ß-Glucan exacerbates allergic asthma independent of fungal sensitization and promotes steroid-resistant TH2/TH17 responses.

BACKGROUND: Allergic sensitization to fungi has been associated with asthma severity. As a result, it has been largely assumed that the contribution of fungi to allergic disease is mediated through their potent antigenicity. OBJECTIVE: We sought to determine the mechanism by which fungi affect asthma development and severity. METHODS: We integrated epidemiologic and experimental asthma models to explore the effect of fungal exposure on asthma development and severity. RESULTS: We report that fungal exposure enhances allergen-driven TH2 responses, promoting severe allergic asthma. This effect is independent of fungal sensitization and can be reconstituted with ß-glucan and abrogated by neutralization of IL-17A. Furthermore, this severe asthma is resistant to steroids and characterized by mixed TH2 and TH17 responses, including IL-13+IL-17+CD4+ double-producing effector T cells. Steroid resistance is dependent on fungus-induced TH17 responses because steroid sensitivity was restored in IL-17rc-/- mice. Similarly, in children with asthma, fungal exposure was associated with increased serum IL-17A levels and asthma severity. CONCLUSION: Our data demonstrate that fungi are potent immunomodulators and have powerful effects on asthma independent of their potential to act as antigens. Furthermore, our results provide a strong rationale for combination treatment strategies targeting IL-17A for this subgroup of fungus-exposed patients with difficult-to-treat asthma.

Disaster Preparedness Training for Emergency Medicine Residents Using a Tabletop Exercise.

Introduction: Emergency medicine (EM) physicians serve at the frontline of disasters in our communities. The 2016 Model of Clinical Practice according to the American Board of EM identifies disaster management as an integral task of EM physicians. We described a low-cost and feasible tabletop exercise to implement such training for EM residents. Methods: The exercise took place during 2 hours of resident didactic time. A lecture introduced the incident command system (ICS) and triage concepts, followed by a tabletop scenario with a map of a disaster scene or emergency department. Facilitators presented situational prompts of tasks for residents to address during the exercise. These exposed residents to challenges in disaster scenarios, such as surge and limited resources. The exercise concluded with a debrief and short lecture reviewing scenario-specific topics and challenges. Residents completed an online pre- and postexercise assessment, evaluating knowledge and perceptions of disaster scenario management. Results: Eighteen residents participated in this exercise. The response rates to the pre- and postsurvey were 76% and 72% respectively. Using a Mann Whitney U test, no statistically significant difference was demonstrated on the medical knowledge component of the survey. There was, however, a statistically significant increase in perceived confidence of the residents' ability to manage disaster incidents. Discussion: We developed a simple exercise that is an easily adaptable and practical option for introduction to disaster preparedness training. These concepts are difficult to teach and assess among learners, however it remains an important component of education for EM physicians-in-training.

Trends in musculoskeletal imaging in trauma patients: how has our practice changed over time?

OBJECTIVES: The purpose of the study was to review diagnostic imaging in trauma patients. We hypothesized that diagnostic musculoskeletal imaging has increased over time, but at a lesser rate than radiography performed for other purposes. Two trauma centers were compared. DESIGN: Retrospective multicenter study. SETTING: Two level 1 trauma centers. PATIENTS/PARTICIPANTS: Five hundred patients per year from each trauma centers were reviewed for 2002, 2005, and 2008. MAIN OUTCOME MEASUREMENTS: Effective doses [millisieverts (mSv)] and total charges for radiography were calculated. RESULTS: Most imaging was performed within 24 hours of injury. In 2002, 15% of all radiographic studies were computed tomography (CT) scans compared with 33% in 2008 (P < 0.0001). Center 1 used more CT, and center 2 used more projection (plain) radiography. The percentage of musculoskeletal CTs increased from 26% in 2002 to 49% in 2008 (P < 0.0001), without change in patient acuity. The mean effective dose per patient was 17.3 mSv in 2002, 30.0 mSv in 2005, and 34.1 mSv in 2008 (P < 0.001). The percentage of total dose attributable to musculoskeletal studies increased from 25% in 2002, to 29% in 2005, and 31% in 2008 (P < 0.001). Mean total charges per patient were $4529 in 2002; $6922 in 2005; and $7750 in 2008 (P < 0.001), with higher 2008 mean charges at center 1 versus 2 ($8694 vs. $6806, P = 0.001), primarily because of more CT scans. CONCLUSIONS: The number of diagnostic imaging tests, radiation dose, and related charges in trauma patients increased over time at both trauma centers, with CT scans accounting for most of the radiation dose and costs. A shift toward more advanced imaging from conventional projection radiography was noted at both trauma centers. Effective dose per patient more than doubled over the course of study at center 1. By 2008, half of all radiographic studies were for musculoskeletal purposes. Previous studies have suggested an increased risk of cancer with exposures of 20-40 mSv, making the mean total radiation doses in excess of 30.0 mSv since 2005 of great concern. Variability in ordering patterns between the 2 centers with similar patient acuity suggests opportunity for discussion about indications for utilization, which could result in lower radiation doses and fewer expenses.