Feasibility of the Transport PLUS intervention to improve the transitions of care for patients transported home by ambulance: a non-randomized pilot study.

BACKGROUND: The growing population of patients over the age of 65 faces particular vulnerability following discharge after hospitalization or an emergency room visit. Specific areas of concern include a high risk for falls and poor comprehension of discharge instructions. Emergency medical technicians (EMTs), who frequently transport these patients home from the hospital, are uniquely positioned to aid in mitigating transition of care risks and are both trained and utilized to do so using the Transport PLUS intervention. METHODS: Existing literature and focus groups of various stakeholders were utilized to develop two checklists: the fall safety assessment (FSA) and the discharge comprehension assessment (DCA). EMTs were trained to administer the intervention to eligible patients in the geriatric population. Using data from the checklists, follow-up phone calls, and electronic health records, we measured the presence of hazards, removal of hazards, the presence of discharge comprehension issues, and correction or reinforcement of comprehension. These results were validated during home visits by community health workers (CHWs). Feasibility outcomes included patient acceptance of the Transport PLUS intervention and accuracy of the EMT assessment. Qualitative feedback via focus groups was also obtained. Clinical outcomes measured included 3-day and 30-day readmission or ED revisit. RESULTS: One-hundred three EMTs were trained to administer the intervention and participated in 439 patient encounters. The intervention was determined to be feasible, and patients were highly amenable to the intervention, as evidenced by a 92% and 74% acceptance rate of the DCA and FSA, respectively. The majority of patients also reported that they found the intervention helpful (90%) and self-reported removing 40% of fall hazards; 85% of such changes were validated by CHWs. Readmission/revisit rates are also reported. CONCLUSIONS: The Transport PLUS intervention is a feasible, easily implemented tool in preventative community paramedicine with high levels of patient acceptance. Further study is merited to determine the effectiveness of the intervention in reducing rates of readmission or revisit. A randomized control trial has since begun utilizing the knowledge gained within this study.

Difficult Delivery and Neonatal Resuscitation: A Novel Simulation for Emergency Medicine Residents.

INTRODUCTION: Newborn delivery and resuscitation are rare, but essential, emergency medicine (EM) skills. We evaluated the effect of simulation on EM residents' knowledge, confidence, and clinical skills in managing shoulder dystocia and neonatal resuscitation. METHODS: We developed a novel simulation that integrates a shoulder dystocia with neonatal resuscitation and studied a convenience sample of EM residents. Each 15-minute simulation was run with one learner, a simulated nurse, and a standardized patient in situ in the emergency department. The learner was required to reduce a shoulder dystocia and then perform neonatal resuscitation. We debriefed with plus/delta format, standardized teaching points, and individualized feedback. We assessed knowledge with a nine-question multiple choice test, confidence with five-point Likert scales, and clinical performance using a checklist of critical actions. Residents repeated all measures one year after the simulation. RESULTS: A total of 23 residents completed all measures. At one-year post-intervention, residents scored 15% higher on the knowledge test. All residents increased confidence in managing shoulder dystocia on a five-point Likert scale (1.4 vs 2.8) and 80% increased confidence in performing neonatal resuscitation (1.8 vs 3.0). Mean scores on the checklist of critical actions improved by 19% for shoulder dystocia and by 27% for neonatal resuscitation. CONCLUSION: Implementing simulation may improve EM residents' knowledge, confidence, and clinical skills in managing shoulder dystocia and neonatal resuscitation.

Type-I prenyl protease function is required in the male germline of Drosophila melanogaster.

Many proteins require the addition of a hydrophobic prenyl anchor (prenylation) for proper trafficking and localization in the cell. Prenyl proteases play critical roles in modifying proteins for membrane anchorage. The type I prenyl protease has a defined function in yeast (Ste24p/Afc1p) where it modifies a mating pheromone, and in humans (Zmpste24) where it has been implicated in a disease of premature aging. Despite these apparently very different biological processes, the type I prenyl protease gene is highly conserved, encoded by a single gene in a wide range of animal and plant groups. A notable exception is Drosophila melanogaster, where the gene encoding the type I prenyl protease has undergone an unprecedented series of duplications in the genome, resulting in five distinct paralogs, three of which are organized in a tandem array, and demonstrate high conservation, particularly in the vicinity of the active site of the enzyme. We have undertaken targeted deletion to remove the three tandem paralogs from the genome. The result is a male fertility defect, manifesting late in spermatogenesis. Our results also show that the ancestral type I prenyl protease gene in Drosophila is under strong purifying selection, while the more recent replicates are evolving rapidly. Our rescue data support a role for the rapidly evolving tandem paralogs in the male germline. We propose that potential targets for the male-specific type I prenyl proteases include proteins involved in the very dramatic cytoskeletal remodeling events required for spermatid maturation.