Snakes and ladders: An integrative literature review of refugee doctors' workforce integration needs.

INTRODUCTION: Healthcare systems worldwide are facing a workforce crisis; meanwhile, refugee doctors throughout the world face difficulties in accessing work. The aims of this review were to explore the integration needs of refugee doctors into host healthcare systems from the refugee perspective, synthesise the literature to construct a theory of refugee doctor integration needs and explore how these needs are met or challenged on the pathway to full integration. METHODS: In this integrative literature review, 11 databases and eight grey literature sources were searched by combining terms for refugee doctor and social integration and limiting to research published in or after 2003. Data were extracted, and quality scoring was completed independently by two researchers. This study utilised template analysis to perform a qualitative synthesis of the data. The multidimensional template included a pre-defined template based on a theoretical framework and a concurrent fully inductive template. RESULTS: Twenty-two papers were included, incorporating the views of 339 doctors from 30 different home countries and 10 different host countries. The resultant theory included 'foundations' (rights and responsibilities) and three pillars. The 'learning' pillar included required knowledge and skills acquisition. The 'being' pillar encompassed necessary identity work. The 'connecting' pillar comprised social connections, which impacted all other domains. The random and non-linear path to integration faced by refugee doctors was also presented as a serious game. DISCUSSION: This study produced a theory exploring refugee doctors' integration needs and how these are met or challenged. Medical educators developing courses for refugee doctors should attend not only to knowledge and skills acquisition but also social connections, identity work and rights and responsibilities. The theory highlights the central importance of social connections. Medical educators can therefore have a transformative impact on refugee doctors' integration. This may also contribute to society by helping to alleviate the workforce crisis.

Blending dark green vegetables with fruits in commercially available infant foods makes them taste like fruit.

Vegetables are an important but under consumed part of a healthy diet. There is growing interest in promoting vegetable acceptance and consumption among infants to help establish life-long healthy eating patterns. A recent survey of commercial baby food products in the United States by Moding and colleagues revealed a lack of variety in the types of vegetables offered. Most notably, there were no commercially available single, dark green vegetable products. Instead, dark green vegetables were often mixed with fruits or red/orange vegetables (e.g., squash) that provide additional sweetness. In order for liking for vegetables to be learned, the flavors from the vegetables must still be perceptible within the mixture. Thus, the objective of the research reported here was to understand the sensory profiles of vegetable-containing Stage 2 infant products commercially available in the United States and how ingredient composition affects flavor profiles. We performed descriptive analysis to quantitatively profile the sensory properties of 21 commercial vegetable-containing infant foods and one prepared in our laboratory. Eleven experienced panelists participated in 14.5 h of lexicon generation and training prior to rating all 22 products (in triplicate) for 14 taste, flavor, and texture attributes. Products that contained fruit were not only sweeter than products that did not contain fruit but were also higher in fruit flavors and lower in vegetable flavors. In general, sensory profiles were driven by the first ingredient in the product. Because few products had dark green vegetables as a first ingredient, dark green vegetable flavor was not prevalent in this category. This suggests the sensory profiles of commercially available infant vegetables foods may not be adequate to facilitate increased acceptance of green vegetables.

Left anterior descending coronary artery blood flow and left ventricular unloading during extracorporeal membrane oxygenation support in a swine model of acute cardiogenic shock.

The impact of extracorporeal membrane oxygenation (ECMO) support on coronary blood flow and left ventricular unloading is still debated. This study aimed to further characterize the influence of ECMO on coronary artery blood flow and its ability to unload the left ventricle in a short-term model of acute cardiogenic shock. Seven anesthetized pigs were intubated and then underwent median sternotomy and cannulation for venoarterial (VA) ECMO. Flow in the left anterior descending (LAD) artery, left atrial pressure (LAP), left ventricular end-diastolic pressure (LVEDP), and mean arterial pressure (MAP) were measured before and after esmolol-induced cardiac dysfunction and after initiating VA-ECMO support. Induction of acute cardiogenic shock was associated with short-term increases in LAP from 8 ± 4 mm Hg to 18 ± 14 mm Hg (P = 0.9) and LVEDP from 5 ± 2 mm Hg to 13 ± 17 mm Hg (P = 0.9), and a decrease in MAP from 63 ± 16 mm Hg to 50 ± 24 mm Hg (P = 0.3). With VA-ECMO support, blood flow in the LAD increased from 28 ± 25 mL/min during acute unsupported cardiogenic shock to 67 ± 50 mL/min (P = 0.003), and LAP and LVEDP decreased to 8 + 5 mm Hg (P = 0.7) and 5 ± 3 mm Hg (P = 0.5), respectively. In this swine model of acute cardiogenic shock, VA-ECMO improved coronary blood flow and provided some degree of left ventricular unloading for the short duration of the study.

Pediatric extracorporeal life support systems: education and training at Penn State Hershey Children's Hospital.

The following is a description of the training offered to extracorporeal life support (ECLS)-trained staff at the Penn State Hershey Children's Hospital. Changes with the ECLS circuit prompted the need for an initiative to train staff in the care of patients requiring ECLS support. In addition to didactic material, we incorporated a "hands-on" approach in designing the education. During the didactic portion, the circuit was demonstrated as a wet lab. The final step offered a voluntary visit to the animal research facility utilizing clinical case scenarios which allowed participants to articulate and demonstrate proper circuit management.The effort throughout this process was to build a competent ECLS team which will ultimately provide our patients with the greatest chance for a full recovery.

Midazolam enhances the analgesic properties of dexmedetomidine in the rat.

OBJECTIVE: To investigate the analgesic properties of different dose combinations of midazolam and dexmedetomidine administered intraperitoneally (IP) in the rat. STUDY DESIGN: Prospective experimental trial. ANIMALS: Seventy adult male Sprague Dawley rats weighing 250-300 g. METHODS: Dexmedetomidine (D) 0.03, 0.06, 0.09, 0.12, 0.15, 0.18, 0.21 mg kg(-1) and midazolam (M) 5, 10, 25, 50 mg kg(-1) were administered IP, alone then in combinations ranging from 0.03 D:5 M to 0.18 D:30 M mg kg(-1). Analgesia was evaluated using the tail-flick test at time 0 (before injection), 15, 30, 45, 60 and 75 minutes. RESULTS: Midazolam at all doses administered (5-50 mg kg(-1)) did not significantly change tail-flick latencies from baseline values whereas D showed clear dose-dependent increases in tail-flick latency for doses administered in the range of 0.03-0.18 mg kg(-1). Tail-flick latencies in rats administered D+M combinations were significantly greater than D alone (p<0.05). CONCLUSIONS: A dose-related analgesic effect was demonstrated for D in the rat, which was enhanced by co-administration of M. CLINICAL RELEVANCE: The combination of D+M administered IP to rats at doses of 0.12:20 and 0.09:15 mg kg(-1) was shown to be a good combination to provide sedation/analgesia with a duration of action greater than 60 minutes. The onset of sedation was rapid (1-3 minutes), and onset of profound analgesia was reached within 5-10 minutes.

Survey of canine use and safety of isoxazoline parasiticides.

A veterinarian and pet owner survey (Project Jake) examined the use and safety of isoxazoline parasiticides given to dogs. Data were received during August 1-31, 2018 from a total of 2,751 survey responses. Forty-two percent (1,157) reported no flea treatment or adverse events (AE), while 58% (1594) had been treated with some parasiticide for flea control, and of those that received a parasiticide, the majority, or 83% (1,325), received an isooxazoline. When any flea treatment was given, AE were reported for 66.6% of respondents, with no apparent AE noted for 36.1%. Project Jake findings were compared to a retrospective analysis of publicly available Food and Drug Administration (FDA) and European Medicines Agency (EMA) reported AE. The number of total AE reported to FDA and EMA were comparable, although a 7 to 10 times higher occurrence of death and seizures was reported from the EMA or from outside the United States (US). Serious AE responses for death, seizures and neurological effects reported in our survey were higher than the FDA but moderately lower than the EMA reports. These sizable global data sets combined with this pre- and post-parasiticide administration survey indicated that isoxazoline neurotoxicity was not flea- and tick-specific. Post-marketing serious AE were much higher than in Investigational New Drug (IND) submissions. Although the labels have recently been updated, dogs, cats and their caregivers remain impacted by their use. These aggregate data reports support the need for continued cross-species studies and critical review of product labelling by regulatory agencies and manufacturers.

Animal model development for the Penn State pediatric ventricular assist device.

In March 2004, the National Heart, Lung, and Blood Institute awarded five contracts to develop devices providing circulatory support for infants and small children with congenital and acquired cardiac disease. Since 2004, the team at Penn State College of Medicine has developed a pneumatically actuated ventricular assist device (VAD) with mechanical tilting disk valves. To date, hemodynamic performance, thrombogenesis, and hemolysis have been chronically evaluated in 16 animals, including 4 pygmy goats and 12 sheep. Major complications, mainly respiratory failure, have been encountered and resolved by a multi-disciplinary team. Multi-modal analgesia, appropriate antibiotic therapy, and attentive animal care have contributed to successful outcomes. Time after implant has ranged from 0 to 40 days. Most recently, a sheep implanted with Version 3 Infant VAD was electively terminated at 35 days postimplant, with no major adverse events. This report describes a successful in vivo model for evaluating a pediatric VAD.

Increasing flavor variety with herbs and spices improves relative vegetable intake in children who are propylthiouracil (PROP) tasters relative to nontasters.

American children do not meet the recommended daily servings of vegetables, and previous research suggests children who can taste the bitterness of 6-n-propylthiouracil (PROP) are more likely to have low vegetable intake. This study tested the hypothesis that adding multiple herb and spice blends to vegetables to increase flavor variety within a meal would increase vegetable intake in 3-5year-old children. Children attended two laboratory visits and consumed two test meals of common foods: macaroni and cheese, applesauce, carrots, milk, and water. On one visit, the meal included three servings of carrots with different herb and spice blends (Variety condition). On the other visit, all three servings of carrots were seasoned with the same herb and spice blend (No Variety condition). Overall, children consumed similar amounts of carrots by condition (36.5±40.5g versus 35.9±43.8g at the Variety and No Variety conditions, respectively); however, this relationship was moderated by PROP status. Children who tasted PROP as bitter (tasters) consumed a greater proportion of carrots during the Variety condition relative to nontasters (p=0.03). These findings suggest that children who taste PROP as bitter may be more receptive than nontasters to manipulations that increase flavor-variety of vegetables using herbs and spices.

Complications of elastase-induced arterial saccular aneurysm in rabbits: case reports and literature review.

Endoluminal infusion and incubation of elastase with or without collagenase into the rabbit common carotid artery is an established model of arterial saccular aneurysm. The model mimics naturally occurring human cerebral aneurysms in many ways, including histologic and morphologic characteristics, hemodynamic pressures, and shear stresses. However, complications have been associated with the model. Here, we report 2 complications: 1) the first known case of iatrogenic laryngeal hemiplegia in a rabbit; and 2) histopathologically confirmed iatrogenic hippocampal and cerebellar infarcts (stroke). Finally, we present and review data from current literature on the morbidity and mortality associated with this model.

Chronic in vivo testing of the Penn State infant ventricular assist device.

The Penn State Infant Ventricular Assist Device (VAD) is a 12-14 ml stroke volume pneumatically actuated pump, with custom Björk-Shiley monostrut valves, developed under the National Heart, Lung, and Blood Institute Pediatric Circulatory Support program. In this report, we describe the seven most recent chronic animal studies of the Infant VAD in the juvenile ovine model, with a mean body weight of 23.5 ± 4.1 kg. The goal of 4-6 weeks survival was achieved in five of seven studies, with support duration ranging from 5 to 41 days; mean 26.1 days. Anticoagulation was accomplished using unfractionated heparin, and study animals were divided into two protocol groups: the first based on a target activated partial thromboplastin time of 1.5-2 times normal, and a second group using a target thromboelastography R-time of two times normal. The second group required significantly less heparin, which was verified by barely detectable heparin activity (anti-Xa). In both groups, there was no evidence of thromboembolism except in one animal with a chronic infection and fever. Device thrombi were minimal and were further reduced by introduction of the custom valve. These results are consistent with results of adult VAD testing in animals and are encouraging given the extremely low levels of anticoagulation in the second group.

Translational research in pediatric extracorporeal life support systems and cardiopulmonary bypass procedures: 2011 update.

Over the past 6 years at Penn State Hershey, we have established the pediatric cardiovascular research center with a multidisciplinary research team with the goal to improve the outcomes for children undergoing cardiac surgery with cardiopulmonary bypass (CPB) and extracorporeal life support (ECLS). Due to the variety of commercially available pediatric CPB and ECLS devices, both in vitro and in vivo translational research have been conducted to achieve the optimal choice for our patients. By now, every component being used in our clinical settings in Penn State Hershey has been selected based on the results of our translational research. The objective of this review is to summarize our translational research in Penn State Hershey Pediatric Cardiovascular Research Center and to share the latest results with all the interested centers.