Simulation-Based Education in US Undergraduate Medical Education: A Descriptive Study.

PURPOSE: Simulation-based education (SBE) provides experiential learning, improvement in quality of care, and reduction in errors. In 2011, the Association of American Medical Colleges described adoption of SBE in 68.0% of medical schools and 25.0% of teaching hospitals. We sought to examine current trends of SBE integration in American undergraduate medical education since previous publications. METHODS: From 2016 to 2019, University of Texas Southwestern Medical Center postgraduate year 1 residents were invited to participate in a survey assessing medical school simulation experience with 26 clinical tasks from three categories: procedural, communication, and other. Deidentified results were analyzed to assess demographics including sex, specialty, residency program type, allopathic versus osteopathic medical school, and medical school region. RESULTS: Nine hundred sixty-seven of 1047 (92.3%) responses were obtained, representing 139 US medical schools, 91% from allopathic training. Of procedural tasks, most simulated was suturing (n = 848, 89.6%) and least simulated was thoracentesis (n = 737, 80.9%). Of communication tasks, most simulated was taking a history (n = 475, 51.1% reporting simulation >30) and least simulated (never or ≤1) were obtaining a consent (n = 669, 73.2%) and disclosing a medical error (n = 666, 72.4%). Of other tasks, most simulated was chest compressions (n = 898, 96.0%) and least simulated was operating a defibrillator (n = 206, 22.1%). Results were similar regardless of procedural or nonprocedural program. There was no significant difference in SBE exposure between allopathic and osteopathic students ( P = 0.89). Two participants (0.002%) reported no simulation exposure. CONCLUSIONS: Our study is the first to describe a high prevalence of SBE adoption in medical schools nationwide since the Association of American Medical Colleges' 2011 publication, with overall equal exposure for students regardless of residency type and allopathic or osteopathic medical school. Despite widespread adoption of simulation, opportunities remain to expand SBE use to teach critically important communication skills.

Hydrostannylation of Red Phosphorus: A Convenient Route to Monophosphines.

The preparation of valuable and industrially relevant organophosphorus compounds currently depends on indirect multistep procedures involving difficult-to-handle white phosphorus as a common P atom source. Herein, we report a practical and versatile method for the synthesis of a variety of monophosphorus compounds directly from the bench-stable allotrope red phosphorus (Pred ). The relatively inert Pred was productively functionalised by using the cheap and readily available radical reagent tri-n-butyltin hydride, and subsequent treatment with electrophiles yields useful P1 compounds. Remarkably, these transformations require only modest inert-atmosphere techniques and use only reagents that are inexpensive and commercially available, making this a convenient and practical methodology accessible in most laboratory settings.

Late onset of injection site reactions after vaccination with the 13-valent pneumococcal conjugate vaccine in adult study populations.

Injection site reactions (ISRs; redness, swelling and pain) commonly occur within 1-2 days after vaccination. After administration of toxoid vaccines including diphtheria toxoid, a later onset of ISRs has also been observed. As the serotype capsular polysaccharides in the 13-valent pneumococcal conjugate vaccine (PCV13) are conjugated to cross-reactive material 197 (CRM197), a nontoxic variant of diphtheria toxin, the onset of ISRs over 14 days was explored in 8 adult studies with 19 cohorts. Subjects received PCV13 with aluminum phosphate (AlPO4, n = 5667) or without AlPO4 (n = 304); 1097 subjects received 23-valent pneumococcal polysaccharide vaccine (PPSV23). Late ISRs with onset between days 6-14 were observed in 8/8 cohorts aged ≥65 years after PCV13 with AlPO4 (incidence across cohorts for redness, 2.3%-19.6%; swelling, 0.9%-10.8%; pain, 1.6%-10.0%) and in 1/1 cohort after PCV13 without AlPO4 (redness 10.5%; swelling 7.5%; pain 12.3%); and in 2/4 cohorts aged 50 to 64 years after PCV13 (redness 3.1%-4.8%; swelling 1.0%-3.2%; pain 3.7%-5%). Late ISRs were not generally observed in 1/1 cohort aged 18 to 49 years after PCV13; in 2/2 cohorts aged ≥53 years after PCV13 revaccination; and in 3/3 cohorts aged ≥60 years who received PPSV23, which does not contain CRM197. Post hoc analysis demonstrated numerically higher pneumococcal immune responses in subgroups with late ISRs versus those without. In conclusion, causality of late ISRs is likely multifactorial, with age and the PCV13 carrier protein CRM197 potentially associated. AlPO4, a vaccine adjuvant, did not appear causally related. Observations do not affect the favorable risk-benefit profile of PCV13.

Preclinical pharmacology, ocular tolerability and ocular hypotensive efficacy of a novel non-peptide bradykinin mimetic small molecule.

We sought to characterize the ocular pharmacology, tolerability and intraocular pressure (IOP)-lowering efficacy of FR-190997, a non-peptidic bradykinin (BK) B2-receptor agonist. FR-190997 possessed a relatively high receptor binding affinity (Ki = 27 nM) and a high in vitro potency (EC50 = 18.3 ± 4.4 nM) for inositol-1-phosphate generation via human cloned B2-receptors expressed in host cells with mimimal activity at B1-receptors. It also mobilized intracellular Ca2+ in isolated human trabecular meshwork (h-TM), ciliary muscle (h-CM), and in immortalized non-pigmented ciliary epithelial (h-iNPE) cells (EC50s = 167-384 nM; Emax = 32-86% of BK-induced response). HOE-140, a selective B2-receptor antagonist, potently blocked the latter effects of FR-190997 (e.g., IC50 = 7.3 ± 0.6 nM in h-CM cells). FR-190997 also stimulated the release of prostaglandins (PGs) from h-TM and h-CM cells (EC50s = 60-84 nM; Emax = 29-44% relative to max. BK-induced effects). FR-190997 (0.3-300 µg t.o.) did not activate cat corneal polymodal nociceptors and did not cause ocular discomfort in Dutch-Belted rabbits, but it was not well tolerated in New Zealand albino rabbits and Hartley guinea pigs. A single topical ocular (t.o.) dose of 1% FR-190997 in Dutch-Belted rabbits and mixed breed cats did not lower IOP. However, FR-190997 efficaciously lowered IOP of conscious ocular hypertensive cynomolgus monkey eyes (e.g., 34.5 ± 7.5% decrease; 6 h post-dose of 30 µg t.o.; n = 8). Thus, FR-190997 is an unexampled efficacious ocular hypotensive B2-receptor non-peptide BK agonist that activates multiple signaling pathways to cause IOP reduction.

Anatomic distribution and mortality of arterial injury in the wars in Afghanistan and Iraq with comparison to a civilian benchmark.

OBJECTIVE: The purpose of this study was to examine the anatomic distribution and associated mortality of combat-related vascular injuries comparing them to a contemporary civilian standard. DESIGN: The Joint Trauma Theater Registry (JTTR) was queried to identify patients with major compressible arterial injury (CAI) and noncompressible arterial injury (NCAI) sites, and their outcomes, among casualties in Iraq and Afghanistan from 2003 to 2006. The National Trauma Data Bank (NTDB) was then queried over the same time frame to identify civilian trauma patients with similar arterial injuries. Propensity score-based matching was used to create matched patient cohorts from both populations for analysis. RESULTS: Registry queries identified 380 patients from the JTTR and 7020 patients from the NTDB who met inclusion criteria. Propensity score matching for age, elevated Injury Severity Score (ISS; >15), and hypotension on arrival (systolic blood pressure [SBP] <90) resulted in 167 matched patients from each registry. The predominating mechanism of injury among matched JTTR patients was explosive events (73.1%), whereas penetrating injury was more common in the NTDB group (61.7%). In the matched cohorts, the incidence of NCAI did not differ (22.2% JTTR vs 26.6% NTDB; P = .372), but the NTDB patients had a higher incidence of CAI (73.7% vs 59.3%; P = .005). The JTTR cohort was also found to have a higher incidence of associated venous injury (57.5% vs 23.4%; P < .001). Overall, the matched JTTR cohort had a lower mortality than NTDB counterparts (4.2% vs 12.6%; P = .006), a finding that was also noted among patients with NCAI (10.8% vs 36.4%; P = .008). There was no difference in mortality between matched JTTR and NTDB patients with CAI overall (2.0% vs 4.1%; P = .465), or among those presenting with Glasgow Coma Scale (GCS) <8 (28.6% vs 40.0%; P = 1.00) or shock (SBP <90; 10.5% vs 7.7%; P = 1.00). The JTTR mortality rate among patients with CAI was, however, lower among patients with ISS >15 compared with civilian matched counterparts (10.7% vs 42.4%; P = .006). CONCLUSIONS: Mortality of injured service personnel who reach a medical treatment facility after major arterial injury compares favorably to a matched civilian standard. Acceptable mortality rates within the military cohort are related to key aspects of an organized Joint Trauma System, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines. Aspects of this comprehensive combat casualty care strategy may translate and be of value to management of arterial injury in the civilian sector.