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Introduction: Emergency medicine (EM) is one of few specialties with variable training lengths. Hiring a three-year graduate to continue fellowship training in a department that supports a four-year residency program can lead to conflicts around resident supervision. We sought to understand hiring and clinical supervision, or staffing, patterns of non-Accreditation Council for Graduate Medical Education (ACGME) fellowships hosted at institutions supporting four-year residency programs. Methods: We performed a web-based, cross-sectional survey of non-ACGME fellowship directors (FD) hosted at institutions supporting four-year EM residency programs. We calculated descriptive statistics. Our primary outcome was the proportion of programs with four-year EM residencies that hire non-ACGME fellows graduating from three-year EM residencies. Results: Of 119 eligible FDs, 88 (74%) completed the survey. Seventy FDs (80%) indicated that they hire graduates of three-year residencies. Fifty-six (80%) indicated that three-year graduates supervise residents. Most FDs (74%) indicated no additional requirements exist to supervise residents outside of being hired as faculty. The FDs cited department policy, concerns about quality and length of training, and resident complaints as reasons for not hiring three-year graduates. A majority (10/18, 56%) noted that not hiring fellows from three-year programs negatively impacts recruitment and gives them access to a smaller applicant pool. Conclusion: Most non-ACGME fellowships at institutions with four-year EM programs recruit three-year graduates and allow them to supervise residents. This survey provides programs information on how comparable fellowships recruit and staff their departments, which may inform policies that fit the needs of their learners, the fellowship, and the department.

Branched-chain amino acids (BCAAs) are known to be neurorestorative after traumatic brain injury (TBI). Despite clinically significant improvements in severe TBI patients given BCAAs after TBI, the approach is largely an unrecognized option. Further, TBI continues to be the most common cause of morbidity and mortality in adolescents and adults. To date, no study has evaluated whether BCAAs can be preventive or neuroprotective if taken before a TBI. We hypothesized that if BCAAs were elevated in the circulation before TBI, the brain would readily access the BCAAs and the severity of injury would be reduced. Before TBI induction with a standard weight-drop method, 50 adult mice were randomized into groups that were shams, untreated, and pre-treated, post-treated, or pre- + post-treated with BCAAs. Pre-treated mice received BCAAs through supplemented water and were dosed by oral gavage 45?min before TBI induction. All mice underwent beam walking to assess motor recovery, and the Morris water maze assessed cognitive function post-injury. On post-injury day 14, brains were harvested to assess levels of astrocytes and microglia with glial fibrillary acidic protein (GFAP) and ionized calcium-binding adapter molecule 1 (IBA-1) immunohistochemistry, respectively. Pre-treated and pre- +post-treated mice exhibited significantly better motor recovery and cognitive function than the other groups. The pre- + post-treated group had the best overall memory performance, whereas the pre-treated and post-treated groups only had limited improvements in memory compared to untreated animals. Pre- + post-treated brains had levels of GFAP that were similar to the sham group, whereas the pre-only and post-only groups showed increases. Although trends existed, no meaningful changes in IBA-1 were detected. This is the first study, animal or human, to demonstrate that BCAA are neuroprotective and substantiates their neurorestorative benefits after TBI, most likely through the important roles of BCAAs to glutamate homeostasis.

Abstract Introduction Point-of-care ultrasound (US) is used in clinical practice across many specialties. Ultrasound (US) curricula for medical students are increasingly common. Optimal timing, structure, and effect of ultrasound education during medical school remains poorly understood. This study aims to retrospectively determine the association between participation in a preclinical, longitudinal US curriculum and medical student academic performance. Methods All first-year medical students at a medical school in the Midwest region of the United States were offered a voluntary longitudinal US curriculum. Participants were selected by random lottery. The curriculum consisted of five three-hour hands on-sessions with matching asynchronous content covering anatomy and pathologic findings. Content was paired with organ system blocks in the standard first year curriculum at our medical school. Exam scores between the participating and non-participating students were compared to evaluate the objective impact of US education on performance in an existing curriculum. We hypothesized that there would be an association between participation in the curriculum and improved medical student performance. Secondary outcomes included shelf exam scores for the surgery, internal medicine, neurology clerkships and USMLE Step 1. A multivariable linear regression model was used to evaluate the association of US curriculum participation with student performance. Scores were adjusted for age, gender, MCAT percentile, and science or engineering degree. Results 76 of 178 students applied to participate in the curriculum, of which 51 were accepted. US curriculum students were compared to non-participating students (n = 127) from the same class. The US curriculum students performed better in cardiovascular anatomy (mean score 92.1 vs. 88.7, p = 0.048 after adjustment for multiple comparisons). There were no significant differences in cumulative cardiovascular exam scores, or in anatomy and cumulative exam scores for the gastroenterology and neurology blocks. The effect of US curriculum participation on cardiovascular anatomy scores was estimated to be an improvement of 3.48 points (95% CI 0.78-6.18). No significant differences were observed for USMLE Step 1 or clerkship shelf exams. There were no significant differences in either preclinical, clerkship or Step 1 score for the 25 students who applied and were not accepted and the 102 who did not apply. Conclusions Participation in a preclinical longitudinal US curriculum was associated with improved exam performance in cardiovascular anatomy but not examination of other cardiovascular system concepts. Neither anatomy or comprehensive exam scores for neurology and gastrointestinal organ system blocks were improved.

Abstract Performing repeat pore‐fluid sampling over long time‐scales can provide valuable information on unsaturated zone contaminants and their potential flux to ground water. This information can be used to manage groundwater remedies and identify contaminants that need to be sequestered in the vadose zone to minimize flux to ground water. Pore‐water samples are commonly used to obtain contaminant concentrations within the vadose zone, but existing methods are limited as they only provide a single sample at one location and time. The vadose zone advanced monitoring system (VZAMS) has been designed to integrate multiple technologies into a single down‐borehole system that allows for sampling of pore fluids (liquid and gas) to provide information about contamination and hydraulic conditions at multiple depths (∼0.3‐m intervals) within a cased borehole. Testing has been completed at the laboratory scale to verify the sampling elements of VZAMS, including geochemical testing for representative contaminants known to exist at the Hanford Site, located in southeastern Washington State. Physical tests focused on the ability of the sampler to draw fluid under unsaturated conditions. Initial geochemical testing showed that the stainless steel material used with the porous cuff may affect the sampled concentrations of redox‐sensitive contaminants under very dry conditions. Additional laboratory testing demonstrated that the VZAMS components are able to collect representative samples for substances of interest under expected field conditions. In this paper, the design and functionality of a novel instrument are demonstrated in support of subsequent testing in the field.

Background: More could be known about baseline factors related to desirable Intensive Interdisciplinary Pain Treatment (IIPT) outcomes. This study examined how baseline characteristics (age, gender, child pain catastrophizing (PCS-C), pain interference, pain intensity, anxiety, depression, paediatric health-related quality of life (PedsQLTM), and parent catastrophizing (PCS-P)) were associated with discharge and 3-month follow-up scores of PCS-C, pain intensity, and pain interference. Methods: PCS-C, pain intensity, and pain interference T-scores were acquired in 45 IIPT patients aged 12–18 at intake (baseline), discharge, and 3-month follow-up. Using available and imputed data, linear mixed models were developed to explore associations between PCS-C, pain intensity, and pain interference aggregated scores at discharge and follow-up with baseline demographics and a priori selected baseline measures of pain, depression, anxiety, and PCS-C/P. Results: PCS-C and pain interference scores decreased over time compared to baseline. Pain intensity did not change significantly. Baseline PCS-C, pain interference, anxiety, depression, and PedsQLTM were associated with discharge/follow-up PCS-C (available and imputed data) and pain interference scores (available data). Only baseline pain intensity was significantly associated with itself at discharge/follow-up. Conclusions: Participants who completed the IIPT program presented with reduced PCS-C and pain interference over time. Interventions that target pre-treatment anxiety and depression may optimize IIPT outcomes.

Nanometer-curved surfaces are abundant in biological systems as well as in nano-sized technologies. Properly functionalized polymer-grafted nanoparticles (PGNs) adhere to surfaces with different geometries and curvatures. This work explores some of the energetic and mechanical characteristics of the adhesion of PGNs to surfaces with positive, negative and zero curvatures using Coarse-Grained Molecular Dynamics (CGMD) simulations. Our calculated free energies of binding of the PGN to the curved and flat surfaces as a function of separation distance show that curvature of the surface critically impacts the adhesion strength. We find that the flat surface is the most adhesive, and the concave surface is the least adhesive surface. This somewhat counterintuitive finding suggests that while a bare nanoparticle is more likely to adhere to a positively curved surface than a flat surface, grafting polymer chains to the nanoparticle surface inverts this behavior. Moreover, we studied the rheological behavior of PGN upon separation from the flat and curved surfaces under external pulling force. The results presented herein can be exploited in drug delivery and self-assembly applications.

The antenna pattern synthesis is one of the significant problems in the phased array antenna. Pattern synthesis refers to the optimized weight excitation of each antenna element in order to steer the beam electronically without mechanically rotating the antenna. It can be achieved by using a combination of phase shifters and attenuator circuits. In this paper, a 2 by 2 dipole antennas with an RF beamforming circuit has been designed to steer the main beam along the azimuth plane. The main beam coverage from 100° to 140° with a step size of 10° has been successfully optimized using a hybrid of the induced EMF method and a genetic algorithm. The optimization results were compared to the full-wave simulation technique implemented in Empire XCCel. The design is realistically implemented at 2.45 GHz, with both simulation and measurement results shown. The measured reflection coefficient of the phased array antenna is −48 dB at 2.56 GHz. The feasibility of the beam synthesis has been validated successfully with the main beam being steered at 110°. The possibility of a fabrication discrepancy resulting in minor radiation degradation is also discussed in this research. The dipole antenna system with RF beamformer circuit can be applied to indoor positioning systems such as Wi-Fi, wireless local area network (WLAN), and fifth-generation.

As demand for emergency care (EC) systems in low- and middle-income countries (LMICs) grows, there is an urgent need to expand the evidence base for clinical and systems interventions in resource limited EC settings. Clinicians are well placed to identify, define and address unanswered research questions using both quantitative and qualitative approaches. This paper summarises established research priorities for global EC and provides a step-wise approach to developing a research question.Research priorities for global EC broadly fall into two categories: systems-based research and research with a clinical care focus. Systems research is integral to understanding the essential components of safe and effective EC delivery, while clinical research aims to answer questions related to particular disease states, presentations or population groups.Developing a specific research question requires an enquiring, questioning and critical approach to EC delivery. In quantitative research, use of the PECO formula (Population, Exposure, Comparator, Outcome) can help frame a research question. Qualitative research, which aims to understand, explore and examine, often requires application of a theoretical framework. Writing a brief purpose statement can be a helpful tool to clarify the objectives of a qualitative study.This paper includes lists of tips, pitfalls and resources to assist EC clinical researchers in developing research questions. Application of these tools and frameworks will assist EC clinicians in resource limited settings to perform impactful research and improve outcomes for patients with acute illness and injury.

Introduction Severe limb ischaemia (SLI) is the end stage of peripheral arterial occlusive disease where the viability of the limb is threatened. Around 25% of patients with SLI will ultimately require a major lower limb amputation, which has a substantial adverse impact on quality of life. A newly established rapid-access vascular limb salvage clinic and modern revascularisation techniques may reduce amputation rate. The aim of this study was to investigate the 12-month amputation rate in a contemporary cohort of patients and compare this to a historical cohort. Secondary aims are to investigate the use of frailty and cognitive assessments, and cardiac MRI in risk-stratifying patients with SLI undergoing intervention and establish a biobank for future biomarker analyses.Methods and analysis This single-centre prospective cohort study will recruit patients aged 18–110 years presenting with SLI. Those undergoing intervention will be eligible to undergo additional venepuncture (for biomarker analysis) and/or cardiac MRI. Those aged ≥65 years and undergoing intervention will also be eligible to undergo additional frailty and cognitive assessments. Follow-up will be at 12 and 24 months and subsequently via data linkage with NHS Digital to 10 years postrecruitment. Those undergoing cardiac MRI and/or frailty assessments will receive additional follow-up during the first 12 months to investigate for perioperative myocardial infarction and frailty-related outcomes, respectively. A sample size of 420 patients will be required to detect a 10% reduction in amputation rate in comparison to a similar sized historical cohort, with 90% power and 5% type I error rate. Statistical analysis of this comparison will be by adjusted and unadjusted logistic regression analyses.Ethics and dissemination Ethical approval for this study has been granted by the UK National Research Ethics Service (19/LO/0132). Results will be disseminated to participants via scientific meetings, peer-reviewed medical journals and social media.Trial registration number NCT04027244.

A new species of the New Zealand endemic grass Simplicia, S. felix is described. The new species is segregated from and compared with S. buchananii and S. laxa. Simplicia felix occurs mostly in lightly shaded areas of seasonally dry alluvial forest. A distribution map and an assessment of the conservation status of the new species are presented. Genetic variation in the genus was examined, building on previously published work but including additional sampling. Analysis of nrDNA ITS and ETS and plastid trnL intron and trnL–F intergenic spacer sequences show S. felix to be more closely related to S. laxa than to S. buchananii. NeighborNet analyses of AFLP profiles for the three species of Simplicia show each to consist of distinct clusters of genotypes well separated from each other.

Introduction: Emergency medicine (EM) is one of few specialties with variable training lengths. Hiring a three-year graduate to continue fellowship training in a department that supports a four-year residency program can lead to conflicts around resident supervision. We sought to understand hiring and clinical supervision, or staffing, patterns of non-Accreditation Council for Graduate Medical Education (ACGME) fellowships hosted at institutions supporting four-year residency programs.Methods: We performed a web-based, cross-sectional survey of non-ACGME fellowship directors (FD) hosted at institutions supporting four-year EM residency programs. We calculated descriptive statistics. Our primary outcome was the proportion of programs with four-year EM residencies that hire non-ACGME fellows graduating from three-year EM residencies.Results: Of 119 eligible FDs, 88 (74%) completed the survey. Seventy FDs (80%) indicated that they hire graduates of three-year residencies. Fifty-six (80%) indicated that three-year graduates supervise residents. Most FDs (74%) indicated no additional requirements exist to supervise residents outside of being hired as faculty. The FDs cited department policy, concerns about quality and length of training, and resident complaints as reasons for not hiring three-year graduates. A majority (10/18, 56%) noted that not hiring fellows from three-year programs negatively impacts recruitment and gives them access to a smaller applicant pool.Conclusion: Most non-ACGME fellowships at institutions with four-year EM programs recruit three-year graduates and allow them to supervise residents. This survey provides programs information on how comparable fellowships recruit and staff their departments, which may inform policies that fit the needs of their learners, the fellowship, and the department.

While the control of soil-borne phytopathogenic fungi becomes increasingly difficult without using chemicals, concern over the intensive use of pesticides in agriculture is driving more environmentally sound crop protection managements. Among these approaches, the use of compost to suppress fungal diseases could have great potential. In this study, a multidisciplinary approach has been applied to characterize microbiota composition of two on-farm composts and assess their suppress and biostimulant activities. The on-farm composting system used in this study was able to produce two composts characterized by an antagonistic microbiota community able to suppress plant pathogens and biostimulate plant growth. Our results suggest a potential role for Nocardiopsis and Pseudomonas genera in suppression, while Flavobacterium and Streptomyces genera seem to be potentially involved in plant biostimulation. In conclusion, this study combines different techniques to characterize composts, giving a unique overview on the microbial communities and their role in suppressiveness, helping to unravel their complexity.

Metacognitive skills regulate and control learning processes. A developmental study (Van der Stel & Veenman, 2014) revealed that metacognitive growth is interrupted at the age of 14-15 years, while metacognitive skills are generalized over tasks and domains at the same time. The present study seeks to confirm this pause or decline in metacognitive growth, however, with a gender-age interaction. Females are expected to run one year ahead of males in metacognitive development. Additionally, the usefulness of computer-logfile analysis as an unobtrusive method for assessing metacognitive development is investigated. A hundred and nineteen secondary-school students (66 male; 53 female) at the age of 13 to 16 years performed a computerized inductive-learning task. Traces of learner activities were stored in logfiles and automatically scored on metacognitive skills. Afterwards, participants completed a learning posttest. Results substantiate the expected gender-age interaction in the metacognition data. Females started low at 14 years, recovered at 15 years, and peaked at 16 years, whereas males started positive at 14 years, declined at 15 years, and recovered at 16 years. Posttest data show a significant effect of age with improved learning performance at 16 years. Implications for the study of metacognitive development are discussed.

Nuclear Pore Complexes (NPCs) are key cellular transporter that control nucleocytoplasmic transport in eukaryotic cells, but its transport mechanism is still not understood. The centerpiece of NPC transport is the assembly of intrinsically disordered polypeptides, known as FG nucleoporins, lining its passageway. Their conformations and collective dynamics during transport are difficult to assess in vivo. In vitro investigations provide partially conflicting results, lending support to different models of transport, which invoke various conformational transitions of the FG nucleoporins induced by the cargo-carrying transport proteins. We show that the spatial organization of FG nucleoporin assemblies with the transport proteins can be understood within a first principles biophysical model with a minimal number of key physical variables, such as the average protein interaction strengths and spatial densities. These results address some of the outstanding controversies and suggest how molecularly divergent NPCs in different species can perform essentially the same function.

Ventral calcified meningiomas of the upper thoracic spine provide a unique challenge due to their location. The posterior approach has long been utilized for resection of ventral meningiomas with high success rates and low morbidity. There are a number of anatomical factors that can increase the difficulty in the case including patient body habitus, calcified tumors ventrally located can be adherent to the cord or anterior spinal artery, angle of the ribs and the vascularity in and around the tumor. We present a very challenging case of a large ventral calcified meningioma at T4 in a patient with body mass index of 50 (5′6, 337 lbs) who presented with progressive paraplegia.

OBJECTIVE: To compare the mean time to next exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) before and after the implementation of standing orders.

Plant functional traits capture important variation in plant strategy and function. Recent literature has revealed that within-species variation in traits is greater than previously supposed. However, we still have a poor understanding of how intraspecific variation is coordinated among different traits, and how it is driven by environment. We quantified intraspecific variation in wood density and five leaf traits underpinning the leaf economics spectrum (leaf dry matter content, leaf mass per unit area, size, thickness and density) within and among four widespread Nothofagus tree species in southern New Zealand. We tested whether intraspecific relationships between wood density and leaf traits followed widely reported interspecific relationships, and whether variation in these traits was coordinated through shared responses to environmental factors. Sample sites varied widely in environmental variables, including soil fertility (25-900 mg kg(-1) total P), precipitation (668-4875 mm yr(-1)), temperature (5.2-12.4 °C mean annual temperature) and latitude (41-46 °S). Leaf traits were strongly correlated with one another within species, but not with wood density. There was some evidence for a positive relationship between wood density and leaf tissue density and dry matter content, but no evidence that leaf mass or leaf size were correlated with wood density; this highlights that leaf mass per unit area cannot be used as a surrogate for component leaf traits such as tissue density. Trait variation was predicted by environmental factors, but not consistently among different traits; e.g., only leaf thickness and leaf density responded to the same environmental cues as wood density. We conclude that although intraspecific variation in wood density and leaf traits is strongly driven by environmental factors, these responses are not strongly coordinated among functional traits even across co-occurring, closely-related plant species.

The prostaglandin endoperoxide synthase (PTGS) pathway is a potent driver of tumour development in humans by enhancing the biosynthesis and signalling of prostaglandin (PG) E(2). PTGS2 expression and PGE(2) biosynthesis is elevated in endometrial adenocarcinoma, however the mechanism whereby PTGS and PGE(2) regulate endometrial tumour growth is unknown. Here we investigated (a) the expression profile of the PGE synthase enzymes (PTGES, PTGES-2, PTGES-3) and PGE receptors (PTGER1-4) in endometrial adenocarcinomas compared with normal endometrium and (b) the role of PTGER4 in endometrial tumorigenesis in vivo. We found elevated expression of PTGES2 and PTGER4 and suppression of PTGER1 and PTGER3 in endometrial adenocarcinomas compared with normal endometrium. Using WT Ishikawa endometrial adenocarcinoma cells and Ishikawa cells stably transfected with the full length PTGER4 cDNA (PTGER4 cells) xenografted in the dorsal flanks of nude mice, we show that PTGER4 rapidly and significantly enhances tumour growth rate. Coincident with enhanced PTGER4-mediated tumour growth we found elevated expression of PTGS2 in PTGER4 xenografts compared with WT xenografts. Furthermore we found that the augmented growth rate of the PTGER4 xenografts was not due to enhanced angiogenesis, but regulated by an increased proliferation index and hypoxia. In vitro, we found that PGE(2) and hypoxia independently induce expression of PTGER4 indicating two independent pathways regulating prostanoid receptor expression. Finally we have shown that PGE(2) and hypoxia synergise to promote cellular proliferation of endometrial adenocarcinoma cells.

The generic relationships of the extinct Trilepidea adamsii (Cheeseman) Tiegh. from New Zealand have been uncertain due to the paucity and age of available plant material. Last seen nearly seventy years ago in 1954, fresh material has not been available for comparative studies. Trilepidea adamsii has morphological affinities to Alepis flavida (Hook.f.) Tiegh., Peraxilla colensoi (Hook.f.) Tiegh. and P. tetrapetala (L.f.) Tiegh. with all taxa being placed in subtribe Elytranthinae, but precise phylogenetic relationships have not been determined. Using leaf material of Trilepidea adamsii from a specimen in Allan Herbarium (CHR) collected in 1920 from near Thames, Coromandel Peninsula, North Island, we recovered approximately 93% of the plastid genome by mapping Illumina sequence reads to a plastid genome sequence of Elytranthe albida (Blume) Blume, with Elytranthe being another genus of Loranthaceae. We also sequenced plastid genomes of Alepis flavida, Peraxilla colensoi and Peraxilla tetrapetala and conducted a phylogenetic analysis using other Loranthaceae plastid genome sequences from GenBank. Phylogenetic analyses of the plastid genome sequences confirmed T. adamsii as sister to a clade comprising Alepis and Peraxilla. While the level of sequence divergence is low, we do not consider that the generic boundaries need to be reassessed. We suggest re-examination of anatomical and morphological traits is warranted to better understand evolution in this lineage of four endemic mistletoe species. [ABSTRACT FROM AUTHOR]

Introduction This review aimed to compile an exhaustive list of all outcome measures and identify different characteristics of the outcomes reported in studies of intermittent claudication as the first step in developing a core outcome set for intermittent claudication. Method Medline and Embase were searched for all studies including individuals with intermittent claudication and reporting ≥1 outcome from January 2015 to August 2024. Abstract, full text screening and data extraction were performed by two investigators independently. All reported outcome measures were extracted verbatim and categorized by Dodd's domains (Core Outcome Measures in Effectiveness Trials registration: COMIC Study, 1590; https://www.comet-initiative.org/Studies/Details/1590). Results 4985 studies were screened and 408 were included. A total of 541 unique outcomes across 25 Dodd's domains were identified. Ankle–brachial pressure index was the most frequently reported outcome. Among the 541 unique outcomes, 386 outcomes were only reported once. Only 38.9% of the studies exclusively included patients with intermittent claudication. Patient-reported outcomes were reported in 36.2% of studies. There were wide variations in the definition of commonly used outcome measures (for example, major adverse limb event and primary patency) across different studies. Conclusion There is substantial heterogeneity in reported outcomes in studies of intermittent claudication. Most reported outcomes are clinical/physiology oriented rather than patient centred. Development of a core outcome set for intermittent claudication is vital to improve and standardize reporting in future research. [ABSTRACT FROM AUTHOR]

The article discusses the outcomes and impact of an advanced clinical ultrasound track in an emergency medicine residency program. The study describes the implementation of the track and its effects on residents' post-graduation academic career choices. Results show that residents in the ultrasound track performed more ultrasound studies compared to non-track residents, and a higher percentage of track graduates pursued academic careers or entered fellowships. The study suggests that participation in the ultrasound track may predict an academic career in emergency medicine. [Extracted from the article]