Integrating Battlefield Documentation into Virtual Reality Medical Simulation Training: Virtual Battlefield Assisted Trauma Distributed Observation Kit (BATDOK).

INTRODUCTION: Clinical documentation is an essential component of the provision of medical care, enabling continuity of information across provider and site handoffs. This is particularly important in the combat casualty care setting when a single casualty may be treated by four or more or five completely disparate teams across the roles of care. The Battlefield Assisted Trauma Distributed Observation Kit (BATDOK) is a digital battlefield clinical documentation system developed by the Air Force Research Laboratory to address this need. To support the deployment of this tool, we integrated BATDOK into a commercially available virtual reality (VR) medical simulation platform used by the U.S. Air Force and Defense Health Agency personnel in order to provide an immersive simulation training experience which included battlefield documentation. METHODS: A multidisciplinary team consisting of medical educators, VR simulation engineers, emergency physicians and pararescuemen, and BATDOK developers first developed a specification for a virtual BATDOK capability, including a detailed listing of learning objectives, critical interfaces and task plans, and sensor integrations. These specifications were then implemented into the commercially available Virtual Advancement of Learning for Operational Readiness VR Medical Simulation System and underwent developmental testing and evaluation during pararescueman training exercises at the Air Force Special Operations Command Special Operations Center for Medical Integration and Development. RESULTS AND CONCLUSIONS: The BATDOK capability was successfully implemented within the VR Medical Simulation System. The capability consisted of a virtual tablet with replicated interfaces and capabilities based on the developed specifications. These capabilities included integrated point-of-care ultrasound capability, multi-patient management, vitals sign monitoring with sensor pairing and continuous monitoring, mechanism of injury documentation (including injury pattern documentation), intervention logging (including tourniquets, dressing, airways, lines, tubes and drains, splints, fluids, and medications), and event logging. The capability was found to be operational and in alignment with learning objectives and user acceptance goals.

Preparing students for residency interviews in the age of COVID: Lessons learned from a standardized video interview preparation program.

Objectives: The COVID-19 pandemic has necessitated the widescale adoption of video-based interviewing for residency applications. Video interviews have previously been used in the residency application process through the pilot program of the American Association of Medical Colleges standardized video interview (SVI). We conducted an SVI preparation program with our students over 3 years that consisted of an instructional lecture, deliberate practice in video interviewing, and targeted feedback by emergency medicine faculty. The aim of this investigation was to summarize the feedback students received on their practice SVIs to provide the guidance they need for preparing for the video interviews that will replace in-person interviews with residency programs. Methods: A retrospective thematic analysis was conducted on faculty feedback provided to students who had completed SVI practice videos in preparation for their application to an EM residency between June 2017 and July 2019. Categorized comments were also sorted by type of faculty feedback: positive reinforcement, constructive criticism, or both. Results: Forty-six medical students received 334 feedback elements from three faculty. Feedback was balanced between positive reinforcement statements and constructive criticism. Students performed well on appearance and attire, creating a proper recording environment, and response content. They needed the most guidance with the delivery of content and the technical quality of the video. Conclusions: Our results demonstrate a need for formal instruction in how to communicate effectively through the video medium. Medical educators will need to formally prepare students for tele-interviews with residency programs, with an emphasis on communication skills and techniques for improving the quality of their video presentation, including lighting and camera placement.

Understanding the Effects of a Polymer on the Surface Dissolution of Pharmaceutical Cocrystals Using Combined Experimental and Molecular Dynamics Simulation Approaches.

The molecular interactions between the surfaces of cocrystals [i.e., flufenamic acid and theophylline (FFA-TP), flufenamic acid and nicotinamide (FFA-NIC), and carbamazepine and nicotinamide (CBZ-NIC)] and the polymers [i.e., polyethylene glycol (PEG), polyvinylpyrrolidone (PVP), and copolymer of vinylpyrrolidone (60%)/vinyl acetate (40%) (PVP-VA)] were investigated through combined experimental and molecular dynamics simulation approaches to resolve the mechanisms of cocrystal dissolution and precipitation. It was found that adsorption of the polymers on the surfaces of cocrystals might prevent the precipitation of the parent drug and alter the dissolution rate. The effect of polymers on precipitation could be determined by the cocrystal dissolution rate, the interactions of polymers with the surfaces of cocrystals, the characters of the noncovalent bonds formed between the polymers and the cocrystal surfaces, and the mobility and conformation of the polymers. The etching experiments of single cocrystals revealed that FFA-NIC and CBZ-NIC appeared as surface precipitation cocrystals while FFA-TP could lead to bulk precipitation. Both PVP and PVP-VA were good precipitation inhibitors for FFA-NIC, and they could completely inhibit the recrystallization of FFA III on the surfaces of dissolving cocrystals. In addition, as the adsorption of the polymer was slower than dissolution rate of the cocrystals, PVP and PVP-VA could only partially inhibit the recrystallization of CBZ dihydrate on the surface of CBZ-NIC. While PEG had no inhibitory effect on the surface crystallization of FFA-NIC and CBZ-NIC, due to its weak interactions with the surfaces of the cocrystals, it enhanced the dissolution performance of FFA-TP. In contrast, PVP and PVP-VA reduced the dissolution rate of FFA-TP and subsequently undermined the performance of cocrystals. Taken together, the approach of combining experimental and molecular dynamics simulation provided insights into the mechanisms of cocrystal dissolution as well as the polymers acting as inhibitory excipients for precipitation/recrystallization, making contribution to the development of novel formulations.

Beyond observation: Protocols and capabilities of an Emergency Department Observation Unit.

OBJECTIVE: Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. Our hospital has a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. We wanted to understand how the different protocols performed and what types of care were provided. METHODS: This was an IRB-approved, retrospective chart review study. A random 10% of ED patient charts with a "transfer to observation" order were selected monthly from October 2015 through June 2017. This database was designed to identify high and low functioning protocols based on length of stays (LOS) and admission rates. RESULTS: Over 20 months, a total of 984 patients qualified for the study. The average age was 49.5 ±â€¯17.2 years, 57.3% were women, and 32.3% were non-Caucasian. The admission rate was 23.5% with an average LOS in observation of 13.7 h [95% CI 13.3-14.1]. Thirty day return rate was 16.8% with 5.3% of the patients returning to the ED within the first 72 h. Thirty six different protocols were used, with the most common being chest pain (13.9%) and general (13.2%). Almost 70% received a consultation from another service, and 7.2% required a procedure while in observation. Procedures included fluoroscopic-guided lumbar punctures, endoscopies, dental extractions, and catheter replacements (nephrostomy, gastrostomy, and biliary tubes). CONCLUSIONS: An Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate.

Replacing Lectures with Small Groups: The Impact of Flipping the Residency Conference Day.

The flipped classroom, an educational alternative to the traditional lecture, has been widely adopted by educators at all levels of education and across many disciplines. In the flipped classroom, learners prepare in advance of the face-to-face meeting by learning content material on their own. Classroom time is reserved for application of the learned content to solving problems or discussing cases. Over the past year, we replaced most residency program lectures with small-group discussions using the flipped-classroom model, case-based learning, simulation and procedure labs. In the new model, residents prepared for conference by reviewing a patient case and studying suggested learning materials. Conference day was set aside for facilitated small-group discussions about the case. This is a cross-cohort study of emergency medicine residents who experienced the lecture-based curriculum to residents in the new flipped-classroom curriculum using paired comparisons (independent t-tests) on in-training exam scores while controlling for program year level. We also compared results of the evaluation of various program components. We observed no differences between cohorts on in-training examination scores. Small-group methods were rated the same across program years. Two program components in the new curriculum, an updated format of both adult and pediatric case conferences, were rated significantly higher on program quality. In preparation for didactics, residents in the new curriculum report spending more time on average with outside learning materials, including almost twice as much time reviewing textbooks. Residents found the new format of the case conferences to be of higher quality because of the inclusion of rapid-fire case discussions with targeted learning points.

Bringing the Flipped Classroom to Day 1: A Novel Didactic Curriculum for Emergency Medicine Intern Orientation.

Most emergency medicine (EM) residency programs provide an orientation program for their incoming interns, with the lecture being the most common education activity during this period. Our orientation program is designed to bridge the gap between undergraduate and graduate medical education by ensuring that all learners demonstrate competency on Level 1 Milestones, including medical knowledge (MK). To teach interns core medical knowledge in EM, we reformulated orientation using the flipped-classroom model by replacing lectures with small group, case-based discussions. Interns demonstrated improvement in medical knowledge through higher scores on a posttest. Evaluation survey results were also favorable for the flipped-classroom teaching format.

Epidemiology of clinical feline herpesvirus infection in zoo-housed cheetahs (Acinonyx jubatus).

OBJECTIVE To determine the incidence of and risk factors for clinical feline herpesvirus (FHV) infection in zoo-housed cheetahs and determine whether dam infection was associated with offspring infection. DESIGN Retrospective cohort study. ANIMALS 144 cheetah cubs born in 6 zoos from 1988 through 2007. PROCEDURES Data were extracted from the health records of cheetahs and their dams to identify incident cases of clinical FHV infection and estimate incidence from birth to 18 months of age. Univariate and multivariable Cox proportional hazards models, controlling for correlations among cheetahs with the same dam, were used to identify risk factors for incident FHV infection. RESULTS Cumulative incidence of FHV infection in cheetah cubs was 35% (50/144). No significant association between dam and offspring infection was identified in any model. Factors identified as significant through multivariable analysis varied by age group. For cheetahs up to 3 months of age, the most important predictor of FHV infection was having a dam that had received a preparturition FHV vaccine regimen that included a modified-live virus vaccine versus a dam that had received no preparturition vaccine. Other risk factors included being from a small litter, being born to a primiparous dam, and male sex. CONCLUSIONS AND CLINICAL RELEVANCE This study provided the first population-level characterization of the incidence of and risk factors for FHV infection in cheetahs, and findings confirmed the importance of this disease. Recognition that clinical FHV infection in the dam was not a significant predictor of disease in cubs and identification of other significant factors have implications for disease management.

Emergency Medicine Resident Orientation: How Training Programs Get Their Residents Started.

INTRODUCTION: The first formal orientation program for incoming emergency medicine (EM) residents was started in 1976. The last attempt to describe the nature of orientation programs was by Brillman in 1995. Now almost all residencies offer orientation to incoming residents, but little is known about the curricular content or structure of these programs. The purpose of this project was to describe the current composition and purpose of EM resident orientation programs in the United States. METHODS: In autumn of 2014, we surveyed all U.S. EM residency program directors (n=167). We adapted our survey instrument from one used by Brillman (1995). The survey was designed to assess the orientation program's purpose, structure, content, and teaching methods. RESULTS: The survey return rate was 63% (105 of 167). Most respondents (77%) directed three-year residencies, and all but one program offered intern orientation. Orientations lasted an average of nine clinical (Std. Dev.=7.3) and 13 non-clinical days (Std. Dev.=9.3). The prototypical breakdown of program activities was 27% lectures, 23% clinical work, 16% skills training, 10% administrative activities, 9% socialization and 15% other activities. Most orientations included activities to promote socialization among interns (98%) and with other members of the department (91%). Many programs (87%) included special certification courses (ACLS, ATLS, PALS, NRP). Course content included the following: use of electronic medical records (90%), physician wellness (75%), and chief complaint-based lectures (72%). Procedural skill sessions covered ultrasound (94%), airway management (91%), vascular access (90%), wound management (77%), splinting (67%), and trauma skills (62%). CONCLUSION: Compared to Brillman (1995), we found that more programs (99%) are offering formal orientation and allocating more time to them. Lectures remain the most common educational activity. We found increases in the use of skills labs and specialty certifications. We also observed increases in time dedicated to clinical work during orientation. Only a few programs reported engaging in baseline or milestone assessments, an activity that could offer significant benefits to the residency program.

Development of a case definition for clinical feline herpesvirus infection in cheetahs (Acinonyx jubatus) housed in zoos.

The identification of feline herpesvirus (FHV) infected cheetahs (Acinonyx jubatus) and characterization of shedding episodes is difficult due to nonspecific clinical signs and limitations of diagnostic tests. The goals of this study were to develop a case definition for clinical FHV and describe the distribution of signs. Medical records from six different zoologic institutions were reviewed to identify cheetahs with diagnostic test results confirming FHV. Published literature, expert opinion, and results of a multiple correspondence analysis (MCA) were used to develop a clinical case definition based on 69 episodes in FHV laboratory confirmed (LC) cheetahs. Four groups of signs were identified in the MCA: general ocular signs, serious ocular lesions, respiratory disease, and cutaneous lesions. Ocular disease occurred with respiratory signs alone, with skin lesions alone, and with both respiratory signs and skin lesions. Groups that did not occur together were respiratory signs and skin lesions. The resulting case definition included 1) LC cheetahs; and 2) clinically compatible (CC) cheetahs that exhibited a minimum of 7 day's duration of the clinical sign groupings identified in the MCA or the presence of corneal ulcers or keratitis that occurred alone or in concert with other ocular signs and skin lesions. Exclusion criteria were applied. Application of the case definition to the study population identified an additional 78 clinical episodes, which represented 58 CC cheetahs. In total, 28.8% (93/322) of the population was identified as LC or CC. The distribution of identified clinical signs was similar across LC and CC cheetahs. Corneal ulcers and/or keratitis, and skin lesions were more frequently reported in severe episodes; in mild episodes, there were significantly more cheetahs with ocular-only or respiratory-only disease. Our results provide a better understanding of the clinical presentation of FHV, while presenting a standardized case definition that can both contribute to earlier diagnoses and be used for population-level studies.

Integrated medical school ultrasound: development of an ultrasound vertical curriculum.

BACKGROUND: Physician-performed focused ultrasonography is a rapidly growing field with numerous clinical applications. Focused ultrasound is a clinically useful tool with relevant applications across most specialties. Ultrasound technology has outpaced the education, necessitating an early introduction to the technology within the medical education system. There are many challenges to integrating ultrasound into medical education including identifying appropriately trained faculty, access to adequate resources, and appropriate integration into existing medical education curricula. As focused ultrasonography increasingly penetrates academic and community practices, access to ultrasound equipment and trained faculty is improving. However, there has remained the major challenge of determining at which level is integrating ultrasound training within the medical training paradigm most appropriate. METHODS: The Ohio State University College of Medicine has developed a novel vertical curriculum for focused ultrasonography which is concordant with the 4-year medical school curriculum. Given current evidenced-based practices, a curriculum was developed which provides medical students an exposure in focused ultrasonography. The curriculum utilizes focused ultrasonography as a teaching aid for students to gain a more thorough understanding of basic and clinical science within the medical school curriculum. The objectives of the course are to develop student understanding in indications for use, acquisition of images, interpretation of an ultrasound examination, and appropriate decision-making of ultrasound findings. RESULTS: Preliminary data indicate that a vertical ultrasound curriculum is a feasible and effective means of teaching focused ultrasonography. The foreseeable limitations include faculty skill level and training, initial cost of equipment, and incorporating additional information into an already saturated medical school curriculum. CONCLUSIONS: Focused ultrasonography is an evolving concept in medicine. It has been shown to improve education and patient care. The indications for and implementation of focused ultrasound is rapidly expanding in all levels of medicine. The ideal method for teaching ultrasound has yet to be established. The vertical curriculum in ultrasound at The Ohio State University College of Medicine is a novel evidenced-based training regimen at the medical school level which integrates ultrasound training into medical education and serves as a model for future integrated ultrasound curricula.

Monteggia lesion in an Asian small-clawed otter (Aonyx cinerea).

A 10-yr-old female Asian small-clawed otter (Aonyx cinerea) presented with a history of right forelimb lameness. Antebrachial radiographs revealed a Monteggia lesion, classified by cranial radial head luxation and distal diaphyseal ulnar fracture. Open reduction with placement of an ulnar-radial positional screw was performed. The lateral collateral ligament was reconstructed using suture anchored by a condylar screw and bone tunnel in the radius. Reduction and proper implant placement was confirmed on postoperative radiographs. The ulnar-radial positional screw was removed 6 wk postoperatively to allow proper supination and pronation. Limb function was greatly improved at this time; however, a mild lameness was still observed. At 7 mo postoperatively, the otter was ambulating lameness-free. Radiographs documented proper joint reduction and stable condylar screw. At 32 mo postoperatively, the otter continued to exhibit normal ambulation.

Rapid Resolution of Acute Fulminant Myocarditis after IVIG and Steroid Treatment.

We report a case of a 59-year-old woman who presented with worsening dyspnea which rapidly progressed to severe heart failure. Coronary arteries showed no obstruction. Supportive measures stabilized the patient's hemodynamics. Initially intravenous solumedrol was given, but when the patient's condition continued to deteriorate, intravenous immunoglobulin (IVIG) was added to the treatment regimen and her condition improved. Studies show no benefit to using immunosuppressive agents in viral myocarditis, but benefits have been demonstrated in other etiologies. Patients presenting with acute fulminant myocarditis with unknown etiology that continue to deteriorate with aggressive heart failure treatment may benefit from steroids and IVIG.

Pituitary cystadenoma, enterolipidosis, and cutaneous mycosis in an Everglades ratsnake (Elaphe obsoleta rossalleni).

An 11-yr-old captive-born male Everglades ratsnake (Elaphe obsoleta rosalleni) presented with dysecdysis, hyperkeratosis, and inappetance. Two skin biopsies demonstrated a diffuse hyperkeratosis with both a bacterial and fungal epidermitis. Fusarium oxysporum was cultured from both biopsies and considered an opportunistic infection rather than a primary pathogen. Medical management was unsuccessful, and the snake was euthanized. Histologic findings included a pituitary cystadenoma arising from the pars intermedia, severe intestinal lipidosis, generalized epidermal hyperkeratosis, and lesions consistent with sepsis. It is hypothesized that endocrine derangements from the pituitary tumor may have caused the skin and intestinal lesions.

Use of a Mycobacterium tuberculosis rapid lateral flow test for assessment of non-specific tuberculin responses in silvered langurs (Trachypithecus cristatus ultima).

Nonspecific responses to intradermal tuberculin skin testing (TST) have been frequently documented in silvered langurs (Trachypithecus cristatus ultima) at the Wildlife Conservation Society's Bronx Zoo. A commercial rapid lateral flow immunoassay (RT) for the identification of Mycobacterium tuberculosis and M. bovis antibodies was employed to assess this test's correlation with TST results and tuberculosis status. Twenty-two silvered langurs were tested with both TST and RT. TST results were characterized into three groups as nonspecific tuberculin responses (n=9), responses to avian tuberculin only (n=6), or negative (n=7). Rapid lateral flow test results were negative in 20 of 22 individuals with equivocal results in two avian tuberculin responders. There was no difference in RT results between TST groups (P = 0.178). Rapid lateral flow test results were not in agreement with mammalian old tuberculin TST results (kappa = 0.08) but showed raw agreement with tuberculosis status (proportion of overall agreement = 0.909). Results suggest the RT assay may useful in the confirmation of nonspecific TST responders in silvered langurs.

Characterization of basal seminal traits and reproductive endocrine profiles in North American river otters and Asian small-clawed otters.

In this study, fecal samples were collected from 24 North American river (NARO) and 17 Asian small-clawed otters (ASCO) for 6-36 months and semen collected seasonally from NARO males (n=4/season) via electroejaculation. Our main objectives were to: (1) characterize endocrine parameters by longitudinal monitoring of fecal hormone metabolites and (2) investigate semen collection and basal seminal traits in NARO. NARO demonstrated a distinct seasonality in the spring, with females having a monoestrual estrogen elevation lasting 15.33+/-1.98 (mean+/-SEM) days and males peaking in testosterone production for 25.50+/-7.51 days. Pregnancy was characterized by 7-9 months of basal fecal progesterone, presumably corresponding to embryonic diapause, followed by a rapid increase over the final 68-73 days to term. Pseudopregnancy exhibited a similar late winter progesterone peak of 68-72 days, which could not be differentiated from pregnancy. Geographic latitude possibly influenced the timing of increased testosterone in males and increased progesterone in pregnant/pseudopregnant females. In ASCO, monitoring of fecal estrogens did not allow consistent detection of peak values associated with behavioral estrus. Both pregnancy and pseudopregnancy were characterized by a moderate rise in fecal progesterone for 14-16 days postovulation followed by a marked increase. Total gestation length was 67-77 days compared with 62-84 days for pseudopregnancy. In NARO, optimal sperm recovery and quality occurred only in the spring, corresponding with seasonal increases in testicular volume and fecal testosterone. These findings represent the first comprehensive information on normative endocrine and seminal traits in freshwater otter species.

Chemotherapy and radiotherapy for treatment of cutaneous lymphoma in a ground cuscus (Phalanger gymnotis).

A 15-year-old female ground cuscus (Phalanger gymnotis) was presented with an isolated ulcerated, nonhealing lesion on the lateral thorax. Histopathology and immunohistochemistry were diagnostic for cutaneous T-cell lymphoma with incomplete excision. Oral chemotherapy with CCNU (lomustine) resulted in clinical remission that lasted 255 days, with no appreciable toxicity. Tumor recurrence was treated with radiation therapy, which resulted in 120 additional days of clinical remission. Subsequently, the tumor developed at a distant site and the cuscus was humanely euthanized. A slight decrease in appetite early in disease progression was the only adverse effect noted throughout the treatment period. Oral, minimally invasive chemotherapy, and adjunct radiation therapy were viable treatment options for this ground cuscus and should be considered for treatment of neoplasia in other nontraditional species.

Immunodeficiency associated with multiple concurrent infections in captive Pallas' cats (Otocolobus manul).

Five neonatal Pallas' cats (Otocolobus manul) at the Oklahoma City Zoo died from toxoplasmosis with concurrent herpesvirus infection. These multiple infections suggested underlying immunodeficiency, perhaps caused by concurrent infection with feline immunodeficiency virus (FIV); so blood samples were collected for serology, serum protein electrophoresis, lymphocyte proliferation assays, and cytokine analysis by reverse transcriptase-quantitative competitive polymerase chain reaction (RT-qcPCR). Resulting data were compared with data from FIV-infected and control domestic short-haired cats. In addition, peripheral blood mononuclear cell cultures were propagated to detect FIV virus by both RT-qcPCR and detection of reverse transcriptase activity. Serum protein electrophoresis showed that four of six Pallas' cats had increased alpha, globulins. At least two Pallas' cats had decreased lymphoproliferation responses to mitogen. and all three tested animals exhibited defective interleukin-12 gene expression. Although these clinical and laboratory findings suggested an immunodeficiency syndrome, FIV infection could not be confirmed. On the basis of repeated blood test results, it can be concluded that nutritional, metabolic, or other systemic problems probably did not contribute to the disease syndrome. Further investigation of other possible causes of immunodeficiency, including a possible genetic component, in this population is needed.