Effective methods of teaching and learning in anatomy as a basic science: A BEME systematic review: BEME guide no. 44.

BACKGROUND: Anatomy is a subject essential to medical practice, yet time committed to teaching is on the decline, and resources required to teach anatomy is costly, particularly dissection. Advances in technology are a potential solution to the problem, while maintaining the quality of teaching required for eventual clinical application. AIM: To identify methods used to teach anatomy, including those demonstrated to enhance knowledge acquisition and retention. METHODS: PubMed, CINAHL, ERIC, Academic OneFile, ProQuest, SAGE journals and Scopus were search from the earliest entry of each database to 31 August 2015. All included articles were assessed for methodological quality and low quality articles were excluded from the study. Studies were evaluated by assessment scores, qualitative outcomes where included as well as a modified Kirkpatrick model. RESULTS: A total of 17,820 articles were initially identified, with 29 included in the review. The review found a wide variety of teaching interventions represented in the range of studies, with CAI/CAL studies predominating in terms of teaching interventions, followed by simulation. In addition to this, CAI/CAL and simulation studies demonstrated better results overall compared to traditional teaching methods and there is evidence to support CAI/CAL as a partial replacement for dissection or a valuable tool in conjunction with dissection. CONCLUSIONS: This review provides evidence in support of the use of alternatives to traditional teaching methods in anatomy, in particular, the use of CAI/CAL with a number of high quality, low risk of bias studies supporting this.

Hyperbaric oxygen for the treatment of nonhealing arterial insufficiency ulcers.

There is limited data regarding hyperbaric oxygen's effectiveness in the treatment of nonhealing arterial insufficiency ulcers. This study was designed to analyze healing rates and amputation rates in patients who underwent adjunctive hyperbaric oxygen for a nonhealing arterial insufficiency ulcer. A retrospective chart review was completed on patients who underwent hyperbaric oxygen for arterial insufficiency ulcers that failed to heal despite standard treatment. Information collected included complete ulcer healing, amputation, and patient characteristics. There were 82 patients identified. A majority did not have diabetes (84.1%). The overall rate of healing was 43.9%. The overall major amputation rate was 17.1%. The amputation rate among those who healed was 0% compared to 42.4% among those not healed (p < 0.0001). Dialysis was predictive of major amputation (p = 0.03). Our findings suggest hyperbaric oxygen can play a role in management of arterial insufficiency ulcers that have failed standard treatment. The overwhelming majority of these patients did not have diabetes, which allows this study to be translated to patients with a primary arterial insufficiency ulcer. These results support the use of hyperbaric oxygen for select nonhealing arterial insufficiency ulcers that have failed standard therapy and the need for a prospective pilot study.

Analysis of weight change and Borg rating of perceived exertion as measurements of runner health and safety during a 6-day, multistage, remote ultramarathon.

OBJECTIVE: To determine the feasibility of using weight change and Borg score as tools for monitoring runner health and safety during a multistage, remote ultramarathon. DESIGN: Observational cohort study of feasibility on nonblinded event participants. SETTING: Six-day, multistage, remote ultramarathon in Utah. PARTICIPANTS: Twenty-seven athletes in the 2012 Desert R.A.T.S. (Race Across the Sand) ultramarathon. ASSESSMENT OF RISK FACTORS: Participant weight, health conditions that limited race participation, such as fatigue or exhaustion, and Borg score were reviewed. MAIN OUTCOME MEASURES: Inability to complete a stage of the race (Did Not Finish status) or development of a clinically significant health condition during the race. Potential prognostic risk factors, such as a high Borg score and weight loss, were analyzed. RESULTS: An overall decrease in weight was observed over the course of the event. Median percent weight changes were losses of 2.96% (day 1), 7.42% (day 2), 2.21% (day 4), and 3.35% (day 6). There was no statistically significant difference in percent weight change between the 14 runners who finished the race and the 13 runners who did not finish the race (U = 73; z = 0.189; P = 0.85). Runners' ability to complete the race was related to the development of adverse health conditions (P = 0.004). Median Borg scores reported were 15 (day 1), 17 (day 2), 13 (day 3), 16 (day 4), and 15 (day 6). Only 2 racers who finished the entire event without adverse events ever gave a Borg score of ≥ 18. CONCLUSIONS: The feasibility of weight change as a tool for monitoring runner health and safety in this setting is limited, but the Borg rating of perceived exertion warrants further study as a potential field expedient tool for monitoring runner health and safety during a multiday, remote ultramarathon.

Middle ear barotrauma in hyperbaric oxygen therapy.

INTRODUCTION: Middle ear barotrauma (MEB) is a common complication of hyperbaric oxygen (HBO2) therapy. The purpose of this study was to determine the overall incidence of MEB and evaluate for differences in the incidence of MEB at different rates of compression (ROC). The study also sought to identify other potential risk factors for MEB. METHODS: A retrospective chart review was performed on patients undergoing HBO2 at an academic regional level 1 trauma center. The MEB overall incidence as well as incidence at different ROC were determined. RESULTS: 236 patients representing 4,981 treatments were analyzed. The overall incidence of MEB was 43.2%. There was no statistically significant difference in the incidence of MEB at different ROC. There was a statistically significant higher incidence of TEED 4 MEB in intubated patients (p < 0.0001). The vast majority of MEB was minor when considering severity based on overall lower TEED scores of 1 or 2 (84%). DISCUSSION: The overall incidence of MEB in this study is consistent with those previously reported. It is important to note that a vast majority of MEB was minor. This supports HBO2 as a safe treatment modality with minimal overall risk. The current study supports standardization of most treatment protocols to a ROC of 2 psi/minute.

Seizure incidence by treatment pressure in patients undergoing hyperbaric oxygen therapy.

INTRODUCTION: Hyperbaric oxygen (HBO2) therapy uses different maximum treatment pressures. A side effect of HBO2 is oxygen toxicity seizure. The purpose of this study was to determine the overall incidence of oxygen toxicity seizure and assess risk at different treatment pressures. METHOD: A retrospective chart review was performed on patients who underwent HBO2 at a university hospital and at an outpatient center. Statistical analysis was performed to determine overall incidence of seizure and identify risk factors including maximum treatment pressure. RESULTS: A total of 931 patients were identified representing a total of 23,328 treatments. The overall incidence of seizure was one in 2,121 treatments (five per 10,000). There were zero per 10,000 at 2.0 atmospheres absolute/atm abs (0/16,430), 15 per 10,000 at 2.4/2.5 atm abs (1/669) and 51 per 10,000 at 2.8 atm abs (1/197). There was a statistically significant difference for seizure between the different pressures (χ2 (2, 23,540) = 31.38, p < .001). DISCUSSION: The overall incidence of oxygen toxicity seizure in this study is consistent with recent reports. This study demonstrated a statistically significant increased risk of seizure with increasing treatment pressure. Treatment at higher pressure should be chosen based on demonstrable benefit with a clear understanding of increased risk with higher pressure.

Salinisphaera japonica sp. nov., a moderately halophilic bacterium isolated from the surface of a deep-sea fish, Malacocottus gibber, and emended description of the genus Salinisphaera.

A moderately halophilic, slightly acidophilic, aerobic bacterium, designated strain YTM-1(T), was isolated from the body surface of Malacocottus gibber. Cells were Gram-stain-negative, short rods or cocci, approximately 0.9-1.1 µm long and 1.0-1.8 µm wide. Strain YTM-1(T) was able to grow with 1-30% NaCl (optimum, 7.5-10%, w/v), at 4-30 °C (optimum, 20-25 °C) and at pH 3.8-9.5 (optimum, pH 5.0-5.5). Phylogenetic analysis based on 16S rRNA gene sequence similarities showed that strain YTM-1(T) belonged to the genus Salinisphaera with low similarity values to the type strains of recognized species of this genus (<94.8-94.4%). The polar lipids of strain YTM-1(T) consisted of diphosphatidylglycerol, phosphatidylcholine, phosphatidylglycerol, phosphatidylethanolamine, phosphatidylserine, three unknown phospholipids and one unknown lipid. The predominant isoprenoid quinone was Q-8. The major fatty acids were C19:0ω8c cyclo, C18:1ω7c, C16:1ω5c and C16:0. The DNA G+C content of strain YTM-1(T) was 67.3 mol%. These phylogenetic, physiological and chemotaxonomic data indicated that strain YTM-1(T) represents a novel species of the genus Salinisphaera, for which the name Salinisphaera japonica sp. nov. is proposed. The type strain is YTM-1(T) (=JCM 18087(T)=CECT 8012(T)). An emended description of the genus Salinisphaera is also proposed.

Evaluation of emergency medicine discharge instructions in pediatric head injury.

OBJECTIVES: Pediatric head trauma is a common occurrence. There is mounting evidence that even patients with minor head injury require limits on school activities and/or removal from sports and play to help speed recovery and limit morbidity. The objective of this study was to determine whether discharge instructions given to children who had sustained head injuries included information regarding activity restrictions, activity time constraints, and/or specifics of follow-up care. METHODS: This was a retrospective chart review of patients aged 2 to 18 years evaluated and treated for head injury during a 4-month period at a level I trauma center (volume ∼23,000 pediatric patients per year). Included were those children seen, evaluated, and diagnosed with any of the following: mild head injury, concussion, minor head trauma, or mild traumatic brain injury (mTBI). Subjects were excluded if there was a positive acute head injury computed tomography finding (other than findings of a simple linear skull fracture) or if the subject required admission. RESULTS: Among the 204 patients meeting eligibility, 95.1% received instruction to follow up with a physician, 82.8% received anticipatory guidance regarding expected symptoms, 15.2% received specific restriction time from sports, and 21.5% were removed from sports. Of these patients, 113 patients were determined "likely" to have sustained an mTBI. Patients with sports-related mTBI received return-to-sports restrictions (χ2 = 11.225, P < 0.008) and to remove the child from play (χ2 = 9.781, P < 0.004) as discharge instructions significantly more than did patients with motor vehicle accident or other mechanisms of injury. CONCLUSIONS: Children sustaining head injury were inadequately instructed to restrict athletic activities upon discharge. This is particularly true for patients who sustain an mTBI from non-sports-related activity.

Professional attitudes in regard to hyperbaric oxygen therapy for dental extractions in irradiated patients: a comparison of two specialties.

OBJECTIVES: Mandibular osteoradionecrosis (ORN) is a serious complication of radiation therapy. The current use of hyperbaric oxygen therapy (HBO2) to prevent ORN when dental extractions are performed has been called into question. We sought to determine the current acceptability and confidence in this treatment by practitioners from two different specialties. METHODS: We surveyed both hyperbaric medicine physicians and radiation oncologists regarding their views on the use of HBO2 for the prevention of ORN. Separate web-based anonymous surveys were sent via email invitation. These two groups were compared, including statistical analysis using the chi-square test when appropriate. RESULTS: 175 radiation oncologists and 118 hyperbaric medicine physicians participated. Among those not recommending HBO2, lack of evidence was cited by 52% of radiation oncologists and 38% of hyperbaric medicine physicians (chi2 = 5.0, p = 0.03, 95%, CI 1.9% to 25.6%). A majority of radiation oncologists (79%) and hyperbaric medicine physicians (85%) believe it is important that a new randomized controlled trial (RCT) is conducted (chi2 = 1.3, p = NS). CONCLUSIONS: While HBO2 has been used for decades, recent tissue-sparing radiation techniques and advanced surgical techniques are now calling into question the continued use of HBO2 for ORN prevention. Our results demonstrate that there is overwhelming support among responding practitioners for a new RCT.

Bacterial and archaeal diversity in two hot spring microbial mats from the geothermal region of Tengchong, China.

We investigated the bacterial and archaeal diversity in two hot spring microbial mats from the geothermal region of Tengchong in the Yunnan Province, China, using direct molecular analyses. The Langpu (LP) laminated mat was found by the side of a boiling pool with temperature of 60-65 °C and a pH of 8.5, while the Tengchong (TC) streamer mat consisted of white streamers in a slightly acidic (pH 6.5) hot pool outflow with a temperature of 72 °C. Four 16S rRNA gene clone libraries were constructed and restriction enzyme analysis of the inserts was used to identify unique sequences and clone frequencies. From almost 200 clones screened, 55 unique sequences were retrieved. Phylogenetic analysis showed that the LP mat consisted of a diverse bacterial population [Cyanobacteria, Chloroflexi, Chlorobia, Nitrospirae, 'Deinococcus-Thermus', Proteobacteria (alpha, beta and delta subdivisions), Firmicutes, Bacteroidetes and Actinobacteria], while the archaeal population was dominated by methanogenic Euryarchaeota and Crenarchaeota. In contrast, the TC streamer mat consisted of a bacterial population dominated by Aquificae, while the archaeal population also contained Korarchaeota as well as Crenarchaeota and methanogenic Euryarchaeota. These mats harboured clone sequences affiliated to unidentified lineages, suggesting that they are a potential source for discovering novel bacteria and archaea.

Rates of positive blood, urine, and cerebrospinal fluid cultures in children younger than 60 days during the vaccination era.

BACKGROUND: Fever is a common reason children present to the emergency department. The goal of this study was to determine the rates and the etiology of bacterial infection in children younger than 2 months during the vaccination era. METHODS: This is a retrospective chart review performed at a tertiary care hospital. Electronic medical records were used to identify patients who had a workup for fever/sepsis in the emergency department. The search was limited to identifying only children younger than 60 days. RESULTS: A total of 207 patients satisfied the inclusion/exclusion criteria. In children younger than 28 days, the blood culture-positive rate was 2.7% (range, 0.0%-6.4%), the urine culture-positive rate was 10.7% (range, 3.5%-17.8%), and the cerebrospinal fluid-positive rate (excluding enteroviral infections) was 0% (range, 0.0%-3.9%). In children 29 to 60 days, the blood culture-positive rate was 1.5% (range, 0.0%-3.6%), urine culture-positive rate was 8.5% (range, 3.7%-13.3%), and the cerebrospinal fluid-positive rate (excluding enteroviral infections) was 1.7% (range, 0.0%-5.0%). Urinary tract infections due to Escherichia coli were very common, whereas no cases of Haemophilus influenzae and one case of Streptococcus pneumoniae were detected. CONCLUSIONS: Urinary tract infections due to E. coli are very common in this age group. The classic pathogens H. influenzae and S. pneumoniae were essentially nonexistent in this study possibly because of herd immunity obtained through current vaccination practices.

Salarchaeum japonicum gen. nov., sp. nov., an aerobic, extremely halophilic member of the Archaea isolated from commercial salt.

Strain YSM-79(T) was isolated from commercial salt made from seawater in Yonaguni island, Okinawa, Japan. The strain is an aerobic, Gram-negative, chemo-organotrophic and extremely halophilic archaeon. Cells are short rods that lyse in distilled water. Growth occurs at 1.5-5.3 M NaCl (optimum 2.5-3.0 M), pH 5.0-8.8 (optimum pH 5.2-6.3) and 20-55 °C (optimum 40 °C). Mg²âº is required for growth, with maximum growth at 200-300 mM Mg²âº. Polar lipid analysis revealed the presence of phosphatidylglycerol, phosphatidylglycerophosphate methyl ester, sulfated diglycosyl diether-1 and five unidentified glycolipids. The G+C content of the DNA was 64 mol%. On the basis of 16S rRNA gene sequence analysis, strain YSM-79(T) was determined to be a member of the family Halobacteriaceae, with the closest related genus being Halobacterium (94 % sequence identity). In addition, the rpoB' gene sequence of strain YSM-79(T) had <88 % sequence similarity to those of other members of the family Halobacteriaceae. The results of phenotypic, chemotaxonomic and phylogenetic analysis suggested that strain YSM-79(T) should be placed in a new genus, Salarchaeum gen. nov., as a representative of Salarchaeum japonicum sp. nov. The type strain is YSM-79(T) ( = JCM 16327(T)  = CECT 7563(T)).

Comparison of a modified longitudinal simulation-based advanced cardiovascular life support to a traditional advanced cardiovascular life support curriculum in third-year medical students.

BACKGROUND: Simulation is an effective tool for teaching medical students in cardiac arrest management. PURPOSE: The purpose of this article is to compare the efficacy of a traditional Advanced Cardiovascular Life Support (ACLS) course versus a modified longitudinal ACLS course using high-fidelity simulation in medical students. METHODS: One group enrolled in a 2-day traditional ACLS course while another group participated in independent learning over 2 weeks and 2 simulation sessions using Laerdal Sim-Man. The modified curriculum also included environmental fidelity with simulation, access to materials electronically, smaller class sizes, and integration of real experiences in the Emergency Department into their learning. Student performance was measured with a scripted, videotaped mega code, followed by a survey. RESULTS: We enrolled 21 students in a traditional ACLS program and 29 students in the simulation-based program (15 and 26 videos available for analysis). There was no difference in Time to Initiate CPR or Time to Shock between the groups, but the modified curriculum group demonstrated higher performance scores. They also felt better prepared to run the code during a simulation and in a hospital setting compared to students in the traditional ACLS curriculum. CONCLUSIONS: Students in a modified longitudinal simulation-based ACLS curriculum demonstrated better proficiency in learning ACLS compared to a traditional curriculum.

Natronoarchaeum mannanilyticum gen. nov., sp. nov., an aerobic, extremely halophilic archaeon isolated from commercial salt.

Strain YSM-123(T) was isolated from commercial salt made from Japanese seawater in Niigata prefecture. Optimal NaCl and Mg(2+) concentrations for growth were 4.0-4.5 M and 5 mM, respectively. The isolate was a mesophilic and slightly alkaliphilic haloarchaeon, whose optimal growth temperature and pH were 37 °C and pH 8.0-9.0. Phylogenetic analysis based on 16S rRNA gene sequence analysis suggested that strain YSM-123(T) is a member of the phylogenetic group defined by the family Halobacteriaceae, but there were low similarities to type strains of other genera of this family (≤90 %); for example, Halococcus (similarity <89 %), Halostagnicola (<89 %), Natronolimnobius (<89 %), Halobiforma (<90 %), Haloterrigena (<90 %), Halovivax (<90 %), Natrialba (<90 %), Natronobacterium (<90 %) and Natronococcus (<90 %). The G+C content of the DNA was 63 mol%. Polar lipid analysis revealed the presence of phosphatidylglycerol, phosphatidylglycerophosphate methyl ester, disulfated diglycosyl diether and an unknown glycolipid. On the basis of the data presented, we propose that strain YSM-123(T) should be placed in a new genus and species, Natronoarchaeum mannanilyticum gen. nov., sp. nov. The type strain of Natronoarchaeum mannanilyticum is strain YSM-123(T) (=JCM 16328(T) =CECT 7565(T)).

Mass-gathering medical care: retrospective analysis of patient presentations over five years at a multi-day mass gathering.

INTRODUCTION: There is a scarcity of analytical data regarding mass-gathering medical care. The purpose of this study was to identify and evaluate the range and nature of illness and injury for patrons of an annual, multi-day, mass gathering. METHODS: Encounter data from all patients seen by emergency physicians at the New York State Fair Infirmary during the past five years were analyzed. From these data, a category list was consolidated to 36 reasons for the visit based on chief complaint, nursing notes, and physician notes. The most common reasons for being seen by a physician were analyzed to determine age and gender discrepancies. RESULTS: The average number of attendees at the Fair per year from 2004-2008 was 950,973. Emergency physicians evaluated a total of 2,075 patients from 2004-2008. The average patient presentation rate over the past four years (2005-2008) was 4.8 +/-1.1/10,000 patrons. The average transport to hospital rate over the past four years was 2.7 +/-1.1/100,000 patrons. The average age of all patients seen was 34.4 +/-21.6 years, and 58.1% of the patients were female. The most common reasons to seek medical attention included: dehydration/heat-related illness (11.4%); abrasion/laceration (10.6%); and fall-related injury (10.2%). Two groups, dehydration/heat-related illness 74% (t (4) = 2.90, p <0.05), and fall-related injury (68%; t (4) = 5.17, p <0.05) were disproportionately female. There also was a direct relationship between age and female gender within the fall-related injury category (X(2) (1, n = 213) = 11.41, p <0.05). CONCLUSIONS: Patron data from fairs and expositions is a valuable resource for studying mass-gathering medical care. A majority (58%) of patients seen at the infirmary were female. The most common reason for being seen was dehydration/heat-related illness, which heavily favored females, but favored no age groups. The abrasion/laceration category did not contribute to the gender discrepancy. Patients who fell tended to be females >40 years of age. Further analysis is required to determine the reason for the gender discrepancies. Planners of multi-day mass gatherings should develop public education programs and evaluate their impact on the at-risk populations identified by this analysis.

Metagenomics and recovery of enzyme genes from alkaline saline environments.

Enzymes functioning at alkaline pH are widely used in the detergent industry as additives to improve the stain removal properties of domestic and industrial cleaning products. This industry provides by far the major mass market for enzymes. With constantly changing formulations in detergents and concerns over energy demands, new and improved enzymes are constantly in demand. Soda lakes host dense populations of alkali-loving microbes and, as such, provide vast reservoirs of potentially useful enzymes for such an industry. Traditional recovery methods for new enzymes have involved the isolation of microbes, preferably from a compatible chemical environment such as a soda lake, followed by screening of the isolates for useful enzymic activity. At least two commercially significant enzymes originating from soda lake microbes have been marketed following this route. However, the failure to cultivate more than a small percentage of microbes from most environments necessarily markedly reduces the recovery of new enzymes. In recent years, interest has focussed on more comprehensive recovery methods based around detecting appropriate enzyme genes in nucleic acids extracted from potentially useful sites, thus maximizing coverage of the whole genetic resource in a particular biotope. Here we review progress to date in soda lake biotopes and discuss ways the field may develop in the future.

View from the door: Making pediatric transport decisions based on first impressions.

INTRODUCTION: The primary goal of the Pediatric Assessment Triangle (PAT) is to objectify the "view from the door." Although the PAT is widely taught to prehospital providers and health-care professionals, the tool has not yet been validated. Before one can study the validity of the PAT, one needs to fully describe the practicality and functionality of the tool by exploring whether it's being used, and if so, how it's being used. The primary objective of this study was to determine if experienced providers can use the information gathered from the "view from the door" to make transport decisions on pediatric patients, and if that information fits in with the PAT. METHODS: This is a study using ethnographic analysis strategies for development of themes. A convenience group of 12 EMTs was recruited to observe two videos of pediatric patients and make a transport decision based on their observations. RESULTS: The mean time to transport decision was 12.25 seconds with a standard deviation of 8.8 seconds. Medics chose to "load and go" in 71% of the cases, and there was no correlation between CUPS status and transport decision as measured by chi square analysis. The information used most frequently to make transport decisions by medics in this study included: a simultaneous airway/breathing assessment, a level of consciousness assessment, a circulatory status assessment, a treatment plan and an anticipation of negative outcomes. CONCLUSIONS: The data from this study support that there are several features of the "view from the door" that experienced prehospital providers are using to make transport decisions on pediatric patients, and they fit in with the PAT. The data also support that the tool is a time-efficient method of triaging patients.

Microbial biogeography of six salt lakes in Inner Mongolia, China, and a salt lake in Argentina.

We used cultivation-independent methods to investigate the prokaryotic biogeography of the water column in six salt lakes in Inner Mongolia, China, and a salt lake in Argentina. These lakes had different salt compositions and pH values and were at variable geographic distances, on both local and intercontinental scales, which allowed us to explore the microbial community composition within the context of both contemporary environmental conditions and geographic distance. Fourteen 16S rRNA gene clone libraries were constructed, and over 200 16S rRNA gene sequences were obtained. These sequences were used to construct biotic similarity matrices, which were used in combination with environmental similarity matrices and a distance matrix in the Mantel test to discover which factors significantly influenced biotic similarity. We showed that archaeal biogeography was influenced by contemporary environmental factors alone (Na+, CO3(2-), and HCO3(-) ion concentrations; pH; and temperature). Bacterial biogeography was influenced both by contemporary environmental factors (Na+, Mg2+, and HCO3(-) ion concentrations and pH) and by geographic distance.