Medical student‐led simulation in COVID‐19 crisis

Background: Simulation training is an effective tool for improving confidence in healthcare workers. During the recent COVID‐19 pandemic, large numbers of staff required re‐training to manage unfamiliar situations. We present a set of medical student‐led clinical simulation sessions and evaluate their effects on (i) confidence among redeployed healthcare workers managing COVID‐19 patients and (ii) medical students’ confidence as educators. / Methods: Half‐day simulation training sessions consisting of three COVID‐related clinical scenarios were devised by senior medical students and delivered to a group of approximately 150 healthcare workers over six repeated sessions prior to redeployment to COVID‐19 wards. We distributed an anonymous pre‐ and post‐simulation questionnaire to 36 participants in the final group exploring their experiences. The confidence scores were analysed using the Wilcoxon signed‐rank test. Following the delivery of teaching, medical students completed a questionnaire assessing their personal experiences of designing and delivering the exercises. / Results: Data are available for 35/36 participants approached. Respondents reported being significantly more confident after the training in all aspects of managing COVID‐19 patients, including triage, complex discharge, recognising deterioration, initiating basic life support, managing symptoms and advising on visiting policies (p < 0.001); 97% of respondents rated the training as useful. Thematic analysis of medical students’ responses demonstrated mutual benefit. / Discussion: This study demonstrates the strengths of simulation training in helping to build staff confidence in a rapidly evolving situation and highlights the value of medical students in supporting a hospital’s response to an outbreak. We recommend further studies of student‐led simulation exercises, including longer‐term follow‐up

Left ventricular dysfunction after open repair of simple congenital heart defects in infants and children: Quantitation with the use of a conductance catheter immediately after bypass

AbstractObjective: Quantification of myocardial injury after the simplest pediatric operations by load-independent indices of left ventricular function, using conductance and Mikro-Tip pressure catheters (Millar Instruments, Inc., Houston, Tex.) inserted through the left ventricular apex. Methods: Sixteen infants and children with intact ventricular septum undergoing cardiac operations had left ventricular function measured, immediately before and after bypass. Real-time pressure-volume loops were generated by conductance and Mikro-Tip pressure catheters placed in the long-axis via the left ventricular apex, and preload was varied by transient snaring of the inferior vena cava. Results: Good quality pressure-volume loops were generated in 13 patients (atrial septal defects, n = 11; double-chambered right ventricle, n = 1; supravalvular aortic stenosis, n = 1; age 0.25 to 14.4 years, weight 3.1 to 46.4 kg). Their mean bypass time was 41 ± 14 minutes and mean aortic crossclamp time 27 ± 11 minutes. End-systolic elastance decreased by 40.7% from 0.34 ± 0.17 to 0.21 ± 0.15 mm Hg-1·ml-1·kg-1 (p < 0.001). There were no significant changes in the slope of the stroke work–end-diastolic volume relationship, end-diastolic elastance, time constant of isovolumic relaxation, and normalized values of the maxima and minima of the first derivative of developed left ventricular pressure. Conclusion: Load-independent indices of left ventricular function can be derived from left ventricular pressure-volume loops generated by conductance and Mikro-Tip pressure catheters during the perioperative period in infants and children undergoing cardiac operations. Incomplete myocardial protection was demonstrated by a deterioration in systolic function after even short bypass and crossclamp times.Ignorance of the cause of postoperative myocardial dysfunction in the immature heart is compounded by the incomplete myocardial protection afforded by current cardioplegic strategies.1,5 Investigations of the mechanisms and treatment of postoperative ventricular dysfunction are hampered by use of nonspecific clinical end points as indirect estimates of ventricular function, for example, requirement for inotropic agents, duration of ventilation, intensive care unit stay, and mortality. These clinical indices are relatively insensitive to changes in ventricular function and necessitate large cohorts of patients to detect even major differences in outcome from differing myocardial protective strategies.To measure left ventricular function optimally during the perioperative period, with its dramatic changes in loading conditions, necessitates the use of load-independent indices of systolic and diastolic function. In infants and children with an intact ventricular septum undergoing cardiac operations (mainly atrial septal defect closure), we report the changes in left ventricular function assessed from the pressure-volume plane with the use of a conductance catheter and Mikro-Tip pressure catheter (Millar Instruments, Inc., Houston, Tex). In animal and human studies the conductance catheter is placed in the long axis of the left ventricle, most commonly through the aortic valve, with the use of retrograde arterial cannulation or aortotomy.6-11 This is clearly impractical in children undergoing bypass procedures, and in this study we report the first clinical use of custom-built miniature catheters placed in the same long axis, but via the left ventricular apex

Intratumoral Hydrogen Peroxide With Radiation Therapy in Locally Advanced Breast Cancer: Results From a Phase 1 Clinical Trial.

Purpose Hydrogen peroxide (H2O2) plays a vital role in normal cellular processes but at supraphysiological concentrations causes oxidative stress and cytotoxicity, a property that is potentially exploitable for the treatment of cancer in combination with radiation therapy (RT). We report the first phase 1 trial testing the safety and tolerability of intratumoral H2O2 + external beam RT as a novel combination in patients with breast cancer and exploratory plasma marker analyses investigating possible mechanisms of action.Methods and materials Twelve patients with breast tumors ≥3 cm (surgically or medically inoperable) received intratumoral H2O2 with either 36 Gy in 6 twice-weekly fractions (n = 6) or 49.5 Gy in 18 daily fractions (n = 6) to the whole breast ± locoregional lymph nodes in a single-center, nonrandomized study. H2O2 was mixed in 1% sodium hyaluronate gel (final H2O2 concentration 0.5%) before administration to slow drug release and minimize local discomfort. The mixture was injected intratumorally under ultrasound guidance twice weekly 1 hour before RT. The primary endpoint was patient-reported maximum intratumoral pain intensity before and 24 hours postinjection. Secondary endpoints included grade ≥3 skin toxicity and tumor response by ultrasound. Blood samples were collected before, during, and at the end of treatment for cell-death and immune marker analysis.Results Compliance with H2O2 and RT was 100%. Five of 12 patients reported moderate pain after injection (grade 2 Common Terminology Criteria for Adverse Events v4.02) with median duration 60 minutes (interquartile range, 20-120 minutes). Skin toxicity was comparable to RT alone, with maintained partial/complete tumor response relative to baseline in 11 of 12 patients at last follow-up (median 12 months). Blood marker analysis highlighted significant associations of TRAIL, IL-1β, IL-4, and MIP-1α with tumor response.Conclusions Intratumoral H2O2 with RT is well tolerated with no additional toxicity compared with RT alone. If efficacy is confirmed in a randomized phase 2 trial, the approach has potential as a cost-effective radiation response enhancer in multiple cancer types in which locoregional control after RT alone remains poor

Parasite Evolution and Life History Theory

Beth F. Kochin is with Emory University, James J. Bull is with UT Austin, Rustom Antia is with Emory University.As a group, parasites are extraordinarily diverse. Even closely related parasites may behave very differently, infecting different host species, causing different pathologies, or infecting different tissues. For example, Escherichia coli bacteria, a typically harmless inhabitant of the human gut, can, in different forms, cause diarrhea, intestinal bleeding, urinary tract infections, kidney bleeding, meningitis, and other diseases. Underlying this diversity is evolution.This work is supported by the National Institutes of Health and the Fannie and John Hertz Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Cellular and Molecular Biolog

Plasma Magnetohydrodynamics and Energy Conversion

Contains research objectives and reports on four research projects.U.S. Air Force (Aeronautical Systems Division) under Contract AF33(616)-7624 with the Aeronautical Accessories Laboratory, Wright-Patterson Air Force Base, OhioNational Science Foundation under Grant G-24073National Institutes of Health (Grant HTS-5550

A novel cohorting and isolation strategy for suspected COVID-19 cases during a pandemic.

BACKGROUND: The COVID-19 pandemic presents a significant infection prevention and control challenge. The admission of large numbers of patients with suspected COVID-19 disease risks overwhelming the capacity to protect other patients from exposure. The delay between clinical suspicion and confirmatory testing adds to the complexity of the problem. METHODS: We implemented a triage tool aimed at minimizing hospital-acquired COVID-19 particularly in patients at risk of severe disease. Patients were allocated to triage categories defined by likelihood of COVID-19 and risk of a poor outcome. Category A (low-likelihood; high-risk), B (high-likelihood; high-risk), C (high-likelihood; low-risk) and D (low-likelihood; low-risk). This determined the order of priority for isolation in single-occupancy rooms with Category A the highest. Patients in other groups were cohorted when isolation capacity was limited with additional interventions to reduce transmission. RESULTS: Ninety-three patients were evaluated with 79 (85%) receiving a COVID-19 diagnosis during their admission. Of those without a COVID-19 diagnosis: 10 were initially triaged to Category A; 0 to B; 1 to C and 4 to D. All high-risk patients requiring isolation were, therefore, admitted to single-occupancy rooms and protected from exposure. Twenty-eight (30%) suspected COVID-19 patients were evaluated to be low risk (groups C and D) and eligible for cohorting. No symptomatic hospital-acquired infections were detected in the cohorted patients. DISCUSSION: Application of a clinical triage tool to guide isolation and cohorting decisions may reduce the risk of hospital-acquired transmission of COVID-19 especially to individuals at the greatest of risk of severe disease

Visual Recognition of Age Class and Preference for Infantile Features: Implications for Species-Specific vs Universal Cognitive Traits in Primates

Despite not knowing the exact age of individuals, humans can estimate their rough age using age-related physical features. Nonhuman primates show some age-related physical features; however, the cognitive traits underlying their recognition of age class have not been revealed. Here, we tested the ability of two species of Old World monkey, Japanese macaques (JM) and Campbell's monkeys (CM), to spontaneously discriminate age classes using visual paired comparison (VPC) tasks based on the two distinct categories of infant and adult images. First, VPCs were conducted in JM subjects using conspecific JM stimuli. When analyzing the side of the first look, JM subjects significantly looked more often at novel images. Based on analyses of total looking durations, JM subjects looked at a novel infant image longer than they looked at a familiar adult image, suggesting the ability to spontaneously discriminate between the two age classes and a preference for infant over adult images. Next, VPCs were tested in CM subjects using heterospecific JM stimuli. CM subjects showed no difference in the side of their first look, but looked at infant JM images longer than they looked at adult images; the fact that CMs were totally naïve to JMs suggested that the attractiveness of infant images transcends species differences. This is the first report of visual age class recognition and a preference for infant over adult images in nonhuman primates. Our results suggest not only species-specific processing for age class recognition but also the evolutionary origins of the instinctive human perception of baby cuteness schema, proposed by the ethologist Konrad Lorenz

Ultra-Rapid Categorization of Fourier-Spectrum Equalized Natural Images: Macaques and Humans Perform Similarly

BACKGROUND: Comparative studies of cognitive processes find similarities between humans and apes but also monkeys. Even high-level processes, like the ability to categorize classes of object from any natural scene under ultra-rapid time constraints, seem to be present in rhesus macaque monkeys (despite a smaller brain and the lack of language and a cultural background). An interesting and still open question concerns the degree to which the same images are treated with the same efficacy by humans and monkeys when a low level cue, the spatial frequency content, is controlled. METHODOLOGY/PRINCIPAL FINDINGS: We used a set of natural images equalized in Fourier spectrum and asked whether it is still possible to categorize them as containing an animal and at what speed. One rhesus macaque monkey performed a forced-choice saccadic task with a good accuracy (67.5% and 76% for new and familiar images respectively) although performance was lower than with non-equalized images. Importantly, the minimum reaction time was still very fast (100 ms). We compared the performances of human subjects with the same setup and the same set of (new) images. Overall mean performance of humans was also lower than with original images (64% correct) but the minimum reaction time was still short (140 ms). CONCLUSION: Performances on individual images (% correct but not reaction times) for both humans and the monkey were significantly correlated suggesting that both species use similar features to perform the task. A similar advantage for full-face images was seen for both species. The results also suggest that local low spatial frequency information could be important, a finding that fits the theory that fast categorization relies on a rapid feedforward magnocellular signal

Impact on and use of health services by international migrants: questionnaire survey of inner city London A&E attenders

BACKGROUND: Changing immigration trends pose new challenges for the UK's open access health service and there is considerable speculation that migrants from resource-poor countries place a disproportionate burden on services. Data are needed to inform provision of services to migrant groups and to ensure their access to appropriate health care. We compared sociodemographic characteristics and impact of migrant groups and UK-born patients presenting to a hospital A&E/Walk-In Centre and prior use of community-based General Practitioner (GP) services. METHODS: We administered an anonymous questionnaire survey of all presenting patients at an A&E/Walk-In Centre at an inner-city London hospital during a 1 month period. Questions related to nationality, immigration status, time in the UK, registration and use of GP services. We compared differences between groups using two-way tables by Chi-Square and Fisher's exact test. We used logistic regression modelling to quantify associations of explanatory variables and outcomes. RESULTS: 1611 of 3262 patients completed the survey (response rate 49.4%). 720 (44.7%) were overseas born, representing 87 nationalities, of whom 532 (73.9%) were new migrants to the UK (≤10 years). Overseas born were over-represented in comparison to local estimates (44.7% vs 33.6%; p < 0.001; proportional difference 0.111 [95% CI 0.087–0.136]). Dominant immigration status' were: work permit (24.4%), EU citizens (21.5%), with only 21 (1.3%) political asylum seekers/refugees. 178 (11%) reported nationalities from refugee-generating countries (RGCs), eg, Somalia, who were less likely to speak English. Compared with RGCs, and after adjusting for age and sex, the Australians, New Zealanders, and South Africans (ANS group; OR 0.28 [95% CI 0.11 to 0.71]; p = 0.008) and the Other Migrant (OM) group comprising mainly Europeans (0.13 [0.06 to 0.30]; p = 0.000) were less likely to have GP registration and to have made prior contact with GPs, yet this did not affect mode of access to hospital services across groups nor delay access to care. CONCLUSION: Recently arrived migrants are a diverse and substantial group, of whom migrants from refugee-generating countries and asylum seekers comprise only a minority group. Service reorganisation to ensure improved access to community-based GPs and delivery of more appropriate care may lessen their impact on acute services

Early predictors of impaired social functioning in male rhesus macaques (Macaca mulatta)

Autism spectrum disorder (ASD) is characterized by social cognition impairments but its basic disease mechanisms remain poorly understood. Progress has been impeded by the absence of animal models that manifest behavioral phenotypes relevant to ASD. Rhesus monkeys are an ideal model organism to address this barrier to progress. Like humans, rhesus monkeys are highly social, possess complex social cognition abilities, and exhibit pronounced individual differences in social functioning. Moreover, we have previously shown that Low-Social (LS) vs. High-Social (HS) adult male monkeys exhibit lower social motivation and poorer social skills. It is not known, however, when these social deficits first emerge. The goals of this study were to test whether juvenile LS and HS monkeys differed as infants in their ability to process social information, and whether infant social abilities predicted later social classification (i.e., LS vs. HS), in order to facilitate earlier identification of monkeys at risk for poor social outcomes. Social classification was determined for N = 25 LS and N = 25 HS male monkeys that were 1–4 years of age. As part of a colony-wide assessment, these monkeys had previously undergone, as infants, tests of face recognition memory and the ability to respond appropriately to conspecific social signals. Monkeys later identified as LS vs. HS showed impairments in recognizing familiar vs. novel faces and in the species-typical adaptive ability to gaze avert to scenes of conspecific aggression. Additionally, multivariate logistic regression using infant social ability measures perfectly predicted later social classification of all N = 50 monkeys. These findings suggest that an early capacity to process important social information may account for differences in rhesus monkeys’ motivation and competence to establish and maintain social relationships later in life. Further development of this model will facilitate identification of novel biological targets for intervention to improve social outcomes in at-risk young monkeys