The impact of rounds with a psychiatry team in the intensive care unit: A prospective observational pilot study evaluating the effects on delirium incidence and outcomes.

BACKGROUND: Delirium in the intensive care unit (ICU) is a common but serious condition that has been associated with in-hospital mortality and post-discharge psychological dysfunction. The aim of this before and after study is to determine the effect of a multidisciplinary care model entailing daily ICU rounds with a psychiatrist on the incidence of delirium and clinical outcomes. OBJECTIVE: To assess the impact of a proactive psychiatry consultation model in the surgical ICU on the incidence and duration of delirium. METHODS: This was a prospective, single institution, observational controlled cohort pilot study of adult patients admitted to a surgical ICU. A control group that received standard of care (SOC) with daily delirium prevention care bundles in the pre-intervention period was compared to an intervention group, which had a psychiatrist participate in daily ICU rounds (post-intervention period). The primary outcome was delirium incidence. The secondary outcomes were: delirium duration, ventilator days, hospital and ICU length of stay, and in-hospital mortality. RESULTS: A total of 104 patients were enrolled and equally split between SOC and intervention groups; 95 contributed to analysis. The overall incidence of ICU delirium was 19%. SOC and intervention groups had similar rates of delirium (21% vs 18%, p = 0.72). None of the secondary outcomes statistically significantly differed between the two groups. CONCLUSION: Delirium in ICU patients is a potentially preventable condition with serious sequelae. There was no difference in delirium incidence or duration between patients receiving SOC or patients who had multidisciplinary rounds with a psychiatrist.

Mucormycosis following burn injuries: A systematic review.

INTRODUCTION: Mucormycosis is an opportunistic fungal infection with a high mortality rate. Though typically associated with diabetes and other conditions that affect innate immune function, infections can also be precipitated by conditions such as trauma and burns. Burn patients are particularly susceptible to fungal infections due to the immune dysfunction that often accompany their wounds. Indeed case series have described mucormycosis to occur in patients with burn injuries, however the factors contributing to mortality have not been well described. Thus, the purpose of our review was to identify factors contributing to morbidity and mortality in burn patients with Mucormycosis. METHODS: A systematic review of the literature of mucormycosis infection in burn injury patients was performed on Pubmed and Google Scholar using the keywords: Mucor, Mucorales, Mucormycosis, Mucormycotina, Zygomycosis and burn or thermal injury. Clinical trials, observational studies, case reports, and case reviews were included if they provided information regarding mortality in adult and pediatric burn patients diagnosed with mucormycosis, review articles, non-English articles, and articles without patient information were excluded. No time limit was placed on our review. Individual patient data was stratified based on mortality. Statistical analysis was performed to investigate the relationship between patient risk factors and mortality, and the Oxford Level of Evidence was used to evaluate study quality. RESULTS: 46 articles were included in our final review, encompassing 114 patients. On average, survivors had a total body surface area (TBSA)% of 46 (SD 19.8) while non-survivors had a TBSA of 65% (SD 16.4), and this difference was significant (p < .001). Patients with disseminated mucormycosis experienced an 80% mortality rate compared to 36% mortality rate in patients with localized disease (p < .001). We found no statistically significant difference in mean age (p > .05), diabetes (p > .05), mean delay in diagnosis (p > .05), time to antifungal therapy (p > .05), or type of therapy used (p > .05) between survivors and non-survivors. Our review was limited by the lack of prospective, controlled trials; thus, our review primarily consists of case reports. CONCLUSION: Disseminated infections and higher TBSA both increased the risk of mortality in burn patients with mucormycosis, while diabetes did not increase mortality risk. The severity of the initial injury and infection locations must be taken into consideration to inform patient prognosis.

Systematic Review of Advanced AI Methods for Improving Healthcare Data Quality in Post COVID-19 Era.

At the beginning of the COVID-19 pandemic, there was significant hype about the potential impact of artificial intelligence (AI) tools in combatting COVID-19 on diagnosis, prognosis, or surveillance. However, AI tools have not yet been widely successful. One of the key reason is the COVID-19 pandemic has demanded faster real-time development of AI-driven clinical and health support tools, including rapid data collection, algorithm development, validation, and deployment. However, there was not enough time for proper data quality control. Learning from the hard lessons in COVID-19, we summarize the important health data quality challenges during COVID-19 pandemic such as lack of data standardization, missing data, tabulation errors, and noise and artifact. Then we conduct a systematic investigation of computational methods that address these issues, including emerging novel advanced AI data quality control methods that achieve better data quality outcomes and, in some cases, simplify or automate the data cleaning process. We hope this article can assist healthcare community to improve health data quality going forward with novel AI development.

A retrospective data analysis on the induction medications used in trauma rapid sequence intubations and their effects on outcomes.

PURPOSE: Rapid sequence intubation (RSI) in trauma patients is common; however, the induction agents used have been debated. We determined which induction medications were used most frequently for adult trauma RSIs and their associations with hemodynamics and outcomes. We hypothesized that etomidate is the most commonly used induction agent and has similar outcomes to other induction agents. METHODS: This retrospective review at two U.S. level I trauma centers evaluated adult trauma patients undergoing RSI within 24 h of admission, between 01/01/2016 and 12/31/2017. We compared patient characteristics and outcomes by induction agent. Comparisons on the primary outcome of in-hospital mortality and secondary outcomes of peri-intubation hypotension, hospital and ICU length of stay (LOS), ventilator days, and complications used logistic regression or negative binomial regression. Regression models adjusted for hospital site, age, patient severity measures, and intubation location. RESULTS: Among 1303 trauma patients undergoing RSI within 24 h of admission, 948 (73%) were intubated in the emergency department (ED) and 325 (25%) in the operating room (OR). The most common induction agents were etomidate (68%), propofol (17%), and ketamine (11%). In-hospital mortality was highest in the etomidate group (25.5%), followed by ketamine (17%), and propofol (1.8%). CONCLUSION: Etomidate was most commonly used in ED intubations; propofol was most used in the OR. Compared to propofol, patients induced with etomidate had higher mortality and complication rates. Findings should be interpreted with caution given limited generalizability and residual confounding by indication.

Insourcing and scaling a telemedicine solution in under 2 weeks: Lessons for the digital transformation of health care.

The Covid-19 pandemic required rapid scale of telemedicine as well as other digital workflows to maintain access to care while reducing infection risk. Both patients and clinicians who hadn't used telemedicine before were suddenly faced with a multi-step setup process to log into a virtual meeting. Unlike in-person examination rooms, locking a virtual meeting room was more error-prone and posed a risk of multiple patients joining the same online session. There was administrative burden on the practice staff who were generating and manually sending links to patients, and educating patients on device set up was time-consuming and unsustainable. A solution had to be deployed rapidly system-wide, without the usual roll out across months. Our answer was to design and implement a novel EHR-integrated web application called the Switchboard, in just two weeks. The Switchboard leverages a commercial, cloud-based video meeting platform and facilitates an end-to-end virtual care encounter workflow, from pre-visit reminders to post-visit SMS text message-based measurement of patient experience, with tools to extend contact-less workflows to in-person appointments. Over the first 11 months of the pandemic, the in-house platform has been adopted across 6 hospitals and >200 practices, scaled to 8,800 clinicians who at their peak conducted an average of 30,000 telemedicine appointments/week, and enabled over 10,000-20,000 text messages/day to be exchanged through the platform. Furthermore, it enabled our organization to convert from an average of 75% of telehealth visits being conducted via telephone to 75% conducted via video within weeks.

Homeless Tent Fires: A Descriptive Analysis of Tent Fires in the Homeless Population.

Tent fires are a growing issue in regions with large homeless populations given the rise in homelessness within the United States and existing data that suggest worse outcomes in this population. The aim of this study was to describe the characteristics and outcomes of tent fire burn injuries in the homeless population. A retrospective review was conducted involving two verified regional burn centers with patients admitted for tent fire burns between January 2015 and December 2020. Variables recorded include demographics, injury characteristics, hospital course, and patient outcomes. Sixty-nine patients met the study inclusion criteria. The most common mechanisms of injury were by portable stove accident, assault, and tobacco or methamphetamine related. Median percent total body surface area (%TBSA) burned was 6% (interquartile range [IQR] 9%). Maximum depth of injury was partial thickness in 65% (n = 45) and full thickness in 35% (n = 24) of patients. Burns to the upper and lower extremities were present in 87% and 54% of patients, respectively. Median hospital length of stay (LOS) was 10 days (IQR = 10.5) and median ICU LOS was 1 day (IQR = 5). Inhalation injury was present in 14% (n = 10) of patients. Surgical intervention was required in 43% (n = 30) of patients, which included excision, debridement, skin grafting, and escharotomy. In-hospital mortality occurred in 4% (n = 3) of patients. Tent fire burns are severe enough to require inpatient and ICU level of care. A high proportion of injuries involved the extremities and pose significant barriers to functional recovery in this vulnerable population. Strategies to prevent these injuries are paramount.

Fractional CO2 laser treatment for burn scar improvement: A systematic review and meta-analysis.

Burn injury can cause abnormal healing and pathologic scar formation that significantly impairs patients' ability to return to baseline levels of functioning. Quality of life can be significantly diminished due to pain, stiffness, contracture, and the psychological burden of disfigurement. Traditional scar therapies such as silicone sheeting and compression garments are highly reliant on patient compliance, and have not demonstrated satisfactory efficacy. Even more invasive therapies such as intralesional medication delivery or surgical contracture release have high recurrence rates. Recently, fractional CO2 laser therapy has emerged as a promising treatment modality for burn scars, but there is a lack of recent studies that aggregates extant data to demonstrate outcomes after laser therapy. To address this, we conducted a systematic review and meta-analysis to determine the efficacy of fractional CO2 lasers in treating burn scars, and found that laser therapy alone yielded statistically significant improvements in scar profiles. There were very few reports of adverse effects, most treatments were provided as outpatient, and both patient and burn practitioners reported high satisfaction. By sharing our findings, we hope that more burn practitioners will consider adopting laser therapy as a safe and cost-effective first-line therapy for burn scar management.

The Likelihood of Orthognathic Surgery After Orofacial Cleft Repair.

ABSTRACT: Midface hypoplasia is one of the most significant sequelae of cleft lip and/or palate surgery. A complete understanding of the rate of orthognathic surgery across varying cleft phenotypes is a powerful tool for educating patients and families as to the treatment course that the patient will incur during their lifetime. Understanding the average rates of orthognathic intervention also can act to develop metrics for outcome evaluation with different treatment protocols. Attempting to identify the average rates of orthognathic intervention, the authors conducted a systematic review and meta-analysis by combining studies from 1987 to 2016 describing the frequency of orthognathic intervention on the different cleft phenotypes as the primary outcome. Secondary outcomes included identification of surgical protocol, age of patient at orthognathic intervention, and the method by which patients were evaluated for orthognathic intervention. The rate of orthognathic surgery was 38.1% for bilateral cleft lip and palate (BCLP), 30.2% for unilateral cleft lip and palate (UCLP), 4.4% for isolated cleft palate (ICP), and 1.8% for patients with isolated cleft lip (ICL). 71% (n = 10) reported using lateral cephalograms for orthognathic surgery evaluation and only one of those studies reported specific objective cephalometric measurements for orthognathic intervention. Our findings demonstrated that BCLP possessed the highest rate of orthognathic intervention followed by UCLP, ICP, and ICL. ICP and ICL both possessed low rates of orthognathic intervention. By sharing our findings, the authors hope to provide a useful tool for informing patients' families as to their risk of needing orthognathic intervention.

Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine. Objective: To evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic. Design, Setting, and Participants: In this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record. Main Outcomes and Measures: A successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically. Results: A total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties. Conclusions and Relevance: In this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.

Vertical Distraction for the Treatment of Congenital Syngnathia.

Congenital syngnathia is a very rare condition that presents with several unique challenges. There is no consensus on the best operative approach to manage this condition. Readhesion of surgically separated tissues is a relatively common occurrence. The authors propose that the use of a vertical distraction technique helps maintain adequate separation to prevent relapse of the bony fusion. Long-term follow-up will be required to follow mandibular growth and implications of this treatment option.

The Predictive Capacity of American Society of Anesthesiologists Physical Status (ASA PS) Score in Burn Patients.

Advances in burn care continues to improve survival rates and patient outcomes. There are several burn prognostic tools used to predict mortality and outcomes; however, none include patient comorbidities. We used the American Society of Anesthesiologists physical status score as a surrogate measure for comorbidities, and evaluated its role in predicting mortality and outcomes in adult burn patients undergoing surgery. A retrospective analysis was performed on data collected from a single burn center in the United States, which was comprised of 183 patients. We evaluated the American Society of Anesthesiologists physical status score as an independent predictor of mortality and outcomes, including intensive care unit (ICU) length of stay (LOS), hospital LOS, mechanical ventilator (MV) days, and complications. We compared the American Society of Anesthesiologists physical status score to other prognostic models which included the revised Baux score, Belgian Outcome in Burn Injury, and the Abbreviated Burn Severity Index. Our results demonstrated that the revised Baux and American Society of Anesthesiologists physical status scores could be used to determine the mortality risk in adult burn patients. The revised Baux was the best predictor of mortality, ICU LOS, and MV days, while the Abbreviated Burn Severity Index was the best predictor of total LOS.

Statewide Success of Staged Sacral Neuromodulation for the Treatment of Urinary Complaints in California (2005-2011).

PURPOSE: Sacral neuromodulation (SNS) is approved by the Food and Drug Administration as a third-line treatment for refractory overactive bladder, idiopathic urinary retention, and fecal incontinence. Prior to implantation of an implantable pulse generator, all patients undergo a trial phase to ensure symptom improvement. The published success rates of progression from the test phase to permanent implant vary widely (range, 24% to >90%). We sought to characterize success rates using a statewide registry. METHODS: Using nonpublic data, we identified SNS procedures using the California Office of Statewide Planning and Development ambulatory surgery database from 2005 to 2011. A successful trial was defined as receiving a stage 2 generator implantation after trial lead placement. Multivariable logistic regression was performed to identify factors associated with staged success. RESULTS: During the study period, 1396 patients underwent a staged SNS procedure, with 962 (69%) subsequently undergoing generator placement. Successful trial rates were 72% for overactive bladder wet, 69% for urgency/frequency, 68% for interstitial cystitis, 67% for neurogenic bladder, and 57% for urinary retention. On multivariate logistic regression, only male sex (odds ratio, 0.51) and urinary retention [odds ratio, 0.54) were significantly associated with lower odds of success, whereas age, race/ethnicity, medical insurance, and placement at an academic or high-volume institution had no association. CONCLUSIONS: The "real world" success rates for staged SNS implantation in California are less than those observed by some academic centers of excellence but better than previously reported for Medicare beneficiaries. Successful trial rates for interstitial cystitis and neurogenic voiding dysfunction are similar to refractory overactive bladder.

A Novel Clinical Decision Support System for Gastrointestinal Bleeding Risk Stratification in the Critically Ill.

INTRODUCTION: Acid suppression therapy can reduce the development of stress and medication-related mucosal disease when prescribed appropriately. Suboptimal inpatient prescribing of acid suppression therapy therefore may lead to increased development of gastrointestinal hemorrhage in high-risk populations. The aim of this quality improvement study was to improve appropriate acid suppression therapy in patients admitted to ICUs in an academic medical center. INTERVENTION DEVELOPMENT, IMPLEMENTATION, AND ADAPTATION: An adaptable, multifaceted implementation strategy guided by unit-based root cause analysis was initially developed in a single ICU with a high-risk population. Identifiable targets of intervention, including provider awareness, unstructured rounding protocols, and electronic communication tools, were augmented by the development of an automated alert system. This electronic dashboard risk-stratified patients based on information derived from the electronic medical record (EMR). The dashboard then offered clinical decision support. Use of the dashboard and percentage of appropriate acid suppression therapy prescriptions were tracked over time. RESULTS: Appropriate acid suppression therapy prescribing was improved from 72.9% to 86.0% (p < 0.001). CONCLUSION: Automated technology including an EMR-supported electronic dashboard was the foundation of successful intervention. Considering the deleterious effects of both under- and overprescribing of acid suppression therapy, particularly in high-risk patient populations, this type of technology may lead to enhanced patient outcomes.

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study.

Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation. DESIGN: Multi-ICU proof-of-concept study and a single ICU before-after study. SETTING: University hospital ICUs. PATIENTS: Adult patients receiving mechanical ventilation. INTERVENTIONS: An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers. MEASUREMENTS AND MAIN RESULTS: We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01-1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03-1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09-4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13-5.16 d; p = 0.040) shorter, compared with the expected durations without the application. CONCLUSIONS: Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

SAGES Mini Med School: inspiring high school students through exposure to the field of surgery.

OBJECTIVE: The SAGES Mini Med School (SMMS) was designed to expose high school students to the field of surgery through mentoring, knowledge transfer, and hands-on experience with simulation. The objective of this paper is to profile the evolutionary development, performance metrics, and satisfaction queries of this innovative effort. METHODS: Sixty-one high school students, grades 9-12, took part in the (SMMS) program during the 2015 SAGES Annual Congress. The students completed a surgical skills lab session where they attempted tasks associated with the development of open surgical and laparoscopic skills. The lab included a warm-up with the validated Super Monkey Ball video game, Top Gun Pea Drop task, FLS Peg Transfer task, open knot tying station, and open instrument tie station. RESULTS: The following are the results of the surgical skills lab. For the Super Monkey Ball task, 60 students participated with an average score of 73.0 s (SD = 53.9; range 59.1-87.0; median = 74). Sixty students participated in the Surgeons Knot and Pea Drop tasks with average times of 26.6 s (SD = 19.3; range 21.7-31.6; median = 21.0) and 113.8 s (SD = 65.9; range 96.6-131.0; median = 101.0), respectively. Sixty students participated in the Instrument Tie and 56 students participated in the Peg Transfer stations with average times of 51.7 s (SD = 34.5; range 42.8-60.6; median = 39.5) and 173.1 s (SD = 25.0; range 166.4-179.8; median = 180.0), respectively. 51 (83.6%) agreed that the Mini Med School made them more likely to consider a career in medicine. When asked if the program made them more likely to consider a career in surgery 42 (68.8%) agreed. All 61 respondents (100%) said that they would recommend the program to others. CONCLUSIONS: The SMMS program showed that the students had an excellent aptitude for the performance of validated surgical subtasks with high satisfaction, and increased consideration of a career in medicine/surgery. Long-term studies are needed to evaluate the impact on workforce recruitment.

Design and Development of a Novel Distance Learning Telementoring System Using Off-the-Shelf Materials and Software.

OBJECTIVE: To design and develop a distance learning (DL) system for the transference of laparoscopic surgery knowledge and skill constructed from off-the-shelf materials and commercially available software. INTRODUCTION: Minimally invasive surgery offers significant benefits over traditional surgical procedures, but adoption rates for many procedures are low. Skill and confidence deficits are two of the culprits. DL combined with simulation training and telementoring may address these issues with scale. MATERIALS AND METHODS: The system must be built to meet the instruction requirements of a proven laparoscopic skills course (Top Gun). Thus, the rapid sharing of multimedia educational materials, secure two-way audio/visual communications, and annotation and recording capabilities are requirements for success. These requirements are more in line with telementoring missions than standard distance learning efforts. RESULTS: A DL system with telementor, classroom, and laboratory stations was created. The telementor station consists of a desktop computer and headset with microphone. For the classroom station, a laptop is connected to a digital projector that displays the remote instructor and content. A tripod-mounted webcam provides classroom visualization and a Bluetooth® wireless speaker establishes audio. For the laboratory station, a laptop with universal serial bus (USB) expander is combined with a tabletop laparoscopic skills trainer, a headset with microphone, two webcams and a Bluetooth® speaker. The cameras are mounted on a standard tripod and an adjustable gooseneck camera mount clamp to provide an internal and external view of the training area. Internet meeting software provides audio/visual communications including transmission of educational materials. CONCLUSION: A DL system was created using off-the-shelf materials and commercially available software. It will allow investigations to evaluate the effectiveness of laparoscopic surgery knowledge and skill transfer utilizing DL techniques.

Impact of Super Monkey Ball and Underground video games on basic and advanced laparoscopic skill training.

OBJECTIVE: This abstract profiles the comparison of correlations between previously validated Super Monkey Ball (SMB) and recently introduced Underground (U) video game on the Nintendo Wii U to multiple validated tasks used for developing basic and advanced laparoscopic skills. METHODS: Sixty-eight participants, 53 residents and 15 attending surgeons, performed the Top Gun Pea Drop, FLS Peg Pass, intracorporeal suturing, and two video games (SMB and U). SMB is an over-the-counter game, and U was formulated for laparoscopic skill training. RESULTS: Spearman's rank correlations were performed looking at performance comparing the three validated laparoscopic training tasks, and SMB/U. The SMB score had a moderate correlation with intracorporeal suturing (ρ = 0.39, p < 0.01), and the final score involving all three tasks (ρ = 0.39, p < 0.01), but low correlations with Pea Drop Drill and FLS Peg Transfer (ρ = 0.11, 0.18, p < 0.01). The U score had a small correlation with intracorporeal suturing and final score (ρ = 0.09, 0.13, p < 0.01). However, there were correlations between U score and Pea Drop Drill, and FLS Peg Transfer (ρ = 0.24, 0.27, p < 0.01, respectively). CONCLUSION: In this study, SMB had a very significant correlation with intracorporeal suturing. U demonstrated more of a correlation with basic skills. At this point, our conclusion would be that both are effective for laparoscopic skill training, and they should be used in tandem rather than alone.

Sex differences in STEMI activation for patients presenting to the ED 1939.

OBJECTIVE: The objective was to determine whether sex was independently associated with door to ST-elevation myocardial infarction (STEMI) activation time. We hypothesized that women are more likely to experience longer delays to STEMI activation than men. METHODS: We conducted a retrospective cohort study of adults ≥18 years who underwent STEMI activation at 3 urban emergency departments between 2010 and 2014. The Wilcoxon rank sum test and logistic regression were used to compare men and women regarding time to activation and proportion with times <15 minutes, respectively. RESULTS: Of 400 eligible patients, we excluded 61 (15%) with prehospital activations, 44 (11%) arrests, and 3 (1%) transfers. Of the remaining 292 patients, mean age was 61±13 years, 64% were men, 57% were black, and 37% arrived by ambulance. Median door to STEMI activation time was 7.0 minutes longer for women than for men (25.5 vs 18.5 minutes, P=.028). In addition, men were more likely than women to have a door to STEMI activation time <15 minutes (45% vs 28%, P=.006). After adjusting for race, hospital site, Emergency Severity Index triage level, arrival mode, and chief concern of chest pain, the odds of men having STEMI activation times <15 minutes were 1.9 times more likely than women. CONCLUSIONS: Women have longer median door to STEMI activation times than men. A significantly lower proportion of women (28% vs 45%) are treated per American Heart Association guidelines of door to STEMI activation <15 minutes when compared with men, adjusting for confounders. Further investigation may identify possible etiology of bias and potential areas for intervention.

Virus-templated assembly of porphyrins into light-harvesting nanoantennae.

Biological molecules can be used as versatile templates for assembling nanoscale materials because of their unique structures and chemical diversities. Supramolecular organization of molecular pigments, as is found in the natural light-harvesting antenna, has drawn attention for its potential applications to sensors, photocatalytic systems, and photonic devices. Here we show the arrangement of molecular pigments into a one-dimensional light-harvesting antenna using M13 viruses as scaffolds. Chemical grafting of zinc porphyrins to M13 viruses induces distinctive spectroscopic changes, including fluorescence quenching, the extensive band broadening and small red shift of their absorption spectrum, and the shortened lifetime of the excited states. Based on these optical signatures we suggest a hypothetical model to explain the energy transfer occurring in the supramolecular porphyrin structures templated with the virus. We expect that further genetic engineering of M13 viruses can allow us to coassemble other functional materials (e.g., catalysts and electron transfer mediators) with pigments, implying potential applications to photochemical devices.