"This is it this is our normal" - the voices of family members and first responders experiencing duty-related trauma in Ireland.

BACKGROUND: Compared to other occupational groups, first responders (FR) experience worse mental health outcomes due to duty-related trauma and occupational stressors. Despite their best efforts, they bring this stress home to friends and family. Consequently, FR and their supporters suffer from increased psychosocial difficulties and experience stigma and other barriers to help-seeking. Prior work offers little opportunity for open dialogue and shared understanding of the repercussions of this occupation for all members of the first responder community. In this qualitative study, we aimed to: (i) explore the lived experience of Irish FR and their family members (FM) related to occupational stressors, and (ii) identify opportunities to engage FM with existing organizational supports available for FR. METHODS: Using a community based participatory research (CBPR) approach, we conducted six focus groups involving a total of fourteen participants comprising FR, organizational representatives, and FM. All focus groups were audio recorded, transcribed, and analyzed using reflexive thematic analysis. FINDINGS: FR and FM shared their experiences of both joining and learning to live as members of the FR community in Ireland. Through our analysis, we identified a main theme of 'crossing thresholds', characterizing their transformative learning experiences. This learning experience includes recognizing the consequences of this new role for them as individuals and for their relationships. Participants also shared how they have learned to cope with the consequences of their roles and what they need to better support each other. CONCLUSIONS: FM are often unheard, hidden members of the first responder community in Ireland, highlighting an unmet need for FR organizations to acknowledge FM role in supporting FR and to provide them with the appropriate training and resources required. Training for new recruits needs to move beyond the tokenistic involvement of FM and encourage knowledge sharing among experienced and novice members. Cultural change is required to support help-seeking among FR and foster a sense of peer support and community among families.

Evaluation of a conserved tryptophanyl residue in donor substrate binding and catalysis by a phenol sulfotransferase (SULT1A1).

Structural determinations of members of the sulfotransferase (SULT) family suggest a direct interaction between a conserved tryptophanyl side chain and bound 3'-phosphoadenosine-5'-phosphate (PAP). We have prepared and purified mutants of the bovine SULT1A1, a very conserved homolog to the human SULT1A1, in which tryptophanyl-53 was sequentially trimmed to tyrosine, leucine, and alanine. Differential scanning fluorimetry indicated structural stabilities of the mutant proteins comparable to the wild type SULT1A1; however, less thermal stabilizations by PAP plus pentachlorophenol were observed with the mutants, suggesting weakened ligand binding. Protein fluorescence of the wild type enzyme decreased 6.5% upon binding PAP, whereas no changes occurred with the mutant enzymes. This reveals that W53, or its positional counterpart, has been the source of emission intensity changes used in previous investigations of other SULTs. Fluorescence resonance energy transfer from excited tryptophans to bound 7-hydroxycoumarin, as induced by PAP, indicated weakened binding of ligands to the mutant SULTs. This was also encountered and quantified in initial rate kinetic analyses. Ablation of the PAPS adenine-to-W53 ring interaction, shown by the W53A mutant enzyme, resulted in a 6.4-fold increase in KPAPS and a 92% decrease in kcat/KPAPS. Measured KPAPS values reveal the W53 indole ring contribution to PAPS binding to be 1.1 kcal/mol (4.6 kJ/mol). These results verify the structurally-inferred role for the π-π stacking interaction between PAP(S) and the conserved tryptophanyl residue in SULT1A1 and other members of the SULT family.

Isolation and identification of three new chromones from the leaves of Pimenta dioica with cytotoxic, oestrogenic and anti-oestrogenic effects.

CONTEXT: Pimenta dioica (L.) Merr. (Myrtaceae) is used in Costa Rican traditional medicine for women's health. Our previous work showed that P. dioica extracts were oestrogenic. OBJECTIVES: This work identifies phytochemicals from P. dioica that are responsible for the plant's oestrogen-like activities. MATERIALS AND METHODS: P. dioica leaves were collected in Costa Rica in 2005. Fractions resulting from chromatographic separation of a methanol extract were tested at 50 µg/mL in a competitive oestrogen receptor-binding assay. Active compounds were isolated by HPLC and identified by NMR and MS. Pure compounds were tested at 1 µM in the oestrogen-responsive SEAP reporter gene assay. The effects on cell viability, cytotoxicity and apoptosis were investigated in breast cancer (MCF-7 and SK-BR3) and gastric cancer (AGS and NCI-N87) cell lines using the ApoTox-Glo and Caspase-Glo assays and qPCR. RESULTS: Quercitrin and three new chromones, including a 2-phenoxychromone, 6,8-di-C-methylcapillarisin (1) were isolated and identified. Compound 1 caused a 6.2-fold increase in SEAP expression at 1 µM (p < 0.05). This activity was blocked by the ER antagonist ICI 182,780. Compound 2 caused a 6.0-fold increase in SEAP, inhibited the growth of MCF-7, AGS and NCI-N87 cells (IC50 54.27, 38.13 and 51.22 µg/mL, respectively), and induced apoptosis via caspase 8 and increased the Bax/Bcl-2 mRNA ratio in MCF-7 cells. Compound 3 was anti-oestrogenic in MCF-7 cells. DISCUSSION AND CONCLUSIONS: Compounds from P. dioica have oestrogenic, anti-oestrogenic and cytotoxic effects that may explain the ethnomedical use of this plant.

Association of a let-7 miRNA binding region of TGFBR1 with hereditary mismatch repair proficient colorectal cancer (MSS HNPCC).

The purpose of this study was to identify novel colorectal cancer (CRC)-causing alleles in unexplained familial CRC cases. In order to do so, coding regions in five candidate genes (MGMT, AXIN2, CTNNB1, TGFBR1 and TGFBR2) were sequenced in 11 unrelated microsatellite-stable hereditary non-polyposis CRC (MSS HNPCC) cases. Selected genetic variants were genotyped in a discovery set of 27 MSS HNPCC cases and 85 controls. One genetic variant, rs67687202, in TGFBR1 emerged as significant (P = 0.002), and it was genotyped in a replication set of 87 additional MSS HNPCC-like cases and 338 controls where it was also significantly associated with MSS HNPCC cases (P = 0.041). In the combined genotype data, rs67687202 was associated with a moderate increase in CRC risk (OR = 1.68; 95% CI = 1.13-2.50; P = 0.010). We tested a highly correlated SNP rs868 in 723 non-familial CRC cases compared with 629 controls, and it was not significantly associated with CRC risk (P = 0.370). rs868 is contained in a let-7 miRNA binding site in the 3'UTR of TGFBR1, which might provide a functional basis for the association in MSS HNPCC. In luciferase assays, the risk-associated allele for rs868 was associated with half the luciferase expression in the presence of miRNA let-7b-5p compared with protective allele, suggesting more binding of let-7b-5p and less TGFBR1 expression. Thus, rs868 potentially is a CRC risk-causing allele. Our results support the concept that rs868 is associated with lower TGFBR1 expression thereby increasing CRC risk.

Expression of connexin 26 and connexin 43 is reduced in Hirschsprung's disease.

BACKGROUND: Despite having an optimal pull-through operation, some children with Hirschsprung's disease (HSCR) continue to experience persistent bowel symptoms. Coordinated colonic electrical activity depends on intercellular communication between the enteric nerves, interstitial cells of Cajal (ICCs), smooth muscle cells, and fibroblast-like (platelet-derived growth factor receptor-alpha-positive) cells. Gap junctions are low-resistance channels composed of connexin (Cx) proteins which couple cells electrically and chemically. We aimed to evaluate the expression patterns of Cx26, Cx36, and Cx43 in the colon of children with HSCR and in healthy control colon. MATERIALS AND METHODS: Entire resected colonic specimens were collected from children undergoing pull-through surgery for HSCR (n = 10). Colonic controls were collected at colostomy closure in children with imperforate anus (n = 8). Distribution of Cx26, Cx36, and Cx43 was assessed using double-labeled immunofluorescence and confocal microscopy. Protein expression was quantified using Western blot analysis. RESULTS: Sparse punctate Cx36 expression was seen in the myenteric plexus in nerve trunks and some platelet-derived growth factor receptor-alpha-positive cell and ICC fibers. Cx26 was similarly distributed, although it was not coexpressed in ICCs. Cx43 was only coexpressed with ICCs in the myenteric plexus. Expression of Cx26 and Cx43 was markedly reduced in the aganglionic colon in HSCR compared to controls, while Cx26 expression was also moderately reduced in the ganglionic bowel in HSCR. CONCLUSIONS: Reduced expression of Cx26 and Cx43 is implicated in the pathophysiology of colonic dysmotility in the aganglionic bowel as well as, in the case of Cx26, the ganglionic bowel in HSCR.

Challenges in assessing the process-outcome link in practice.

The expanded use of clinical process-of-care measures to assess the quality of health care in the context of public reporting and pay-for-performance applications has led to a desire to demonstrate the value of such efforts in terms of improved patient outcomes. The inability to observe associations between improved delivery of clinical processes and improved clinical outcomes in practice has raised concerns about the value of holding providers accountable for delivery of clinical processes of care. Analyses that attempt to investigate this relationship are fraught with many challenges, including selection of an appropriate outcome, the proximity of the outcome to the receipt of the clinical process, limited power to detect an effect, small expected effect sizes in practice, potential bias due to unmeasured confounding factors, and difficulties due to changes in measure specification over time. To avoid potentially misleading conclusions about an observed or lack of observed association between a clinical process of care and an outcome in the context of observational studies, individuals conducting and interpreting such studies should carefully consider, evaluate, and acknowledge these types of challenges.

Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain.

BACKGROUND: Deaths due to prescription opioid overdoses have increased dramatically. High-quality guidelines could help clinicians mitigate risks associated with opioid therapy. PURPOSE: To evaluate the quality and content of guidelines on the use of opioids for chronic pain. DATA SOURCES: MEDLINE, National Guideline Clearinghouse, specialty society Web sites, and international guideline clearinghouses (searched in July 2013). STUDY SELECTION: Guidelines published between January 2007 and July 2013 addressing the use of opioids for chronic pain in adults were selected. Guidelines on specific settings, populations, and conditions were excluded. DATA EXTRACTION: Guidelines and associated systematic reviews were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and A Measurement Tool to Assess Systematic Reviews (AMSTAR), respectively, and recommendations for mitigating opioid-related risks were compared. DATA SYNTHESIS: Thirteen guidelines met selection criteria. Overall AGREE II scores were 3.00 to 6.20 (on a scale of 1 to 7). The AMSTAR ratings were poor to fair for 10 guidelines. Two received high AGREE II and AMSTAR scores. Most guidelines recommend that clinicians avoid doses greater than 90 to 200 mg of morphine equivalents per day, have additional knowledge to prescribe methadone, recognize risks of fentanyl patches, titrate cautiously, and reduce doses by at least 25% to 50% when switching opioids. Guidelines also agree that opioid risk assessment tools, written treatment agreements, and urine drug testing can mitigate risks. Most recommendations are supported by observational data or expert consensus. LIMITATION: Exclusion of non-English-language guidelines and reliance on published information. CONCLUSION: Despite limited evidence and variable development methods, recent guidelines on chronic pain agree on several opioid risk mitigation strategies, including upper dosing thresholds; cautions with certain medications; attention to drug-drug and drug-disease interactions; and use of risk assessment tools, treatment agreements, and urine drug testing. Future research should directly examine the effectiveness of opioid risk mitigation strategies. PRIMARY FUNDING SOURCE: California Department of Industrial Relations and California Commission on Health and Safety and Workers' Compensation.

Quantification of internal and external training load during a training camp in senior international female footballers.

OBJECTIVE: This study aimed to quantify the internal and external training load profile of an international training camp and identify any differences between positional groups or starting status. METHODS: 18 players were sampled using a global positioning system (GPS) and internal training load (TL) via session rate of perceived exertion (RPE). RESULTS: Internal and external training load variation was present across all six individual training sessions. Results indicated match day -7 (MD-7), had significantly (P= 0.001) less training volume (3339.5 m) than all other training sessions. MD-5 and MD-2 were the most intense (387.5 and 201 m very high speed running (VHSR) and 187.5 and 49 m sprint distance (SPD) respectively in combination with large volume (5933.5 and 5151.5 m). Differences in playing position and starting status were observed in MD-2. Forwards (FW) covered significantly greater distances of VHSR (P= 0.008) and SPD (P= 0.008) in comparison to midfielders (MF) whilst starters reported significantly (P = 0.013) higher internal training loads (TL). CONCLUSION: This study provides the first report on training load in elite female footballers during an international training camp including a competitive fixture highlighting the undulation of training loads across the individual training sessions, playing positions and starting status.

Turning to 'Trusted Others': A Narrative Review of Providing Social Support to First Responders.

First responders, such as paramedics and firefighters, encounter duty-related traumatic exposures, which can lead to post-traumatic stress (PTS). Although social support protects against PTS, we know little about how first responders' families, spouses/partners, friends, and care-partners (i.e., 'trusted others') provide social support. This narrative review explores support behaviors, coping strategies, and resources trusted others use to support first responders. A structured literature search yielded 24 articles. We used House's (1981) conceptual framework to inform our analysis. We identified three main themes: providing support, finding support, and support needs. Additionally, we describe trusted others' self-reported preparedness, coping strategies, and barriers to providing social support. We found that trusted others provided different types of support: (a) emotional (fostering a safe space, giving autonomy over recovery, facilitating coping mechanisms, prioritizing first responders' emotional needs); (b) instrumental (prioritizing first responders' practical needs, handling household tasks, supporting recovery); (c) appraisal (active monitoring, verbal reassurance, positive reframing), and (d) informational (seeking informal learning). In their role, trusted others sought formal (organizational) and informal (peer and personal) support and resources, alongside intrapersonal and interpersonal coping strategies. Identified barriers include inadequate communication skills, maladaptive coping, and disempowering beliefs. Thus, we offer practical, treatment, and social support recommendations.

Aberrant DNA methylation in hereditary nonpolyposis colorectal cancer without mismatch repair deficiency.

BACKGROUND & AIMS: Approximately half of the families that fulfill Amsterdam criteria for Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) do not have evidence of the germline mismatch repair gene mutations that define this syndrome and result in microsatellite instability (MSI). The carcinogenic pathways and the best diagnostic approaches to detect microsatellite stable (MSS) HNPCC tumors are unclear. We investigated the contribution of epigenetic alterations to the development of MSS HNPCC tumors. METHODS: Colorectal cancers were divided into 4 groups: (1) microsatellite stable, Amsterdam-positive (MSS HNPCC) (N = 22); (2) Lynch syndrome cancers (identified mismatch repair mutations) (N = 21); (3) sporadic MSS (N = 92); and (4) sporadic MSI (N = 46). Methylation status was evaluated for CACNAG1, SOCS1, RUNX3, NEUROG1, MLH1, and long interspersed nucleotide element-1 (LINE-1). KRAS and BRAF mutation status was analyzed. RESULTS: MSS HNPCC tumors displayed a significantly lower degree of LINE-1 methylation, a marker for global methylation, than any other group. Although most MSS HNPCC tumors had some degree of CpG island methylation, none presented a high index of methylation. MSS HNPCC tumors had KRAS mutations exclusively in codon 12, but none harbored V600E BRAF mutations. CONCLUSIONS: Tumors from Amsterdam-positive patients without mismatch repair deficiency (MSS HNPCC) have certain molecular features, including global hypomethylation, that distinguish them from all other colorectal cancers. These characteristics could have an important impact on tumor behavior or treatment response. Studies are underway to further assess the cause and effects of these features.

Susceptibility genetic variants associated with colorectal cancer risk correlate with cancer phenotype.

BACKGROUND & AIMS: Ten common low-penetrant genetic variants have been consistently associated with colorectal cancer (CRC) risk; little is known about the correlation between these variants and CRC phenotype. Characterization of such a correlation would improve CRC management and prevention programs. We assessed the association between these genetic variants and CRC phenotype in patients and modeled pairwise combinations to detect epistasis. METHODS: The validation population corresponded to a prospective, multicenter, population-based cohort (EPICOLON I) of 1096 patients with newly diagnosed CRC. The replication set was an independent, prospective, multicenter Spanish cohort (EPICOLON II) of 895 patients with newly diagnosed CRC. For individual single nucleotide polymorphism (SNP) association analyses, a multivariate method using logistic regression was applied in EPICOLON I and subsequently prospectively validated in EPICOLON II. Interactions between SNPs were assessed using the likelihood ratio test. RESULTS: Validated results confirmed that the C allele on 8q23.3 (rs16892766) was significantly associated with advanced-stage tumors (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.15-1.90; P value = 4.9 x 10(-3)). The G allele on 8q24.21 (rs6983267) was more common in patients with a familial history of CRC (OR, 2.02; 95% CI, 1.35-3.03; P value = 3.9 x 10(-4)). The combination of rs6983267 on 8q24.21 and rs9929218 on 16q22.2 was associated with a history of colorectal adenoma (carriers of GG and AA, respectively; OR, 2.28; 95% CI, 1.32-3.93; P = 5.0 x 10(-4)). CONCLUSIONS: CRC susceptibility variants at 8q23.3, 8q24.21, and 16q22.2 appear to be associated with cancer phenotype. These findings might be used to develop screening and surveillance strategies.

Emergency clinicians' knowledge, preparedness and experiences of managing COVID-19 during the 2020 global pandemic in Australian healthcare settings.

BACKGROUND: Emergency clinicians have a crucial role during public health emergencies and have been at the frontline during the COVID-19 pandemic. This study examined the knowledge, preparedness and experiences of Australian emergency nurses, emergency physicians and paramedics in managing COVID-19. METHODS: A voluntary cross-sectional study of members of the College of Emergency Nursing Australasia, the Australasian College for Emergency Medicine, and the Australasian College of Paramedicine was conducted using an online survey (June-September 2020). RESULTS: Of the 159 emergency nurses, 110 emergency physicians and 161 paramedics, 67.3-78% from each group indicated that their current knowledge of COVID-19 was 'good to very good'. The most frequently accessed source of COVID-19 information was from state department of health websites. Most of the respondents in each group (77.6-86.4%) received COVID-19 specific training and education, including personal protective equipment (PPE) usage. One-third of paramedics reported that their workload 'had lessened' while 36.4-40% of emergency nurses and physicians stated that their workload had 'considerably increased'. Common concerns raised included disease transmission to family, public complacency, and PPE availability. CONCLUSIONS: Extensive training and education and adequate support helped prepare emergency clinicians to manage COVID-19 patients. Challenges included inconsistent and rapidly changing communications and availability of PPE.

Evaluation of an Access-Risk-Knowledge (ARK) Platform for Governance of Risk and Change in Complex Socio-Technical Systems.

Three key challenges to a whole-system approach to process improvement in health systems are the complexity of socio-technical activity, the capacity to change purposefully, and the consequent capacity to proactively manage and govern the system. The literature on healthcare improvement demonstrates the persistence of these problems. In this project, the Access-Risk-Knowledge (ARK) Platform, which supports the implementation of improvement projects, was deployed across three healthcare organisations to address risk management for the prevention and control of healthcare-associated infections (HCAIs). In each organisation, quality and safety experts initiated an ARK project and participated in a follow-up survey and focus group. The platform was then evaluated against a set of fifteen needs related to complex system transformation. While the results highlighted concerns about the platform's usability, feedback was generally positive regarding its effectiveness and potential value in supporting HCAI risk management. The ARK Platform addresses the majority of identified needs for system transformation; other needs were validated in the trial or are undergoing development. This trial provided a starting point for a knowledge-based solution to enhance organisational governance and develop shared knowledge through a Community of Practice that will contribute to sustaining and generalising that change.

Impacts of a record-breaking storm on physical and biogeochemical regimes along a catchment-to-coast continuum.

The impacts of changes in climate are often most readily observed through the effects of extremes in local weather, effects that often propagate through multiple ecosystem levels. Precise effects of any extreme weather event depend not only on the type of event and its timing, but also on the ecosystem affected. Here the cascade of effects following the arrival of an atmospheric river (directed by record-breaking Storm Desmond) across terrestrial, freshwater and coastal zones is quantified, using the Burrishoole system on the Atlantic coast of Ireland as a natural observatory. We used a network of high-frequency in-situ sensors to capture in detail the effects of an unprecedented period of rainfall, high wind speeds and above-average winter air temperatures on catchment and estuarine dynamics. In the main freshwater lake, water clarity decreased and acidity increased during Storm Desmond. Surface heat input, due to a warm and moist above-lake air mass, was rapidly distributed throughout the water column. River discharge into the downstream coastal basin was estimated to be the highest on record (since 1976), increasing the buoyancy flux by an order of magnitude and doubling the water column stratification stability. Entrainment of salt into the outflowing freshwater plume exported resident salt from the inner estuarine basin, resulting in net salt loss. Here, the increased stratification markedly reinforced isolation of the bottom waters, promoting deoxygenation. Measurements of current between the inner estuarine basin and the adjacent coastal waters indicated a 20-fold increase in the volume of seaward flowing low-salinity water, as a result of storm rainfall over the watershed. Storm impacts spanned the full catchment-to-coast continuum and these results provide a glimpse into a potential future for hydrological systems where these severe hydroclimatic events are expected to occur more frequently.

The ED-PACT Tool Initiative: Communicating Veterans' Care Needs After Emergency Department Visits.

BACKGROUND: Communication failures between providers threaten patient safety. PURPOSE: We developed, implemented, and formatively evaluated the ED-PACT Tool, which uses the Veterans Health Administration's (VA) electronic health record to send messages from emergency department (ED) providers to primary care patient-aligned care team (PACT) registered nurses (RNs) for Veterans discharged home from the ED with urgent or specific follow-up needs. METHODS: We used Plan-Do-Study-Act quality improvement methodology. RESULTS: Between November 1, 2015, and November 30, 2017, the tool was used to send 4,899 messages in one local VA healthcare system (ED and associated primary care clinics). Formative evaluation revealed that providers and RNs perceive the tool as providing substantial benefit for coordinating post-ED care. Patient-aligned care team leaders reported that RN training and "buy-in" facilitated tool implementation, while insufficient staffing posed a barrier. Emergency department providers noted the advantage of having a standardized and reliable system for communicating with PACTs. CONCLUSIONS/IMPLICATIONS: The ED-PACT Tool encapsulates several best practices (standardized processes, "closed-loop" communication, embedding into workflow) to facilitate communication between VA ED and follow-up care providers. Our development process illustrates key lessons in quality improvement and innovation implementation including the value of using rapid-cycle improvement methodology, with interprofessional collaboration and representatives from intended spread sites.

Effects of cranberry extracts and ursolic acid derivatives on P-fimbriated Escherichia coli, COX-2 activity, pro-inflammatory cytokine release and the NF-kappabeta transcriptional response in vitro.

Cranberry, the fresh or dried ripe fruit of Vaccinium macrocarpon Ait. (Ericaceae), is currently used as adjunct therapy for the prevention and symptomatic treatment of urinary tract infections. Data from clinical trials suggest that extracts of cranberry or cranberry juice reduce the bacterial load of E. coli and also suppress the inflammatory symptoms induced by E. coli infections. A methanol extract prepared from 10 kg of dehydrated cranberries did not directly inhibit the growth of E coli strains ATCC 700336 or ATCC 25922 in concentrations up to 256 mug/mL in vitro. However, the methanol extract (CR-ME) inhibited the activity of cyclooxygenase-2, with an IC(50) of 12.8 mug/mL. Moreover, CR-ME also inhibited the NF-kappabeta transcriptional activation in human T lymphocytes with an IC(50) of 19.4 mug/mL, and significantly (p < 0.01) inhibited the release of interleukin (IL)-1beta, IL-6, IL-8 and tumor necrosis factor-alpha from E. coli lipopolysaccharide (LPS)-stimulated human peripheral blood mononuclear cells in vitro, at a concentration of 50 mug/mL. The extract had no effect on inducible nitric oxide synthase activity in the murine macrophage cell line RAW 264.7. The compounds responsible for this activity were identified using a novel LC-MS based assay as ursolic acid and ursolic acid derivatives. Taken together, these data suggest CR-ME and its constituent chemical compounds target specific pathways involved in E. coli-induced inflammation.

Protein Binding Characteristics of the Principal Green Tea Catechins: A QCM Study Comparing Crude Extract to Pure EGCG.

Label-free detection methods such as the quartz crystal microbalance (QCM) are well suited to the analysis of molecular interactions in complex mixtures such as crude botanical extracts. In the present study, the binding characteristics of epigallocatechin gallate (EGCG) and crude green tea extract solutions to bovine serum albumin (BSA) have been investigated. The adsorbed mass levels onto BSA-functionalized surfaces were measured at various solution concentrations. Langmuir and Freundlich isotherms were used to model the adsorption data. The Langmuir isotherm better described the adsorption behavior with correlations of 0.68 and 0.70 for the EGCG and the crude extract solutions, respectively. The better fit of the Langmuir model indicates that adsorption occurs homogeneously and that aggregation is negligible. The mass saturation is estimated to be 58% higher for the crude green tea solution as compared to the pure EGCG solution (7.9 ng/cm2 for green tea and 5 ng/cm2 for EGCG). The increased adsorption for the crude extract indicates that the additional tea chemical constituents are binding to alternate sites on the protein molecule and that competitive binding is a nondominant effect. However, a reduced adsorption rate for the crude extract was also observed, indicating some presence of competitive mechanisms. The results demonstrate the utility of the QCM for the analysis of protein binding in crude mixtures as well as pure compounds.

Teaching bedside ultrasound to medical students.

OBJECTIVE: Point-of-care ultrasound (POCUS) assists in the rapid diagnosis of conditions in the Emergency Department (ED). POCUS has been introduced to international medical curricula; however, there is no described implementation of clinically focused POCUS education in Australian medical schools. We wanted to investigate whether a formal curriculum can be effective and feasible in an Australian medical school. METHODS: Pre-post intervention study of a focused curriculum based on the Extended Focused Assessment with Sonography in Trauma (E-FAST) examination, consisting of online and practical teaching, was implemented for Year-4 and -5 medical students. An online questionnaire was used to measure knowledge, image interpretation and confidence prior to the intervention. After the intervention and ED placement, the questionnaire was repeated and students were assessed performing the E-FAST examination on a healthy volunteer. RESULTS: Twenty-seven students participated in both the pre-intervention and post-intervention questionnaires. There was a significant improvement in confidence in performing the E-FAST after the intervention [p < 0.001]. There was also a significant improvement in ultrasound knowledge and image interpretation skills. For the formative assessment, the mean score was 31.8 out of 33 and 22 of 27 students (82%) passed the assessment. There is no described implementation of clinically focused point-of-care ultrasound education in Australian medical schools CONCLUSIONS: We have demonstrated that a focused curriculum can improve POCUS knowledge and skills. The curriculum was feasible and well received. With global trends to include POCUS in medical education, Australian institutions should consider upskilling their medical graduates.

Who Has an Unsuccessful Observation Care Stay?

BACKGROUND: With the recent increase use of observation care, it is important to understand the characteristics of patients that utilize this care and either have a prolonged observation care stay or require admission. METHODS: We a conducted a retrospective cohort study utilizing 5% sample data from Medicare patients age ≥65 years that was nationally representative in the year 2013. We performed a generalized estimating equation (GEE) logistic regression analysis to evaluate the relationship between an unsuccessful observation stay (defined as either requiring an inpatient admission from observation or having a prolonged observation stay) compared to having successful observation care. Observation cut offs of "successful" vs. "unsuccessful" were based on the CMS 2 midnight rule. RESULTS: Of 154,756 observation stays in 2013, 19 percent (n = 29,604) were admitted to the inpatient service and 34,275 (22.2%) had a prolonged observation stay. The two diagnoses most likely to have an unsuccessful observation stay were intestinal infections (OR 1.56, 95% CI 1.32⁻1.83) and pneumonia (OR 1.26, 95% CI 1.13⁻1.41). CONCLUSION: We found patients placed in observation care with intestinal infections and pneumonia to have the highest odds of either being admitted from observation or having a prolonged observation stay.

Emergency Department Increased use of Observation Care for Elderly Medicare Patients.

BACKGROUND: Over the past decade, a growing number of older Medicare beneficiaries visit the Emergency Department (ED) and have been placed in observation care. We investigated and compared the prevalence and factors associated with patients age ≥ 65 years with Medicare insurance who are placed in the hospital, observation care, or discharged following an ED visit. METHODS: We conducted a retrospective cohort study using data from a nationally representative 5% sample of Medicare patients age ≥ 65 years during the year 2013. We performed multiple generalized estimating equation (GEE) logistic regression analyses to assess the relationship between placement in a hospital vs. discharge, observation care vs. discharge, and observation care vs. admission. RESULTS: Of 537,455 Medicare beneficiaries age ≥ 65 years who visited an ED in 2013, 48.0% (N= 258,083) were discharged, 10.5% (N=56,184) placed in observation care, and 41.5% (N=223,188) were admitted to the inpatient service following the ED visit. The top 2 diagnoses associated with placement in the hospital vs. discharge were ischemic heart disease and renal disease. Patients with symptomatic diagnoses such as chest pain and dizziness were more likely to be placed in observation care following an ED visit as compared to admission to the hospital. CONCLUSION: Compared to prior studies, we found a greater number of older Medicare ED patients placed in observation care and a lower number admitted to the hospital. Most common diagnoses of placement in observation care were symptom-based as compared to being admitted to the hospital which were disease-based.