Data and debriefing observations on healthcare simulation to prepare for the COVID-19 pandemic.

We report on data and debriefing observations in the context of an immersive simulation conducted to (a) train clinicians and (b) test new protocols and kits, developed in table-top exercises without prior clinical experience to fit anticipated clinical encounters in the setting of the rapidly expanding COVID-19 pandemic. We simulated scenarios with particular relevance for anesthesiology, perioperative and critical care, including (1) cardiac arrest, (2) emergency airway management, (3) tele-instruction for remote guidance and supervision, and (4) transporting an intubated patient. Using a grounded theory approach, three authors (MHA, DLR, EHS) developed emergent themes. First alone and then together, we sought consensus in uncovering overarching themes and constructs from the debriefings. We thus performed an informal qualitative thematic analysis based in a critical realist epistemological position - the understanding that our findings, while real, are affected by situational variables and the observer's perspective[1,2]. We compared data from videos and triangulated the data by member checking. All participants and course instructors volunteered to participate in this educational project and contributed as co-authors to this manuscript. During debriefing, we applied crisis resource management concepts including situation awareness, prioritization of tasks, and clear communication practices, conducting the debriefing with emphasis on current TeamStepps 2.0 terminology and concepts. [3,4] In addition, we re-evaluated formerly familiar processes, as shortcomings of protocols, kits, and interdisciplinary cooperation became apparent. The data provide detailed observations on how immersive simulation and debriefing among peers mitigated the unfamiliarity of individual clinicians and the organization at large with the demands of an unprecedented healthcare crisis. We also observed and report on the anxiety caused by resource constraints, risk to clinicians in the face of limited personal equipment, and the overall uncertainty surrounding COVID-19. We began to summarize, interpret, critique, and discuss our data and debriefing observations in a rapid co-publication in the Journal of Clinical Anesthesia. [Healthcare Simulation to Prepare for the COVID-19 Pandemic][5].

Farnesol is utilized for isoprenoid biosynthesis in plant cells via farnesyl pyrophosphate formed by successive monophosphorylation reactions.

The ability of Nicotiana tabacum cell cultures to utilize farnesol (F-OH) for sterol and sesquiterpene biosynthesis was investigated. [(3)H]F-OH was readily incorporated into sterols by rapidly growing cell cultures. However, the incorporation rate into sterols was reduced by greater than 70% in elicitor-treated cell cultures whereas a substantial proportion of the radioactivity was redirected into capsidiol, an extracellular sesquiterpene phytoalexin. The incorporation of [(3)H]F-OH into sterols was inhibited by squalestatin 1, suggesting that [(3)H]F-OH was incorporated via farnesyl pyrophosphate (F-P-P). Consistent with this possibility, N. tabacum proteins were metabolically labeled with [(3)H]F-OH or [(3)H]geranylgeraniol ([(3)H]GG-OH). Kinase activities converting F-OH to farnesyl monophosphate (F-P) and, subsequently, F-P-P were demonstrated directly by in vitro enzymatic studies. [(3)H]F-P and [(3)H]F-P-P were synthesized when exogenous [(3)H]F-OH was incubated with microsomal fractions and CTP. The kinetics of formation suggested a precursor-product relationship between [(3)H]F-P and [(3)H]F-P-P. In agreement with this kinetic pattern of labeling, [(32)P]F-P and [(32)P]F-P-P were synthesized when microsomal fractions were incubated with F-OH and F-P, respectively, with [gamma-(32)P]CTP serving as the phosphoryl donor. Under similar conditions, the microsomal fractions catalyzed the enzymatic conversion of [(3)H]GG-OH to [(3)H]geranylgeranyl monophosphate and [(3)H]geranylgeranyl pyrophosphate ([(3)H]GG-P-P) in CTP-dependent reactions. A novel biosynthetic mechanism involving two successive monophosphorylation reactions was supported by the observation that [(3)H]CTP was formed when microsomes were incubated with [(3)H]CDP and either F-P-P or GG-P-P, but not F-P. These results document the presence of at least two CTP-mediated kinases that provide a mechanism for the utilization of F-OH and GG-OH for the biosynthesis of isoprenoid lipids and protein isoprenylation.

Prediction of 222Rn from topography in Pennsylvania.

The relationships of Rn levels in basements and first floors of homes to topographic location in a northeastern ridge and valley section of Pennsylvania were investigated. Topographic variables relating to elevation and slope were quantified and related to house Rn levels using both conventional and classification and regression tree (CART) analyses. The original interest was in using topographic correlates to estimate missing values in epidemiologic studies. In this area, Rn levels are usefully predicted by relative and absolute elevations and nearness to hills and ridges. Three- to fourfold differences in geometric mean Rn levels can be obtained for categories representing significant portions of the population of houses. The relationship of first-floor to basement Rn levels was found to be curvilinear and modestly affected by topography.

Precocious myocardial infarction after radiation treatment for Hodgkin's disease.

A 26-year-old man received extensive cardiac radiation in the course of treatment of mediastinal Hodgkin's disease, and six years later, he experienced an acute myocardial infarction. Angiographic studies demonstrated extensive atherosclerotic abnormalities in the coronary arterial system. It is suggested that radiation-induced injury was a provocation of these precocious arterial abnormalities.