Procedural Skills Training During Emergency Medicine Residency: Are We Teaching the Right Things?

Objectives: The Residency Review Committee training requirements for emergency medicine residents (EM) are defined by consensus panels, with specific topics abstracted from lists of patient complaints and diagnostic codes. The relevance of specific curricular topics to actual practice has not been studied. We compared residency graduates’ self-assessed preparation during training to importance in practice for a variety of EM procedural skills.Methods: We distributed a web-based survey to all graduates of the Denver Health Residency Program in EM over the past 10 years. The survey addressed: practice type and patient census; years of experience; additional procedural training beyond residency; and confidence, preparation, and importance in practice for 12 procedures (extensor tendon repair, transvenous pacing, lumbar puncture, applanation tonometry, arterial line placement, anoscopy, CT scan interpretation, diagnostic peritoneal lavage, slit lamp usage, ultrasonography, compartment pressure measurement and procedural sedation). For each skill, preparation and importance were measured on four-point Likert scales. We compared mean preparation and importance scores using paired sample t-tests, to identify areas of under- or over-preparation.Results: Seventy-four residency graduates (59% of those eligible) completed the survey. There were significant discrepancies between importance in practice and preparation during residency for eight of the 12 skills. Under-preparation was significant for transvenous pacing, CT scan interpretation, slit lamp examinations and procedural sedation. Over-preparation was significant for extensor tendon repair, arterial line placement, peritoneal lavage and ultrasonography. There were strong correlations (r>0.3) between preparation during residency and confidence for 10 of the 12 procedural skills, suggesting a high degree of internal consistency for the survey.Conclusions: Practicing emergency physicians may be uniquely qualified to identify areas of under- and over-preparation during residency training. There were significant discrepancies between importance in practice and preparation during residency for eight of 12 procedures. There was a strong correlation between confidence and preparation during residency for almost all procedural skills, re-enforcing the tenet that residency training is the primary locus of instruction for clinical procedures.[WestJEM. 2009;10:152-156.

Comments on the distribution of \u3ci\u3eBotrychium lunarioides\u3c/i\u3e (Ophioglossaceae) in Texas

Botrychium lunarioides (Michx.) Sw. (Ophioglossaceae) is now known to be widespread and abundant throughout the eastern portion of Texas. In 1996, Do, et al. reported ten additional county records in the central portion of the Post Oak Savannah of Texas, thereby extending the known distribution of the species up to 273 km to the west. Additional field studies during 1996 have yielded nineteen new county records for the species in Texas. These new reports are primarily from the Post Oak Savannah, Pineywoods, and Blackland Prairies of northeast Texas and from the southern portion of the Post Oak Savannah. The most notable occurrence of the species is at Lake Bastrop State Recreation Area, Bastrop County, about 45 km ESE of Austin, which extends both the western and southern known limits of the species

Combined Structural and Compositional Evolution of Planetary Rings Due to Micrometeoroid Impacts and Ballistic Transport

We introduce improved numerical techniques for simulating the structural and compositional evolution of planetary rings due to micrometeoroid bombardment and subsequent ballistic transport of impact ejecta. Our current, robust code is capable of modeling structural changes and pollution transport simultaneously over long times on both local and global scales. In this paper, we describe the methodology based on the original structural code of Durisen et al. (1989, Icarus 80, 136-166) and on the pollution transport code of Cuzzi and Estrada (1998, Icarus 132, 1-35). We provide demonstrative simulations to compare with, and extend upon previous work, as well as examples of how ballistic transport can maintain the observed structure in Saturn's rings using available Cassini occultation optical depth data. In particular, we explicitly verify the claim that the inner B (and presumably A) ring edge can be maintained over long periods of time due to an ejecta distribution that is heavily biased in the prograde direction through a balance between the sharpening effects of ballistic transport and the broadening effects of viscosity. We also see that a "ramp"-like feature forms over time just inside that edge. However, it does not remain linear for the duration of the runs presented here unless a less steep ejecta velocity distribution is adopted. We also model the C ring plateaus and find that their outer edges can be maintained at their observed sharpness for long periods due to ballistic transport. We hypothesize that the addition of a significant component of a retrograde-biased ejecta distribution may help explain the linearity of the ramp and is probably essential for maintaining the sharpness of C ring plateau inner edges. This component would arise for the subset of micrometeoroid impacts which are destructive rather than merely cratering. Such a distribution will be introduced in future work

Addressing student models of energy loss in quantum tunnelling

We report on a multi-year, multi-institution study to investigate student reasoning about energy in the context of quantum tunnelling. We use ungraded surveys, graded examination questions, individual clinical interviews, and multiple-choice exams to build a picture of the types of responses that students typically give. We find that two descriptions of tunnelling through a square barrier are particularly common. Students often state that tunnelling particles lose energy while tunnelling. When sketching wave functions, students also show a shift in the axis of oscillation, as if the height of the axis of oscillation indicated the energy of the particle. We find inconsistencies between students' conceptual, mathematical, and graphical models of quantum tunnelling. As part of a curriculum in quantum physics, we have developed instructional materials to help students develop a more robust and less inconsistent picture of tunnelling, and present data suggesting that we have succeeded in doing so.Comment: Originally submitted to the European Journal of Physics on 2005 Feb 10. Pages: 14. References: 11. Figures: 9. Tables: 1. Resubmitted May 18 with revisions that include an appendix with the curriculum materials discussed in the paper (4 page small group UW-style tutorial

Renal phenotype is exacerbated in Os and lpr double mutant mice

Renal phenotype is exacerbated in Os and lpr double mutant mice.BackgroundROP-Os/+ mice are born with oligosyndactyly and oligonephronia and develop renal dysfunction, which includes renal tubular epithelial cell (RTC) Fas-dependent apoptosis and tubular atrophy. MRL/lpr mice harbor a Fas-inactivating mutation and develop glomerulonephritis, whereas mice expressing lpr on a C3H background demonstrate no renal phenotype. We hypothesized that crossing ROP-Os/+ with CH3-lpr/lpr mice would rescue the Os/+ renal phenotype by reducing Fas-dependent RTC apoptosis.MethodsROP-Os/+ mice were intercrossed with C3H-lpr/lpr mice and F2 generation animals were phenotyped by kidney weight, serum creatinine, and albuminuria. Kidney sections were scored for histopathology and apoptosis. Univariate and multivariate analyses were used to examine additive effects of Os and lpr on renal phenotype.ResultsBy 16 weeks, F2Os/+ lpr/lpr mice developed significantly more albuminuria, glomerulosclerosis, and interstitial inflammation compared to Os/++/+ mice. Glomerular cell apoptosis was increased in Os/+ lpr/lpr compared to Os/++/+ mice, with no significant difference in RTC apoptosis. A statistically significant Os-lpr effect on renal phenotype was demonstrated by multivariate analysis, which exceeded the combined independent effects if Os and lpr, indicating a biologic interaction exists between Os and lpr.Conclusion.Os/+mice with a superimposed lpr mutation displayed a more severe renal phenotype, rather than phenotype rescue, suggesting that Fas pathway activation is necessary to delete cells resulting from Os-dependent injury. We further propose that an Os-lpr gene interaction and/or mixed ROP-C3H genetic background regulated the renal phenotype, consistent with the concept that chronic renal disease pathogenesis reflects effects of multiple nephropathy susceptibility alleles

Penetration of Endothelial Cell Coated Multicellular Tumor Spheroids by Iron Oxide Nanoparticles

Iron oxide nanoparticles are a useful diagnostic contrast agent and have great potential for therapeutic applications. Multiple emerging diagnostic and therapeutic applications and the numerous versatile parameters of the nanoparticle platform require a robust biological model for characterization and assessment. Here we investigate the use of iron oxide nanoparticles that target tumor vasculature, via the tumstatin peptide, in a novel three-dimensional tissue culture model. The developed tissue culture model more closely mimics the in vivo environment with a leaky endothelium coating around a glioma tumor mass. Tumstatin-iron oxide nanoparticles showed penetration and selective targeting to endothelial cell coating on the tumor in the three-dimensional model, and had approximately 2 times greater uptake in vitro and 2.7 times tumor neo-vascularization inhibition. Tumstatin provides targeting and therapeutic capabilities to the iron oxide nanoparticle diagnostic contrast agent platform. And the novel endothelial cell-coated tumor model provides an in vitro microtissue environment to evaluate nanoparticles without moving into costly and time-consuming animal models

p190RhoGAP is the convergence point of adhesion signals from α5β1 integrin and syndecan-4

The fibronectin receptors α5β1 integrin and syndecan-4 cocluster in focal adhesions and coordinate cell migration by making individual contributions to the suppression of RhoA activity during matrix engagement. p190Rho–guanosine triphosphatase–activating protein (GAP) is known to inhibit RhoA during the early stages of cell spreading in an Src-dependent manner. This paper dissects the mechanisms of p190RhoGAP regulation and distinguishes the contributions of α5β1 integrin and syndecan-4. Matrix-induced tyrosine phosphorylation of p190RhoGAP is stimulated solely by engagement of α5β1 integrin and is independent of syndecan-4. Parallel engagement of syndecan-4 causes redistribution of the tyrosine-phosphorylated pool of p190RhoGAP between membrane and cytosolic fractions by a mechanism that requires direct activation of protein kinase C α by syndecan-4. Activation of both pathways is necessary for the efficient regulation of RhoA and, as a consequence, focal adhesion formation. Accordingly, we identify p190RhoGAP as the convergence point for adhesive signals mediated by α5β1 integrin and syndecan-4. This molecular mechanism explains the cooperation between extracellular matrix receptors during cell adhesion

Complete RXTE Spectral Observations of the Black Hole X-ray Nova XTE J1550-564

We report on the X-ray spectral behavior of the exceptionally bright X-ray nova XTE J1550-564 during its 1998-99 outburst. Our study is based on 209 pointed observations using the PCA and HEXTE instruments onboard the Rossi X-ray Timing Explorer spanning 250 days and covering the entire double-peaked eruption that occurred from 1998 September until 1999 May. The spectra are fit to a model including multicolor blackbody disk and power-law components. The source is observed in the very high and high/soft outburst states of black hole X-ray novae. During the very high state, when the power-law component dominated the spectrum, the inner disk radius is observed to vary by more than an order of magnitude; the radius decreased by a factor of 16 in one day during a 6.8 Crab flare. If the larger of these observed radii is taken to be the last stable orbit, then the smaller observed radius would imply that the inner edge of the disk is inside the event horizon! However, we conclude that the apparent variations of the inner disk radius observed during periods of increased power-law emission are probably caused by the failure of the multicolor disk/power-law model; the actual physical radius of the inner disk may remain fairly constant. This interpretation is supported by the fact that the observed inner disk radius remains approximately constant over 120 days in the high state, when the power-law component is weak, even though the disk flux and total flux vary by an order of magnitude. The mass of the black hole inferred by equating the approximately constant inner disk radius observed in the high/soft state with the last stable orbit for a Schwarzschild black hole is M_BH = 7.4 M_sun (D/6 kpc) (cos i)^{-1/2}.Comment: Submitted to ApJ, 20 pages including 6 figures + 4 large table