Anesthesia in medical school: A simulation-based curriculum proposal

Introduction Most medical students are not familiar with Anesthesiology, as it is infrequently addressed properly in medical school curricula. However, anesthesiology skills are widely practiced across specialties and commonly performed by general practitioners. Currently, anesthesia curricula are often based on shadowing and lectures without emphasizing relevant skills, behaviors, and attitudes, whereas simulation-based curricula enable a holistic evaluation of the trainee. Objective To implement and assess the perceptions of students and professors of a novel simulation-based anesthesiology curriculum. Methods A descriptive study was planned for evaluating the new proposal. A simulation-based 3-week curriculum was organized using a blended course with skill laboratories. We designed flipped classroom-based lectures (2 weeks) combined with activities using standardized patients, manikins, and hybrid scenarios (1 week). After each activity, feedback was given by an anesthesiologist, as well as individual grading and a survey based on the Kirkpatrick levels. Results From June to November 2020, 53 students were enrolled in the clerkship. Each week, every group of 6-8 students was assigned to the same specialist to perform the activities and track individual progress. The response rate of the survey was 83%. Across the levels of Kirkpatrick, there was an excellent opinion of the activities, as well as a high similarity between the perception of both students and professors. Conclusion Our simulation-based curriculum, which was highly appraised by students and professors, was found to be feasible, appealing, and offered a good introduction to the principles and practices of anesthesiology to medical students.

Introducción: La mayoría de los estudiantes de medicina no están familiarizados con la Anestesiología, ya que la materia pocas veces se aborda adecuadamente en el programa académico de la facultad de medicina. Sin embargo, las habilidades en anestesiología son ampliamente utilizadas por los médicos generales. En la actualidad los currículos de anestesiología suelen basarse en prácticas y conferencias donde no se enfatizan las destrezas pertinentes, las conductas y las actitudes, mientras que los currículos basados en simulación permiten una evaluación integral del aprendiz. Objetivo: Implementar y evaluar las percepciones de estudiantes y de los profesores de un novedoso plan de estudios de anestesiología basado en la simulación. Métodos: Se diseñó un estudio descriptivo para valorar la nueva propuesta. Se organizó un plan de estudios de 3 semanas, basado en simulación, utilizando un curso mixto con habilidades de laboratorio. Diseñamos conferencias basadas en el modelo de aula invertida (2 semanas), combinadas con actividades basadas en pacientes estandarizados, maniquíes y escenarios híbridos (1 semana). Luego de cada actividad, un anestesiólogo ofrecía su retroalimentación, así como calificaciones individuales y una encuesta basada en los niveles de Kirkpatrick. Resultados: Se inscribieron 53 estudiantes en la pasantía de junio a noviembre de 2020. Cada semana se asignaba un grupo de 6-8 estudiantes a un mismo especialista para llevar a cabo las actividades y hacer un seguimiento al progreso alcanzado de manera individual. La tasa de respuesta de la encuesta fue de 83%. En todos los niveles de Kirkpatrick, hubo una excelente opinión sobre las actividades y una elevada similitud en la percepción, tanto de los estudiantes como de los profesores. Conclusión: Nuestro currículo basado en simulación fue muy bien valorado por estudiantes y profesores y se consideró factible, atractivo y que ofrecía a los estudiantes una buena introducción a los principios y prácticas de la anestesiología.

Methicillin-Susceptible, Vancomycin-Resistant Staphylococcus aureus, Brazil.

We report characterization of a methicillin-susceptible, vancomycin-resistant bloodstream isolate of Staphylococcus aureus recovered from a patient in Brazil. Emergence of vancomycin resistance in methicillin-susceptible S. aureus would indicate that this resistance trait might be poised to disseminate more rapidly among S. aureus and represents a major public health threat.

Resistencia a antibióticos de última línea en cocos Gram positivos: la era posterior a la vancomicina / Resistance to "last resort" antibiotics in Gram-positive cocci: The post-vancomycin era

En los últimos años se han desarrollado nuevas alternativas para el tratamiento de infecciones por patógenos Gram positivos multirresistentes, entre los cuales Staphylococcus aureus resistente a la meticilina (SARM) y los enterococos resistentes a la vancomicina (ERV) se consideran un verdadero reto terapéutico, y aunque el uso de la vancomicina en infecciones graves causadas por SARM ha generado serias dudas en los últimos años, continúa siendo escasa la información clínica de respaldo al uso de agentes terapéuticos que la superen en eficacia. El linezolid, la daptomicina y la tigeciclina son agentes que tienen actividad contra los cocos Gram positivos y que fueron aprobados e introducidos en la terapia clínica en la década pasada. Además, se han probado o están en las fases finales de desarrollo otros agentes como las cefalosporinas de última generación (ceftarolina y ceftobiprol). El propósito de esta revisión fue describir las nuevas alternativas terapéuticas, particularmente en la era posterior a la vancomicina, y repasar las características químicas más relevantes de los compuestos y su espectro de actividad, haciendo énfasis en sus mecanismos de acción y resistencia.

New therapeutic alternatives have been developed in the last years for the treatment of multidrug-resistant Gram-positive infections. Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are considered a therapeutic challenge due to failures and lack of reliable antimicrobial options. Despite concerns related to the use of vancomycin in the treatment of severe MRSA infections in specific clinical scenarios, there is a paucity of solid clinical evidence that support the use of alternative agents (when compared to vancomycin). Linezolid, daptomycin and tigecycline are antibiotics approved in the last decade and newer cephalosporins (such as ceftaroline and ceftobiprole) and novel glycopeptides (dalvavancin, telavancin and oritavancin) have reached clinical approval or are in the late stages of clinical development. This review focuses on discussing these newer antibiotics used in the "post-vancomycin" era with emphasis on relevant chemical characteristics, spectrum of antimicrobial activity, mechanisms of action and resistance, as well as their clinical utility.

Genetic basis for in vivo daptomycin resistance in enterococci.

BACKGROUND: Daptomycin is a lipopeptide with bactericidal activity that acts on the cell membrane of enterococci and is often used off-label to treat patients infected with vancomycin-resistant enterococci. However, the emergence of resistance to daptomycin during therapy threatens its usefulness. METHODS: We performed whole-genome sequencing and characterization of the cell envelope of a clinical pair of vancomycin-resistant Enterococcus faecalis isolates from the blood of a patient with fatal bacteremia; one isolate (S613) was from blood drawn before treatment and the other isolate (R712) was from blood drawn after treatment with daptomycin. The minimal inhibitory concentrations (MICs) of these two isolates were 1 and 12 µg per milliliter, respectively. Gene replacements were made to exchange the alleles found in isolate S613 with those in isolate R712. RESULTS: Isolate R712 had in-frame deletions in three genes. Two genes encoded putative enzymes involved in phospholipid metabolism, GdpD (which denotes glycerophosphoryl diester phosphodiesterase) and Cls (which denotes cardiolipin synthetase), and one gene encoded a putative membrane protein, LiaF (which denotes lipid II cycle-interfering antibiotics protein but whose exact function is not known). LiaF is predicted to be a member of a three-component regulatory system (LiaFSR) involved in the stress-sensing response of the cell envelope to antibiotics. Replacement of the liaF allele of isolate S613 with the liaF allele from isolate R712 quadrupled the MIC of daptomycin, whereas replacement of the gdpD allele had no effect on MIC. Replacement of both the liaF and gdpD alleles of isolate S613 with the liaF and gdpD alleles of isolate R712 raised the daptomycin MIC for isolate S613 to 12 µg per milliliter. As compared with isolate S613, isolate R712--the daptomycin-resistant isolate--had changes in the structure of the cell envelope and alterations in membrane permeability and membrane potential. CONCLUSIONS: Mutations in genes encoding LiaF and a GdpD-family protein were necessary and sufficient for the development of resistance to daptomycin during the treatment of vancomycin-resistant enterococci. (Funded by the National Institute of Allergy and Infectious Diseases and the National Institutes of Health.).

Simulation and pre-feasibility analysis of the production process of alpha-methyl ester sulfonates (alpha-MES).

alpha-Methyl esters sulfonates (alpha-MES) are anionic surfactants that are derived from biorenewable resources, offering interesting environmental and chemical properties for application in the detergent industry. A simulation of their production process was conducted using a commercial production process currently used for palm oil. Results, prices of raw materials were submitted to economic analysis, and final MES price was compared with available data for linear alkyl benzene sulfonates (LAS) prices. The results for substances properties and product streams obtained from simulation were reliable in agreement to real values. It was found that increasing methyl ester national price by 20%, 50% and the equivalent to linear alkyl benzene price, the final price of alpha-methyl ester sulfonates was lower than the current price of linear alkyl benzene sulfonates. The capital cost and payout period for a production capacity of 49,000tons of surfactant per year were obtained. Results indicate that the process is economically feasible and can be applied to palm oil-based industries in Colombia.