed to SLPs were assessed for production of inflammatory cytokines, expression of cell surface markers and their ability to generate T helper (Th) cell responses. DCs isolated from C3H/HeN and C3H/HeJ mice were used in order to examine whether SLPs are recognised by TLR4. The role of TLR4 in infection was examined in TLR4-deficient mice. SLPs induced maturation of DCs characterised by production of IL-12, TNFα and IL-10 and expression of MHC class II, CD40, CD80 and CD86. Furthermore, SLP-activated DCs generated Th cells producing IFNγ and IL-17. SLPs were unable to activate DCs isolated from TLR4-mutant C3H/HeJ mice and failed to induce a subsequent Th cell response. TLR4−/− and Myd88−/−, but not TRIF−/− mice were more susceptible than wild-type mice to C. difficile infection. Furthermore, SLPs activated NFκB, but not IRF3, downstream of TLR4. Our results indicate that SLPs isolated from C. difficile can activate innate and adaptive immunity and that these effects are mediated by TLR4, with TLR4 having a functional role in experimental C. difficile infection. This suggests an important role for SLPs in the recognition of C. difficile by the immune system

Evaluating the effect of fishery closures: Lessons learnt from the Plaice Box

To reduce discarding of plaice Pleuronectes platessa in the North Sea flatfish fisheries, the major nursery areas were closed to large trawlers in 1995. The area closed was named the ‘Plaice Box’ (PB) and beam trawl effort fell by over 90% , while the exemption fleets of small flatfish beam trawlers, gill netters targeting sole (Solea solea) and shrimp (Crangon crangon) trawlers increased their effort. Contrary to the expectation, plaice landings and biomass declined. The initial support for the PB from the fisheries was lost, whereas other stakeholder groups claimed that any failure was due to the fact that fishing had never been completely prohibited in the area. To evaluate whether the PB has been an effective management measure, the changes in the ecosystem (plaice, demersal fish, benthos) and fisheries are analysed to test whether the observed changes are due to the PB or to changes in the environment unrelated to the PB. Juvenile growth rate of plaice decreased and juveniles moved to deeper waters outside the PB. Demersal fish biomass decreased, whereas the abundance of epibenthic predators (Asterias rubens and Cancer pagurus) increased in the PB. Endobenthos, in particular the main food items of plaice (polychaetes and small bivalves) remained stable or decreased both inside and outside the PB. Currently catches of both plaice and sole from within the PB are lower than in the late 1980s and the exemption fleet often prefers to fish outside the Plaice Box alongside much larger competitors. It is concluded that the observed changes are most likely related to changes in the North Sea ecosystem, which may be related to changes in eutrophication and temperature. It is less likely that they are related to the change in fishing. This case study highlights the importance setting testable objectives and an appropriate evaluation framework including both ecological and socio-economic indicators when implementing closed areas. Key words: Marine Protected Area, MPA, spatial management, fisheries management, discards, climate change, trawling impact, North Sea, benthos, ecosystem change, stakeholder perceptio

Regulating a complex adaptive system via its wasp-waist: grappling with ecosystem-based management of the New England herring fishery

AbstractBakun, A., Babcock, E. A., and Santora, C. 2009. Regulating a complex adaptive system via its wasp-waist: grappling with ecosystem-based management of the New England herring fishery. – ICES Journal of Marine Science, 66: 1768–1775. We use the New England herring fishery as an example of the unresolved scientific issues pertinent to ecosystem-based management of forage-fish fisheries. The biomass of herring off New England is currently well above maximum sustainable yield (BMSY), leading to pressure for expanded harvests. Associated concerns include: the maintenance of sufficiently abundant forage to meet the current needs of marine mammals and seabirds while supporting the rebuilding of overfished groundfish resources; the preservation of the service functions of a healthy population of pelagic zooplanktivorous fish to prevent possible outbreaks of pests, or hypoxia events; and the limitation of unintended bycatch of marine mammals, seabirds, and juvenile stages of groundfish. Perhaps a self-enhancing feedback loop, involving predation by herring on the early life stages of their groundfish predators, might result in regime shifts that could not be easily reversed. A plausible outcome of these ideas is a dichotomy in management choice between (i) promoting an ecosystem dominated by valuable groundfish resources and (ii) promoting the current ecosystem that features a large herring resource associated with abundant and energy-rich forage for marine mammals, seabirds, and continued high productivity of valuable shellfish resources