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Background Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. Objectives We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. Methods As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. Results Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). Conclusions We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

Background and objective Emergency departments (EDs) often find the number of arriving patients exceeding their capacity and find it difficult to triage them in a timely manner. The potential risk to the safety of patients awaiting assessment by a triage professional has led some hospitals to consider implementing patient self-triage, such as using kiosks. Published studies about patient self-triage are scarce and information about patients' ability to accurately assess the acuity of their condition or predict their need to be hospitalized is limited. In this study, we aimed to compare computer-assisted patient self-triage scores versus the scores assigned by the dedicated ED triage nurse (TN). Methods This pilot study enrolled patients presenting to a tertiary care hospital ED without ambulance transport. They were asked a short series of simple questions based on an algorithm, which then generated a triage score. Patients were asked whether they were likely to be admitted to the hospital. Patients then entered the usual ED system of triage. The algorithm-generated triage score was then compared with the Canadian Triage and Acuity Scale (CTAS) score assigned by the TN. Whether the patients actually required hospital admission was determined by checking their medical records. Results Among the 492 patients enrolled, agreement of triage scores was observed in 27%. Acuity was overestimated by 65% of patients. Underestimation of acuity occurred in 8%. Among patients predicting hospitalization, 17% were admitted, but the odds ratio (OR) for admission was 3.4. Half of the patients with cardiorespiratory complaints were correct in predicting the need for hospitalization. Conclusion The use of a short questionnaire by patients to self-triage showed limited accuracy, but sensitivity was high for some serious medical conditions. The prediction of hospitalization was more accurate with regard to cardiorespiratory complaints.

Left ventricular outflow tract pseudoaneurysms are a rare but life-threatening disorder, often caused by complications of cardiac surgery or myocardial infarction. We present a case report of a patient with no prior risk factors who presented with a six-month history of progressive exertional dyspnea, bilateral leg swelling and cough. Point-of-care ultrasound revealed an unexpected outpouching of the left ventricle. He was diagnosed with a left ventricular outflow tract pseudoaneurysm and subsequently went into cardiogenic shock secondary to extension of pseudoaneurysm causing extrinsic compression of the coronary arteries. The patient underwent successful emergency surgical repair and made a full recovery.

Background: Simulation-based learning has improved medical knowledge, proficiency and performance. The treatment window for acute stroke is limited, making preparedness exceedingly critical. We aimed to assess improvement in performance in first responders to ‘stroke codes’, namely junior Neurology and Emergency Medicine (EM) residents. EM residents were included because EM physicians often make tPA decisions at peripheral and non-academic hospitals. Methods: 14 Neurology and 10 EM residents participated at Upstate Medical University, Syracuse, New York. The simulation consisted of senior Neurology residents playing the roles of stroke patient, CT technician and radiologist, nurse, pharmacist and the stroke fellow on-call. The simulation included the time from patient arrival to acute stroke treatment. Each junior Neurology and EM resident completed this simulation, while the rest of the group observed. Cases included stroke mimics, strokes with large vessel occlusions, dissections, cases ineligible for acute intervention, intracerebral and subarachnoid hemorrhages, basilar thrombosis, wake-up strokes, seizure at onset and dissections. Participants reviewed non-contrast CT head, EKG and CT angiography of the head and neck to make decisions about tPA administration and endovascular interventions. This was followed by a debriefing session by the attending and chief residents. Participants filled a pre-and post-simulation graded questionnaire on medical knowledge and confidence (range 0-25, with higher scores reflecting higher performance). Results: The mean score was 18 (range 14-23) pre-simulation and 22 (range 18-25) post-simulation for Neurology residents and 14 (range 8-24) pre-simulation and 18 (range 10-23) post-simulation for EM residents. For all residents, pre-and post-median score was 17 and 19 (Wilcoxon signed-rank test p Conclusion: Because running an effective stroke code requires coordination and rapid analysis, stroke simulation is an effective way of improving knowledge and confidence among residents and should be integrated into the Neurology and EM residency curriculum.

Study objective Online educational resources such as blogs are increasingly used for education by emergency medicine clinicians. The Social Media Index was developed to quantify their relative impact. The Medical Education Translational Resources: Indicators of Quality (METRIQ) study was conducted in part to determine the association between the Social Media Index score and quality as measured by gestalt and previously derived quality instruments. Methods Ten blogs were randomly selected from a list of emergency medicine and critical care Web sites. The 2 most recent clinically oriented blog posts published on these blogs were evaluated with gestalt, the Academic Life in Emergency Medicine Approved Instructional Resources (ALiEM AIR) score, and the METRIQ-8 score. Volunteer raters (including medical students, emergency medicine residents, and emergency medicine attending physicians) were identified with a multimodal recruitment methodology. The Social Media Index was calculated in February 2016, November 2016, April 2017, and December 2017. Pearson's correlations were calculated between the Social Media Index and the average rater gestalt, ALiEM AIR score, and METRIQ-8 score. Results A total of 309 of 330 raters completed all ratings (93.6%). The Social Media Index correlated moderately to strongly with the mean rater gestalt ratings (range 0.69 to 0.76) and moderately with the mean rater ALiEM AIR score (range 0.55 to 0.61) and METRIQ-8 score (range 0.53 to 0.57) during the month of the blog post's selection and for 2 years after. Conclusion The Social Media Index's correlation with multiple quality evaluation instruments over time supports the hypothesis that it is associated with overall Web site quality. It can play a role in guiding individuals to high-quality resources that can be reviewed with critical appraisal techniques.

Study objective Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r=0.92) and residents (r=0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment.

NO-releasing nonsteroidal anti-inflammatory drugs (NO-NSAIDs) have been shown to have anti-inflammatory, antiproliferative and apoptosis-inducing effects in tumor cells. Herein, we have investigated the effects of NO-exisulind on the growth of UVB-induced skin tumor development in a murine model. We found that the topical treatment with NO-exisulind significantly reduced UVB-induced tumors in SKH-1 hairless mice. The tumors/tumor bearing mouse, the number of tumors/mouse and tumor volume/mouse decreased significantly (P0.05) as compared with vehicle-treated and UVB-irradiated positive controls. Consistently, NO-exisulind-treated animals showed reduced expression of proliferation markers, such as PCNA and cyclin D1. These mice also manifested increased expression of proapoptotic Bax and decreased expression of antiapoptotic Bcl2 with an increase in the number of TUNEL-positive cells in tumors. We also investigated whether NO-exisulind-treated tumors are less invasive and progress less efficiently from benign to malignant carcinomas. For this, tumors were stained for various epithelial-mesenchymal transition (EMT) markers. NO-exisulind decreased the expression of mesenchymal markers, such as Fibronectin, N-cadherin, SNAI, Slug and Twist and enhanced the epithelial marker E-cadherin. Similarly, UVB-induced phosphorylation of Erk1/2 and p38 was decreased in NO-exisulind-treated animals. These data suggest that NO-exisulind reduces tumor growth and inhibits tumor progression by blocking proliferation, inducing apoptosis and reducing EMT.

Automated refactoring is a key feature of modern IDEs. Existing refactorings rely on the transformation of source code declarations, in which references may also be transformed as a side effect. However, there exist situations in which a declaration is not available for refactoring or would be inappropriate to transform, for example, in the presence of dangling references or where a set of references should be retargeted to a different declaration. We investigate the problem of dangling references through a detailed study of three open source libraries. We find that the introduction of dangling references during library migration is a significant real problem, and characterize the specific issues that arise. Based on these findings we provide and test a prototype tool, called Trident, that allows programmers to refactor references. Our results suggest that supporting the direct refactoring of references is a significant improvement over the state-of-the-art.

Context: Uncertainty is an unavoidable issue in software engineering and an important area of investigation. This paper studies the impact of uncertainty on total duration (i.e., make-span) for implementing all features in operational release planning. Objective: The uncertainty factors under investigation are: (1) the number of new features arriving during release construction, (2) the estimated effort needed to implement features, (3) the availability of developers, and (4) the productivity of developers. Method: An integrated method is presented combining Monte-Carlo simulation (to model uncertainty in the operational release planning (ORP) process) with process simulation (to model the ORP process steps and their dependencies as well as an associated optimization heuristic representing an organization-specific staffing policy for make-span minimization). The method allows for evaluating the impact of uncertainty on make-span. The impact of uncertainty factors both in isolation and in combination are studied in three different pessimism levels through comparison with a baseline plan. Initial evaluation of the method is done by an explorative case study at Chartwell Technology Inc. to demonstrate its applicability and its usefulness. Results: The impact of uncertainty on release make-span increases - both in terms of magnitude and variance - with an increase of pessimism level as well as with an increase of the number of uncertainty factors. Among the four uncertainty factors, we found that the strongest impact stems from the number of new features arriving during release construction. We have also demonstrated that for any combination of uncertainty factors their combined (i.e., simultaneous) impact is bigger than the addition of their individual impacts. Conclusion: The added value of the presented method is that managers are able to study the impact of uncertainty on existing (i.e., baseline) operational release plans pro-actively.

Release planning for incremental software development assigns features to releases such that technical, resource, risk and budget constraints are met. Each feature offers a piece of functionality. A feature can be offered as part of a release only if all its necessary tasks are done before the given release date. These tasks require different skills. Staffing for product releases as considered in this paper is the process of assigning human resources from a given pool of developers who might have varying levels of skill to perform different tasks. In addition to that, we consider time windows of absence of the developers. The primary goal of staffing is to provide product releases of best quality where quality means offering the most attractive features to customers in a timely manner. We call the problem STAFF-PRO. The problem is known to be NP-complete. Consequently, we have to be satisfied with solutions that are sufficiently good, but not necessarily optimal in the case of mid-sized or large problems. Search-based methods relying on meta-heuristics have been proven to be successful in similar contexts. In this research, a focused search (FS) method is presented. This refers to a two-phased solution approach where Phase 1 applies integer linear programming to a relaxed version of the full problem. Its solution is used as a starting point to perform FS in a reduced search space in Phase 2. The search itself is conducted by a genetic algorithm. It generates a solution that fulfills all the stated resource and scheduling constraints and is of a proven degree of optimality. We performed an empirical analysis of the proposed solution approach by comparing FS and unfocused search (UFS) (without Phase 1) for a series of 200 test examples. On average, FS performs about 15% better than UFS. The whole method was applied as an industrial case study performed at Chartwell Technology. The case study demonstrates that application of the FS method to STAFF-PRO (i) allows a reduction in the time needed for generating acceptable staffing plans, (ii) generates plans of proven quality that are better than manual plans and (iii) supports the various types of re-planning necessary for varying parameters, budgets and resource. Copyright © 2008 John Wiley & Sons, Ltd.

Introduction: Development of point-of-care ultrasound (POCUS) image-generating skills requires residents to practice on patients awaiting care in the emergency department (ED) for unrelated reasons. While patients are almost universally agreeable to the scans, there is the possibility that they feel pressured to do so and may have negative experiences that go unreported. The objective of this study was to determine the self-reported patient satisfaction and identify any concerns after educational ultrasounds performed in the ED. Methods: We conducted a survey of patients at a single academic ED. Patients were eligible for enrollment if they had volunteered for an ultrasound when study personnel were available. The survey was administered by a representative from the Patient Affairs Department who advised the patients that the results would remain anonymous and would have no impact on their care. The survey included patient demographics, questions about the consent process, communication by the trainee, adverse reactions and patient satisfaction. The primary outcome was the overall satisfaction level reported by the volunteer patients on a 5-point Likert scale. Secondary outcomes included identification of any discomfort or concerns about the process as expressed by patients. Simple descriptive statistics were used to report survey results. Results: Ninety-nine patients fully completed the questionnaire. Fifty (50%) were women. The age range was 18 to 99 years. Satisfaction among volunteers was high, with 94% of respondents giving a rating of 4 or 5 (five being an excellent experience). No patients gave a negative rating (1 or 2). Three (3%) patients felt “somewhat” pressured to volunteer. A majority of patients (72%) experienced no discomfort during the scan however 16% experienced some physical discomfort. Comments indicated that too much pressure applied with the ultrasound probe or cold ultrasound gel were the main sources of discomfort. Despite some discomfort 95 (95%) patients stated they would likely volunteer again if asked in the future. Conclusion: ED patients volunteering as models for residents learning POCUS expressed generally positive perceptions of their experience. While only a small minority of patients experienced some discomfort or felt pressured into participating, it is important to ensure that patients have a process to communicate any concerns about educational ultrasounds in the ED.

Introduction: The process of triage is used to prioritize the care of patients arriving in the emergency department (ED). To our knowledge, self-triage has not been previously studied in the general emergency department (ED) setting. In an attempt to test the feasibility of implementing this in the ED, we sought to assess the ability of ED patients to triage themselves using an electronic questionnaire. Methods: This was a prospective observational study. An iPad-based questionnaire was designed with a series of ‘yes’ or ‘no’ answers related to common chief complaints. A score corresponding to a Canadian Triage and Acuity Scale (CTAS) category was assigned based on their answers, without the knowledge of patients or ED staff. These scores were subsequently compared to the official CTAS score assigned by triage nurses. A convenience sample of ambulatory patients arriving at the ED were enrolled over a four week period. Patients arriving by ambulance were excluded. We also sought to assess patients’ ability to predict their ultimate disposition. Results: A total of 492 patients were enrolled. The mean age of enrolled patients was 43.9. Of enrolled patients, 56 (11.4%) were under 20 years old, 168 (34.1%) between ages 20-39, 116 (23.6%) between ages 40-59 and 152 (30.9%) older than 60 years. We had 245 (49.8%) patients identify as male. Patient-determined CTAS scores were as follows: 146 CTAS 1 (26.7%), 66 CTAS 2 (13.4%), 176 CTAS 3 (35.8%) and 104 CTAS 4 and 5 (21.1%). Formal triage CTAS scores were: 47 CTAS 2 (9.6%), 155 CTAS 3 (31.5%), and 290 CTAS 4 and 5 (59%). With our survey tool, 22.2% of patients matched their official triage scores. We found that that 69.9% of participants over-estimated their CTAS score while 7.9% underestimated it. Two hundred and three patients (41.3%) felt that they needed to be admitted. In fact, 73 patients (17.3%) were admitted to hospital. Conclusion: Using an electronic questionnaire, ambulatory patients frequently overestimated the acuity of their presenting complaint. Patients were also not unable to accurately predict their disposition. Further study of different approaches to self-triage is needed before possible implementation in EDs.

Nitric oxide (NO)-releasing non-steroidal anti-inflammatory drugs (NO-NSAIDs) which have been synthesized to reduce gastro-intestinal and cardiovascular toxicities of NSAIDs, possess anti-proliferative, pro-apoptotic and anti-cancer activities. Here, we show that NO-sulindac inhibited UVB-induced skin tumorigenesis in SKH-1 hairless mice. Topical application of NO-sulindac reduced tumor incidence, number (p

This paper examines the pattern of diffusion of flexible manufacturing systems (FMS) technology across firms in the U.S. tooling and machining industry. Evidence is presented regarding the importance of compatibility standards in determining the timing of adoptions of FMS technology.

Operational release planning (ORP) is concerned with assigning humanresources to development tasks in software projects such that a defined setof product features can be completed under given constraints. In this paper, wepresent a simulation-based approach to study the impact of uncertainty. Uncertaintyparameters considered in this paper are related to the features themselves(functionality, effort) and to developers (availability and productivity). The effectof variation of these four parameters (two static and two dynamic) onmake-span is studied in isolation and in combination. This is done for three levelsof (stochastic) pessimism ("bad", "worse", and "worst"). In addition to that,a comparison is done with a deterministic worst case scenario. To illustrate theapplicability of the method and usefulness of results, we have conducted anexplorative case study at Chartwell Technology Inc.

An evolutionary development approach is increasingly commonplace in industry but presents increased difficulties in risk management, for both technical and organizational reasons. In this context, technical risk is the product of the probability of a technical event and the cost of that event. This paper presents a technique for more objectively assessing and communicating technical risk in an evolutionary development setting that (1) operates atop weakly-estimated knowledge of the changes to be made, (2) analyzes the past change history and current structure of a system to estimate the probability of change propagation, and (3) can be discussed vertically within an organization both with development staff and high-level management. A tool realizing this technique has been developed for the Eclipse IDE.

Nitric oxide (NO)-releasing non-steroid anti-inflammatory drugs (NO-NSAIDs) have been shown to have anti-proliferative, proapoptotic and cancer inhibitory properties. Here, we have investigated the effects of NO-donor sulindac on UVB-induced skin cancer development in SKH-1 hairless mice. Mice (6-8 weeks old) were divided into three groups of ten mice each, which received either vehicle (acetone), vehicle+UVB (180mJ/cm 2) or topical application of NO-sulindac (5mg/mouse)+UVB after dissolving in acetone. Mice-treated with NO-sulindac developed significantly less number of tumors (60%) compared with non-NO-sulindac treated mice and tumor volume was also less by 90% on termination of the experiment at week 30th. Immunohistochemical and western blot analyses revealed that the expression levels of proliferation markers such as proliferating cell nuclear antigen (PCNA) and cell cycle regulatory cyclin D1 were markedly diminished in tumors of NO-sulindac treated mice. However, the treatment of NO-sulindac resulted in enhanced apoptosis in skin tumors as ascertained by the increased terminal deoxynucleotidyl transferase-mediated nick end labeling (TUNEL) assay, reduced Bcl-2 and enhanced Bax expression levels in the tumors and tumor uninvolved skin. To investigate the effects of NO-sulindac on the progression of benign lesions to invasive carcinomas, we examined squamous cell carcinomas (SCC) for various epithelial-mesenchymal transition (EMT) markers. NO-sulindac decreased the expression of mesenchymal markers such as Fibronectin, N-cadherin, SNAI, Slug and Twist whereas the epithelial polarity marker E-cadherin was found to be increased compared to the SCCs of non-NO-sulindac treated group. Down regulation of EMT by NO-sulindac was associated with a remarkable diminution of UVB-induced phosphorylation MAPK proteins such as, extracellular signal-regulated kinase 1/2 (Erk 1/2), c-Jun-NH2 terminal kinase 1/2 (JNK1/2) and p38 in both UVB-exposed skin and skin tumors. Together our results suggest that NO-sulindac is a potential chemopreventive agent for photocarcinogenesis and that inhibition of photocarcinogenesis by NO-sulindac is associated with the inhibition of EMT and MAPK protein expression in skin tumors. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 952.