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The aim of this study was to determine if hypophosphatemia is more common in patients with severe alcohol-induced acute pancreatitis (AAP).This is a retrospective, single institution, cohort study that analyzed 147 patients admitted to the hospital for AAP. Multivariate logistic regression was used to determine if hypophosphatemia would be related to clinical outcomes of disease severity.Hypophosphatemia was more common in patients with severe AAP at admission; in addition, all patients with severe AAP (100%) eventually developed hypophosphatemia during admission, relative to those with mild (43%) and moderately severe (54%) AAP. The magnitude of the lowest phosphate measurement obtained during admission was lower in patients with severe AAP (mean, 1.5 mg/dL, standard deviation [SD], 0.5 mg/dL) relative to those with mild (mean, 2.6 mg/dL; SD, 0.9 mg/dL) and moderately severe (mean, 2.3 mg/dL; SD, 0.9 mg/dL) AAP (P0.001). Finally, patients who developed hypophosphatemia during admission were more likely to require intensive care unit admission (P0.001), vasopressors (P = 0.01), or intubation (P = 0.003).Hypophosphatemia is more common and of greater magnitude in patients admitted to the hospital with severe AAP. In addition, patients with severe AAP who develop hypophosphatemia during admission are more likely to have poorer clinical outcomes.

The aim of this study was to determine if the quick Sepsis-Related Organ Failure Assessment (qSOFA) score assessed at and 48 hours after admission is prognostic for alcohol-induced acute pancreatitis (AAP) severity.This is a retrospective cohort review study of 161 patients admitted to a single academic hospital in Houston, TX, with the diagnosis of AAP. Receiver operator characteristics analysis and logistic regression were used to assess the diagnostic accuracy and prognostic ability of the qSOFA score.A qSOFA score of 2 or higher at and 48 hours after admission had a specificity of 94% or greater and sensitivity of 33% or higher for pancreatitis severity and need for intensive care admission, intubation, or vasopressors. The qSOFA score at and 48 hours after admission was prognostic of intensive care unit admission by an adjusted odds ratio of 48.5 (95% confidence interval [CI], 6.4-1013.3; Plt; 0.001) and 18.8 (95% CI, 2.2-467.3; Plt; 0.05), respectively. The qSOFA score at admission was prognostic of severe pancreatitis by an adjusted odds ratio of 35.3 (95% CI, 7.2-224.3; Plt; 0.001).A qSOFA score of 2 or higher is highly specific and prognostic of multiple clinical outcomes both at and 48 hours after admission in patients with AAP.

Background Successful trauma resuscitation relies on multi-disciplinary collaboration. In most academic programs, general surgery (GS) and emergency medicine (EM) residents rarely train together before functioning as a team. Methods In our Multi-Disciplinary Trauma Evaluation and Management Simulation (MD-TEAMS), EM and GS residents completed manikin-based trauma scenarios and were evaluated on resuscitation and communication skills. Residents were surveyed on confidence surrounding training objectives. Results Residents showed improved confidence running trauma scenarios in multi-disciplinary teams. Residents received lower communication scores from same-discipline vs cross-discipline faculty. EM residents scored higher in evaluation and planning domains; GS residents scored higher in action processes; groups scored equally in team management. Strong correlation existed between team leader communication and resuscitative skill completion. Conclusion MD-TEAMS demonstrated correlation between communication and resuscitation checklist item completion and communication differences by resident specialty. In the future, we plan to evaluate training-related resident behavior changes and specialty-specific communication differences by residents.

BackgroundCOVID necessitated the shift to virtual resident instruction. The challenge of learning via virtual modalities has the potential to increase cognitive load. It is important for educators to reduce cognitive load to optimize learning, yet there are few available tools to measure cognitive load. The objective of this study is to identify and provide validity evidence following Messicks' framework for an instrument to evaluate cognitive load in virtual emergency medicine didactic sessions.MethodsThis study followed Messicks' framework for validity including content, response process, internal structure, and relationship to other variables. Content validity evidence included: (1) engagement of reference librarian and literature review of existing instruments; (2)engagement of experts in cognitive load, and relevant stakeholders to review the literature and choose an instrument appropriate to measure cognitive load in EM didactic presentations. Response process validity was gathered using the format and anchors of instruments with previous validity evidence and piloting amongst the author group. A lecture was provided by one faculty to four residency programs via ZoomTM. Afterwards, residents completed the cognitive load instrument. Descriptive statistics were collected; Cronbach's alpha assessed internal consistency of the instrument; and correlation for relationship to other variables (quality of lecture).ResultsThe 10-item Leppink Cognitive Load instrument was selected with attention to content and response process validity evidence. Internal structure of the instrument was good (Cronbach's alpha=0.80). Subscales performed well-intrinsic load (α=0.96, excellent), extrinsic load (α=0.89, good), and germane load (α=0.97, excellent). Five of the items were correlated with overall quality of lecture (p&nbsp

This is a proof-of-concept study for the development of a field-deployable and low-cost PCR thermocycler (FLC-PCR) to perform Polymerase Chain Reaction (PCR) for the rapid detection of environmental E. coli. Four efficient (77.1 W) peltier modules are used as the central temperature control unit. One 250 W silicone heating pad is used for the heating lid. The PID (proportional–integral–derivative) control algorithm for the thermocycles is implemented by a low-cost 8-bit, 16 MHz microcontroller (ATMEGA328P-PU). ybbW and uidA genes from specific E. coli colonies were used as amplicons for the PCR reactions that were carried out by a commercial PCR machine (Bio-Rad) and our FLC-PCR thermocycler. The heating and cooling speeds averaged 1.11 ± 0.33°C/s which is on a par with the commercial bench-top PCR thermocycler and the efficiency of the heating lid outperformed the Bio-Rad PCR thermocycler. The overall cost of the system is lower than $200 which is more than ten times lower than commercially available units. The heating block can be customized to accommodate different PCR tubes and even microfluidic chambers. An 8000 W portable power generator will be used as the power supply for field studies.

Covid-19 is a systemic viral respiratory illness that can cause gastrointestinal manifestations. There is evidence that Covid-19 can infect liver tissue and may cause transaminemia. A prognostic model is needed to aid clinicians in determining disease severity. The Model for End-Stage Liver Disease-Sodium (MELD-Na) score is a mortality assessment tool in liver transplant patients that has been found to be prognostic in other clinical situations. This study aimed to determine if the MELD-Na score was associated with disease severity in patients with Covid-19, as assessed by multiple clinical outcomes including death within 30 days of discharge and development of an acute kidney injury (AKI). This is a retrospective cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19. The 30-day MELD-Na score was found to be significantly higher in those who died (14.38 ± 6.92) relative to those who survived (9.68 ± 5.69; p = 0.03). Additionally, patients with a MELD-Na score greater than 10 were found to have higher risk of developing an AKI (odds ratio (OR) 3.31 (1.08, 10.17); p = 0.03), need for hemodialysis (OR 9.69 (1.74, 53.96); p = 0.007), require vasopressors (OR 4.55 (1.22, 16.99); p = 0.02), and have a longer hospital stay (OR 4.17 (1.05, 16.47); p = 0.03). The MELD-Na score may serve as a useful clinical scoring system for prognosis in patients admitted to the hospital with Covid-19.

The COVID-19 pandemic has required a substantial change to the approach used for traditional, in-person continuing professional development (CPD) conferences. Running a virtual CPD conference will necessitate consideration of digital platforms and conversion of large group and small group sessions, abstract presentations, and networking events to a digital medium. This paper will discuss these challenges and present strategies to address them for CPD conference planning in the era of COVID-19.

Lectures are a common instructional method in medical education. Understanding the cognitive processes and theories involved in learning is essential for lecturers to be effective. Cognitive load theory is one theory that is becoming increasingly recognized in medical education and addresses the appropriate use of one's working memory. Memory is essential to knowledge acquisition. Two types of memory can be considered, working memory (processing of information) and long-term memory (storage of information). Working memory has a limited capacity. Cognitive load refers to the amount of information processing activity imposed on working memory and can be divided into three domains: intrinsic, extraneous, and germane. By attending to cognitive load, educators can promote learning. This paper highlights various ways of improving cognitive load for learners during lecture-based instruction by minimizing extraneous load, optimizing intrinsic load, and promoting germane load.

Prognostic markers are needed to understand the disease course and severity in patients with Covid-19. There is evidence that Covid-19 causes gastrointestinal symptoms and abnormalities in liver enzymes. We aimed to determine if hepatobiliary laboratory data could predict disease severity in patients with Covid-19. In this retrospective, single institution, cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19, we found that elevations of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT) and Alkaline Phosphatase (AP) at any time during hospital admission increased the odds of ICU admission by 5.12 (95% CI: 1.55–16.89; p = 0.007), 4.71 (95% CI: 1.51–14.69; p = 0.01) and 4.12 (95% CI: 1.21–14.06, p = 0.02), respectively. Hypoalbuminemia found at the time of admission to the hospital was associated with increased mortality (p = 0.02), hypotension (p = 0.03), and need for vasopressors (p = 0.02), intubation (p = 0.01) and hemodialysis (p = 0.002). Additionally, there was evidence of liver injury: AST was significantly elevated above baseline in patients admitted to the ICU (54.2 ± 15.70 U/L) relative to those who were not (9.2 ± 4.89 U/L; p = 0.01). Taken together, this study found that hypoalbuminemia and abnormalities in hepatobiliary laboratory data may be prognostic factors for disease severity in patients admitted to the hospital with Covid-19.

INTRODUCTION: Prognostic markers are needed to understand the disease course and severity in patients with Covid-19, a viral respiratory illness that causes systemic symptoms However, there is no model to date that evaluates the complexity of this illness We hypothesized that the MELD-Na score would be associated with disease severity in patients with Covid-19 METHODS: This is an IRB approved, retrospective, single institution, cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19 between March, 1st 2020 and June 11th, 2020 The primary outcome was mortality at 30 days based on MELD-Na score calculated at the time of admission Secondary outcomes included the development of an Acute Kidney Injury (AKI), need for hemodialysis (HD), need for vasopressor hemodynamic support, need for intubation and hospital stay lasting longer than 7 days RESULTS: The sample size consisted of 99 patients: admission data to calculate a MELD-Na score was available for 63 patients (63%) The MELD-Na score was found to be significantly higher in those who died at 30 days (14 38±6 92) after discharge relative to those who survived (9 68±5 69;P = 0 03);the odds of death at 30 days with a MELD-Na score greater than 10 was 9 00 (95% CI: 2 29, 35 50;P = 0 001) Patients with a MELD-Na score greater than 10 were more likely to have an AKI by an odds ratio (OR) of 3 31 (95% CI: 1 08, 10 17, P = 0 03), need HD by an OR of 9 69 (95% CI: 1 74, 53 96, P = 0 007), need vasopressor support by an OR of 4 55 (95% CI: 1 22, 16 99, P = 0 02) and stay in the hospital longer than 7 days by an OR of 4 17 (95% CI: 1 05, 16 47;P = 0 03) CONCLUSION: The MELD-Na score was found to be higher in patients with Covid-19 who died relative to those who survived at 30 days after discharge A MELD-Na score greater than 10 was prognostic of multiple clinical outcomes, including 30-day all cause mortality, development of an AKI, need for HD, need for vasopressors and longer hospital stay Thus, the MELD-Na score serves as a useful clinical scoring system for prognosis in patients admitted to the hospital with Covid-19 (Table Presented)

INTRODUCTION: Prognostic markers are needed to understand the disease course and severity in patients with Covid-19, a respiratory viral illness There is evidence that Covid-19 causes gastrointestinal symptoms and abnormalities in liver enzymes We aimed to determine if hepatobiliary laboratory data could predict disease severity in patients with Covid-19 METHODS: This is an IRB approved, retrospective, single institution, cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19 between March, 1st 2020 and May 5th, 2020 The primary outcome was the need for Intensive Care Unit (ICU) admission based on elevations in transaminases, Alkaline Phosphatase (AP) and Total Bilirubin (TB) Secondary outcomes included mortality, development of Acute Kidney Injury (AKI) or hypotension and need for supplemental oxygen RESULTS: Sixty patients were included in the analysis Elevation of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT) and Alkaline Phosphatase (AP) increased the odds of ICU admission by 5 12 (95% CI: 1 55,16 89;P = 0 007), 4 71 (95% CI: 1 51,14 69;P = 0 01) and 4 12 (95% CI: 1 21,14 06, P = 0 02), respectively Hypoalbuminemia was associated with increased mortality by an odds ratio of 6 79 (CI: 1 27-36 34, P = 0 02) Additionally, there was evidence of liver injury: the change in AST during admission above baseline was significantly higher in patients admitted to the ICU (54 2±15 70 U/L) relative to those who were not (9 2±4 89 U/L;P = 0 01) CONCLUSION: This study found that hypoalbuminemia and abnormalities in hepatobiliary laboratory data are prognostic factors for disease severity in patients admitted to the hospital with Covid-19 Additionally, there may be evidence of liver injury in Covid-19 patients that is more severe in those admitted to the ICU (Table Presented)

OBJECTIVE Pediatric patients are at risk for the recurrence of brain arteriovenous malformation (AVM) after resection. While there is general consensus on the importance of follow-up after surgical removal of an AVM, there is a lack of consistency in the duration of that follow-up. The object of this systematic review was to examine the role of follow-up imaging in detecting AVM recurrence early and preventing AVM rupture. METHODS This systematic review was performed using articles obtained through a search of the literature contained in the MeSH database, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Search results revealed 1052 articles, 13 of which described 31 cases of AVM recurrence meeting the criteria for inclusion in this study. Detection of AVM occurred significantly earlier (mean ± SD, 3.56 ± 3.67 years) in patients with follow-up imaging than in those without (mean 8.86 ± 5.61 years; p = 0.0169). While 13.34% of patients who underwent follow-up imaging presented with rupture of a recurrent AVM, 57.14% of those without follow-up imaging presented with a ruptured recurrence (p = 0.0377). CONCLUSIONS Follow-up imaging has an integral role after AVM resection and is sometimes not performed for a sufficient period, leading to delayed detection of recurrence and an increased likelihood of a ruptured recurrent AVM.

Aging baby-boomers present significant challenges to accessible, affordable emergency care in America for patients of all ages. St. Louis physicians served as early innovators in the field of geriatric emergency medicine. This manuscript summarizes a multi-institutional November 2016 symposium reviewing the Missouri history of geriatric emergency care. In addition, this manuscript describes multispecialty organizations’ guidelines, healthcare outcomes research, contemporary medical education paradigms, and evolving efforts to disseminate guideline-based geriatric emergency care using a “Boot Camp” approach and implementation science. This manuscript also reviews local adaptations to emergency medical services and palliative care, as well as the perspectives of emergency department leaders exploring the balance between infrastructure and personnel required to promote guideline-based geriatric emergency care with the anticipated benefits. This discussion is framed within the context of the American College of Emergency Physician’s planned geriatric emergency department accreditation process scheduled to begin in 2018.

This study gathered empirical evidence on adoption patterns of self-driving vehicles, their likely use, and how that use might influence the amount of travel, mode choice, auto ownership, and other travel behavior decisions. Because self-driving vehicles were not yet on the market, a car technology acceptance model was applied to understand adoption and use. Researchers implemented a two-stage data collection effort. An online survey was conducted with 556 residents of metropolitan Austin, Texas, to determine intent to use. Four intent-to-use categories were determined: extremely unlikely, 18%; somewhat unlikely, 32%; somewhat likely, 36%; and extremely likely, 14%. Of those who indicated intent to use, qualitative interviews were conducted to ascertain the impact on their travel behavior. Most respondents would rather own a self-driving vehicle than use one such as Car2Go or Uber taxi. In addition, respondents reported that using a self-driving vehicle would make no change in where people would choose to live in Austin (80%), no change to their annual vehicle miles of travel (66%), and no change to the number of vehicles owned (55%).

Physician decision making is partially responsible for the roughly 30% of U.S. healthcare expenditures that are wasted annually on low-value care. In response to both the widespread public demand for higher-quality care and the cost crisis, payers are transitioning toward value-based payment models whereby physicians are rewarded for high-value, cost-conscious care. Furthermore, to target physicians in training to practice with cost awareness, the Accreditation Council for Graduate Medical Education has created both individual objective milestones and institutional requirements to incorporate quality improvement and cost awareness into fellowship training. Subsequently, some professional medical societies have initiated high-value care educational campaigns, but the overwhelming majority target either medical students or residents in training. Currently, there are few resources available to help guide subspecialty fellowship programs to successfully design durable high-value care curricula. The resource-intensive nature of pulmonary and critical care medicine offers unique opportunities for the specialty to lead in modeling and teaching high-value care. To ensure that fellows graduate with the capability to practice high-value care, we recommend that fellowship programs focus on four major educational domains. These include fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. In doing so, pulmonary and critical care educators can strive to train future physicians who are prepared to provide care that is both high quality and informed by cost awareness.

Rationale: Intensive care unit (ICU)-based randomized clinical trials (RCTs) among adult critically ill patients commonly fail to detect treatment benefits. Objectives: Appraise the rates of success, outcomes used, statistical power, and design characteristics of published trials. Methods: One hundred forty-six ICU-based RCTs of diagnostic, therapeutic, or process/systems interventions published from January 2007 to May 2013 in 16 high-impact general or critical care journals were studied. Measurement and Main Results: Of 146 RCTs, 54 (37%) were positive (i.e., the a priori hypothesis was found to be statistically significant). The most common primary outcomes were mortality (n = 40 trials), infection-related outcomes (n = 33), and ventilation-related outcomes (n = 30), with positive results found in 10, 58, and 43%, respectively. Statistical power was discussed in 135 RCTs (92%); 92 cited a rationale for their power parameters. Twenty trials failed to achieve at least 95% of their reported target sample size, including 11 that were stopped early due to insufficient accrual/logistical issues. Of 34 superiority RCTs comparing mortality between treatment arms, 13 (38%) accrued a sample size large enough to find an absolute mortality reduction of 10% or less. In 22 of these trials the observed control-arm mortality rate differed from the predicted rate by at least 7.5%. Conclusions: ICU-based RCTs are commonly negative and powered to identify what appear to be unrealistic treatment effects, particularly when using mortality as the primary outcome. Additional concerns include a lack of standardized methods for assessing common outcomes, unclear justifications for statistical power calculations, insufficient patient accrual, and incorrect predictions of baseline event rates.

The aging population may strain intensive care unit (ICU) capacity and adversely affect patient outcomes. Existing fluctuations in demand for ICU care offer an opportunity to explore such relationships.To determine whether transient increases in ICU strain influence patient mortality, and to identify characteristics of ICUs that are resilient to surges in capacity strain.Retrospective cohort study of 264,401 patients admitted to 155 U.S. ICUs from 2001 to 2008. We used logistic regression to examine relationships of measures of ICU strain (census, average acuity, and proportion of new admissions) near the time of ICU admission with mortality.A total of 36,465 (14%) patients died in the hospital. ICU census on the day of a patient's admission was associated with increased mortality (odds ratio [OR], 1.02 per standardized unit increase; 95% confidence interval [CI]: 1.00, 1.03). This effect was greater among ICUs employing closed (OR, 1.07; 95% CI: 1.02, 1.12) versus open (OR, 1.01; 95% CI: 0.99, 1.03) physician staffing models (interaction P value = 0.02). The relationship between census and mortality was stronger when the census was composed of higher acuity patients (interaction P value0.01). Averaging strain over the first 3 days of patients' ICU stays yielded similar results except that the proportion of new admissions was now also associated with mortality (OR, 1.04 for each 10% increase; 95% CI: 1.02, 1.06).Several sources of ICU strain are associated with small but potentially important increases in patient mortality, particularly in ICUs employing closed staffing models. Although closed ICUs may promote favorable outcomes under static conditions, they are susceptible to being overwhelmed by patient influxes.

Objective The Hemodialysis Reliable Outflow (HeRO) graft is becoming a recognized alternative to lower extremity arteriovenous grafts (LEAVGs) as an option for patients who have exhausted traditional upper extremity access; however, which should be applied preferentially is unclear. Methods A retrospective review of LEAVG and HeRO implants from January 2004 to August 2010 was performed. Patient demographics, medical history, procedural data, and outcomes were evaluated. Results Within the time periods, 60 HeROs were placed in 59 patients and 22 LEAVGs were placed in 21 patients. Demographics were similar between the two groups for many factors; however, the patients who underwent HeRO placement had significantly higher body mass index compared with the LEAVG group. Mean follow-up was 13.9 months for the HeRO group and 11.9 months for the LEAVG group. The HeRO patients underwent a mean of 6.3 previous tunneled dialysis catheter insertions and 3.1 previous AVG/arteriovenous fistula placements. The LEAVG patients underwent placement of a mean of 4.1 previous tunneled dialysis catheters and 2.6 previous AVG/arteriovenous fistulas. The principal difference was the number of interventions to maintain patency, which was 2.21 per year in the HeRO group and 1.17 per year in the AVG group (P = .003) Secondary patency at 6 months was 77% for the HeRO patients and 83% for the LEAVG patients (P = .14). The HeRO and LEAVG groups had no difference in infection rate per 1000 days (0.61 vs 0.71; P = .77) or mortality rate (22% vs 19% respectively; P = .22) at 6 months. Conclusions In access challenged patients, LEAVG and HeRO offer similar rates of secondary patency, infection, and all-cause mortality. The LEAVG required fewer interventions to maintain patency, and the HeRO maintains the benefit of utilizing the upper extremity site of venous drainage. In our practice, we prefer the HeRO to LEAVG, especially in patients with peripheral arterial disease and in the obese population, because it preserves lower extremity access options.

Measuring performance provides a variety of benefits: establishing accountability with the public, enabling management and performance improvements, increasing transparency, and building public trust. The most recent transportation authorization bill, Moving Ahead for Progress in the 21st Century, includes a heavy focus on performance measurement. Despite such strong reasons, measuring the performance of public engagement in transportation planning has proved difficult for a variety of issues, including unclear goals, limited funding, and the situational nature of engagement activities. To address some of these issues, the literature of best practices for public engagement in transportation planning is analyzed, and three principles that encapsulate the contained concepts are derived. The three principles include accessible events, engaging interactions, and an outcome-oriented process. The author developed a performance scorecard rubric to operationalize the three principles. The scorecard provides an intuitive and concise method to measure and display performance information. This paper organizes the disparate and fragmented literature of recommended practices into a usable framework that enables practitioners to understand more easily the important aspects of public engagement and to better measure the performance of engagement activities. The paper also advances the discourse surrounding public engagement and performance measurement. Additional study would provide opportunities for further refinement and investigation of the efficacy of the system developed in a real-world setting.

Background There is an urgent need for a simple and accurate test for the diagnosis of human Mycobacterium tuberculosis, the infectious agent causing tuberculosis (TB). Here we describe a serological test based on light emitting recombinant proteins for the diagnosis of pulmonary Mycobacterium tuberculosis infection. Methods Luciferase Immunoprecipitation Systems (LIPS), a fluid-phase immunoassay, was used to examine antibody responses against a panel of 24 different M. tuberculosis proteins. Three different strategies were used for generating the constructs expressing the recombinant fusion M. tuberculosis proteins with luciferase: synthetic gene synthesis, Gateway recombination cloning, and custom PCR synthesis. A pilot cohort of African pulmonary TB patients was used for initial antibody screening and confirmatory studies with selected antigens were performed with a cohort from Thailand and healthy US blood donors. In addition to testing M. tuberculosis antigens separately, a mixture that tested seven antigens simultaneously was evaluated for diagnostic performance. Results LIPS testing of a pilot set of serum samples from African pulmonary TB patients identified a potential subset of diagnostically useful M. tuberculosis antigens. Evaluation of a second independent cohort from Thailand validated highly significant antibody responses against seven antigens (PstS1, Rv0831c, FbpA, EspB, bfrB, HspX and ssb), which often showed robust antibody levels up to 50- to 1000-fold higher than local community controls. Marked heterogeneity of antibody responses was observed in the patients and the combined results demonstrated 73.5 % sensitivity and 100 % specificity for detection of pulmonary TB. A LIPS test simultaneously employing the seven M. tuberculosis antigen as a mixture matched the combined diagnostic performance of the separate tests, but showed an even higher diagnostic sensitivity (90 %) when a cut-off based on healthy US blood donors was used. Conclusion A LIPS immunoassay employing multiple M. tuberculosis antigens shows promise for the rapid and quantitative serological detection of pulmonary TB. Electronic supplementary material The online version of this article (doi:10.1186/s12866-015-0545-y) contains supplementary material, which is available to authorized users.

To compare magnetic resonance imaging (MRI) to 3D endovaginal ultrasound (EVUS) in the evaluation of major levator ani defects in women with pelvic floor disorders.A total of 21 subjects with pelvic floor with complaints of pelvic floor disorders were included in this study. EVUS imaging of the levator ani muscle (LAM) was performed in all subjects, and the LA muscle groups of interest evaluated were the puboanalis (PA), puborectalis (PR), and pubovisceralis (PV) muscles. The right and left subdivisions were evaluated separately, and classified as (i) normal, normal with only minor irregularities, grossly abnormal, or absent, or (ii) by the levator ani deficiency (LAD) score and classified by no defect (complete attachment of muscle to the pubic bone),50% detachment or loss,50% detachment or loss, and completely detached or complete muscle loss. Paired data were analyzed with McNemar's test or Bowker's test of symmetry.When unilateral LAM subdivisions were classified as "normal," "normal with minor irregularity," "grossly abnormal," and "absent," there were no significant differences between MRI and EVUS by categorization of LAM defects. Comparing "normal" versus "abnormal," there was no difference between imaging modalities. When compared by LAD score evaluation, there were no differences in the categorization of unilateral defects between MRI and EVUS.Endovaginal 3D US is comparable to MRI in its ability to identify both normal and abnormal LAM anatomy. Neurourol. Urodynam. 36:409-413, 2017. © 2015 Wiley Periodicals, Inc.

Background Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post-intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives To report on engagement with non-critical care providers and survivors during the 2012 Society of Critical Care Medicine post-intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting outcomes Future steps were planned regarding 1) recognizing, preventing, and treating post-intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post-intensive care syndrome across the continuum of care, including explicit "functional reconciliation" (assessing gaps between a patient's pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post-intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions Raising awareness of post-intensive care syndrome for the public and both critical care and non-critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

Federal regulation of the automotive industry has traditionally sought to ensure public safety. Autonomous vehicles could greatly reduce crashes from human error, resulting in significant interest from federal transportation agencies. Autonomous vehicles present a new challenge to the regulation of safety-related technologies, due in part to the lack of clarity in how technology will evolve and affect traffic safety. The federal government has already invested significant effort in the study of connected vehicle technologies and their safety-related applications, some of which could be utilized for autonomous vehicle applications. Thus, federal mandates on the inclusion of connected vehicle technologies in future model vehicles offer one pathway for the federal government to provide regulatory guidance on the development of autonomous vehicles. However, it is also possible that such a mandate could stifle autonomous vehicle development, as it is still unclear what technologies are best suited for autonomous vehicle systems. For this research effort, the team interviewed representatives of automotive manufacturers and in-vehicle systems developers who are active in the development of autonomous and connected vehicle technologies to gain their perspective on the potential role of state and federal authorities in establishing public policy related to connected and automated vehicles. In general, the perspective of the industry is that more work needs to be done on resolving potential liability issues and any regulation of the industry needs to occur with a focus on maintaining an environment of innovation.

Detailed data on occupancy and use of mechanical ventilators in U. S. ICU over time and across unit types are lacking. We sought to describe the hourly bed occupancy and use of ventilators in U.S. ICUs to improve future planning of both the routine and disaster provision of intensive care.Retrospective cohort study. We calculated mean hourly bed occupancy in each ICU and hourly bed occupancy for patients on mechanical ventilators. We assessed trends in overall occupancy over the 3 years. We also assessed occupancy and mechanical ventilation rates across different types and sizes of ICUs.Ninety-seven U.S. ICUs participating in Project IMPACT from 2005 to 2007.A total of 226,942 consecutive admissions to ICUs.None.Over the 3 years studied, total ICU occupancy ranged from 57.4% to 82.1% and the number of beds filled with mechanically ventilated patients ranged from 20.7% to 38.9%. There was no change in occupancy across years and no increase in occupancy during influenza seasons. Mean hourly occupancy across ICUs was 68.2% ± 21.3% (SD) and was substantially higher in ICUs with fewer beds (mean, 75.8% ± 16.5% for 5-14 beds vs 60.9% ± 22.1% for 20+ beds, p = 0.001) and in academic hospitals (78.7% ± 15.9% vs 65.3% ± 21.3% for community not-for-profit hospitals, p0.001). More than half of ICUs (53.6%) had 4+ beds available more than half the time. The mean percentage of ICU patients receiving mechanical ventilation in any given hour was 39.5% (± 15.2%), and a mean of 29.0% (± 15.9%) of ICU beds were filled with a patient on a ventilator.Occupancy of U.S. ICUs was stable over time, but there is uneven distribution across different types and sizes of units. Only three of 10 beds were filled at any time with mechanically ventilated patients, suggesting substantial surge capacity throughout the system to care for acutely critically ill patients.

116 Background: Red blood cell (RBC) transfusions are costly, a limited resource, and pose serious medical risk. While most disciplines now transfuse sparingly, hospitalized oncology patients at our institution are often transfused liberally. We conducted a QI initiative to reduce practice variation by adopting a standardized restrictive transfusion strategy. Methods: We performed a retrospective analysis of the total number of pre-transfusion hemoglobin-adjusted RBC transfusions from 02/2015 to 08/2015. Patients with severe gastrointestinal bleeding and acute coronary syndrome were excluded. Extensive feedback from providers was solicited and a comprehensive review of the evidence was performed to understand the process driving existing practices. This information and a root cause analysis were presented to key members of Oncology leadership to gain consensus on a RBC transfusion algorithm. The final algorithm recommended transfusing to a Hg goal of 8 g/dL if the platelet count was ≤ 50K; otherwise the Hg goal was 7 g/dL. We defined low-value RBC transfusions as a transfusion occurring outside the parameters of this algorithm. A multifaceted educational campaign comprising in-person meetings and web-based postings was launched to target ward nurses, advanced practitioners, residents, and attending physicians. RBC transfusions were then tracked to monitor adherence to the algorithm. Results: Analysis of the current process using QI methods found that RBC transfusion practices are most influenced by uncertainty of best practice and variation in attending preference. After the implementation of a RBC transfusion algorithm, the overall number of low-value RBC transfusions decreased from 29.6% to 19.7% (p < 0.001). This reduction was most marked in patients with platelet counts > 50K where there was a reduction from 78.7% to 55.6% (p < 0.001). A 9.9% overall reduction corresponds to roughly 520 fewer RBC transfusions per year, which suggests an annual estimated cost savings of $520,000. Conclusions: By using a standardized QI framework, we were able to successfully decrease variation in practice that results in low-value RBC transfusions in hospitalized oncology patients.

Human herpesvirus 6A (HHV-6A) and human herpesvirus 6B (HHV-6B) are associated with a variety of conditions including rash, fever, and encephalitis and may play a role in several neurological diseases. Here luciferase immunoprecipitation systems (LIPS) was used to develop HHV-6 serologic diagnostic tests using antigens encoded by the U11 gene from HHV-6A (p100) and HHV-6B (p101). Analysis of the antibody responses against Renilla luciferase fusions with different HHV-6B p101 fragments identified an antigenic fragment (amino acids 389 to 858) that demonstrated ~86% seropositivity in serum samples from healthy US blood donors. Additional experiments detected a HHV-6A antigenic fragment (amino acids 751-870) that showed ~48% antibody seropositivity in samples from Mali, Africa, a known HHV-6A endemic region. In contrast to the high levels of HHV-6A immunoreactivity seen in the African samples, testing of US blood donors with the HHV-6A p100 antigenic fragment revealed little immunoreactivity. To potentially explore the role of HHV-6 infection in human disease, a blinded cohort of controls (n=59) and chronic fatigue syndrome (CFS) patients (n=72) from the US was examined for serum antibodies. While only a few of the controls and CFS patients showed high level immunoreactivity with HHV-6A, a majority of both the controls and CFS patients showed significant immunoreactivity with HHV-6B. However, no statistically significant differences in antibody levels or frequency of HHV-6A or HHV-6B infection were detected between the controls and CFS patients. These findings highlight the utility of LIPS for exploring the seroepidemiology of HHV-6A and HHV-6B infection, but suggest that these viruses are unlikely to play a role in the pathogenesis of CFS.

Interhospital critical care transfers are common, yet few studies address the underlying reasons for transfers. We examined clinician and patient/surrogate perceptions about interhospital transfers and assessed their agreement on these transfers.This is a mixed-mode survey of 3 major stakeholders in interhospital transfers to an academic medical intensive care unit from August 2007 to April 2008.Sixty-two hospitals transferred 138 patients during the study period. Response rates varied among stakeholders (accepting physician, 90%; referring physicians, 20%; patients/surrogates, 33%). All 3 groups frequently endorsed quality of care and need for a specific test/procedure as important. Referring hospital reputation and quality were rarely endorsed. Accepting physicians and patients/surrogates substantially agreed on the need for a specific test (κ = 0.70) and increased survival (κ = 0.78) but, otherwise, had fair to poor agreement. Referring physicians and patients/surrogates rarely agreed and sometimes disagreed greater than expected by chance (κ0). Physician pairs strongly agreed on the importance of accepting hospital experience (κ = 0.96) but agreed less on patient satisfaction at the referring hospital (κ = 0.37) and referring hospital reputation (κ = 0.35).Stakeholders do not always agree on the reasons for critical care transfers. Efforts to improve communication are warranted to ensure informed patient choices.

Thousands of users touch the keyboards and mice of public computers at the University of Rochester ever day. In conjunction with the University of Rochester Medical Center we set out to discover what the users leave behind. Samples were taken from the busiest computers on campus and tested for the presence of bacteria and viruses. A variety of cleaning products was also tested to measure the efficacy of cleaning methods.

Reaction of cyanuryl chloride with d,l-amino acids and amino alcohols afforded a new series of triazinyl-substituted benzenesulfonamides incorporating amino acyl/hydroxyalkyl-amino moieties. Inhibition studies of physiologically relevant human carbonic anhydrase (CA, EC 4.2.1.1) isoforms, such as CA I, II, IX, XII and XIV with these compounds are reported. They showed moderate-weak inhibition of the cytosolic, offtarget isozymes CA I and II, but many of them were low nanomolar inhibitors of the transmembrane, tumor-associated CA IX and XII (and also of CA XIV). The X-ray crystal structure of two of these compounds in adduct with CA II allowed us to understand the features associated with this strong inhibitory properties and possibly also their selectivity. Two of these compounds were also investigated for the inhibition of other human isoforms, that is, hCA IV, VA, VB, VI, VII and XIII, as well as inhibitors of the fungal pathogenic CAs Nce103 (Candida albicans) and Can2 (Cryptococcus neoformans), showing interesting activity. The 1,3,5-triazinyl-substituted benzenesulfonamides constitute thus a class of compounds with great potential for obtaining inhibitors targeting both α-class mammalian, tumor-associated, and β-class from pathogenic organisms CAs.

Americans are dissatisfied with their immigration system and are seeking changes. However, additional demands and expectations will be placed on those organizations that have to enforce and implement these changes. How will comprehensive immigration reform affect federal agencies? Determining the specific implementation demands likely to result from comprehensive immigration reform (CIR) legislation without knowing the specific policy elements that will be enacted is a difficult task. Nevertheless, this report presents a broad overview of the probable effects of likely policy changes by presenting an authoritative analysis utilizing a comprehensive literature review, a detailed investigation of relevant case studies, secondary analysis of public opinion polls, and in-depth interviews with eleven-stakeholder groups.

The University of Rochester has developed a dynamic approach to marketing our IT services for incoming students and their families. The "Technology and Student Services Expo" was created with partners across academic and administrative departments, student services organizations and the University community. University IT remains the driving force behind the Expo, as we seek to welcome new students and their families to the University while offering them a "one-stop-shop" to interact with all the services an incoming student may need to begin a successful academic career at the University.

We investigated the inhibitory activity of several 1,3,4-thiadiazole-sulfonamides against all catalytically active CA (EC 4.2.1.1), CA I-XV. The tail derivatizing the 5-position in the 1,3,4-thiadiazole-2-sulfonamide scaffold was observed to be critical as an inhibitory determinant of these compounds. The high resolution X-ray crystal structure of hCA II in complex with 5-(1-adamantylcarboxamido)-1,3,4-thiadiazole-2-sulfonamide, showed the adamantyl moiety of the inhibitor residing in a less utilized binding pocket than that of most hydrophobic inhibitors, lined by the amino acid residues Ile91, Val121 and Phe131. This binding site may explain the diverse inhibition profiles of 5-carboxamide- and sufonamide-derivatized 1,3,4-thiadiazole-2-sulfonamides and offers a hot spot for designing isoform selective inhibitors, considering that residues 91 and 131 are highly variable among the 13 catalytically active isoforms.

Limited IT funds are a fact of life at most institutions. You may be surprised by how much you can do with what you have though. Using new products in conjunction with tried and true existing technologies you can take steps to maintain both your bottom line and your sanity at the same time. Obtaining a competitive price for your computing hardware is the easy part. We're going to go beyond that and work on building a "champagne" lab on a "beer" budget. What components go into building a lab that can wow your customers without driving you crazy you ask? Deployment Tools: Ghost and ASRSoftware Security: DriveShield, MacShield, KeyServerMaintenance: PC-Rdist, Group PolicyFacility Security: Web Cameras, Access Control ReadersPrinting: PharosAffordable tech laden lecterns: touch panels and processors and multimedia projection All of the above components have been used at the U of R to create successful and affordable labs. You can use some or all depending on what you need, and many institutions already have parts of these solutions in place. Knowing what's out there and how to bring it all together is the challenge.