Dopamine transporter blockade during adolescence increases adult dopamine function, impulsivity, and aggression.

Sensitive developmental periods shape neural circuits and enable adaptation. However, they also engender vulnerability to factors that can perturb developmental trajectories. An understanding of sensitive period phenomena and mechanisms separate from sensory system development is still lacking, yet critical to understanding disease etiology and risk. The dopamine system is pivotal in controlling and shaping adolescent behaviors, and it undergoes heightened plasticity during that time, such that interference with dopamine signaling can have long-lasting behavioral consequences. Here we sought to gain mechanistic insight into this dopamine-sensitive period and its impact on behavior. In mice, dopamine transporter (DAT) blockade from postnatal (P) day 22 to 41 increases aggression and sensitivity to amphetamine (AMPH) behavioral stimulation in adulthood. Here, we refined this sensitive window to P32-41 and identified increased firing of dopaminergic neurons in vitro and in vivo as a neural correlate to altered adult behavior. Aggression can result from enhanced impulsivity and cognitive dysfunction, and dopamine regulates working memory and motivated behavior. Hence, we assessed these behavioral domains and found that P32-41 DAT blockade increases impulsivity but has no effect on cognition, working memory, or motivation in adulthood. Lastly, using optogenetics to drive dopamine neurons, we find that increased VTA but not SNc dopaminergic activity mimics the increase in impulsive behavior in the Go/NoGo task observed after adolescent DAT blockade. Together our data provide insight into the developmental origins of aggression and impulsivity that may ultimately improve diagnosis, prevention, and treatment strategies for related neuropsychiatric disorders.

Hippocampal neurogenesis confers stress resilience by inhibiting the ventral dentate gyrus.

Adult neurogenesis in the dentate gyrus of the hippocampus is highly regulated by environmental influences, and functionally implicated in behavioural responses to stress and antidepressants1-4. However, how adult-born neurons regulate dentate gyrus information processing to protect from stress-induced anxiety-like behaviour is unknown. Here we show in mice that neurogenesis confers resilience to chronic stress by inhibiting the activity of mature granule cells in the ventral dentate gyrus (vDG), a subregion that is implicated in mood regulation. We found that chemogenetic inhibition of adult-born neurons in the vDG promotes susceptibility to social defeat stress, whereas increasing neurogenesis confers resilience to chronic stress. By using in vivo calcium imaging to record neuronal activity from large cell populations in the vDG, we show that increased neurogenesis results in a decrease in the activity of stress-responsive cells that are active preferentially during attacks or while mice explore anxiogenic environments. These effects on dentate gyrus activity are necessary and sufficient for stress resilience, as direct silencing of the vDG confers resilience whereas excitation promotes susceptibility. Our results suggest that the activity of the vDG may be a key factor in determining individual levels of vulnerability to stress and related psychiatric disorders.

Interprofessional, older adult, team-based home visits: A 6-year prospective analysis.

This 6-year prospective study describes the impact on student attitudes of an innovative, interprofessional geriatrics curriculum (IPGC) focused on team-based care with older adults in a home-based community setting. Dental, medical, occupational therapy, pharmacy, physical therapy, and physician assistant students were placed into teams each led by faculty members from all of the professions. The curriculum consisted of five, four-hour sessions over one academic year. Teams met with a community-dwelling older adult three times. Students completed the Geriatric Assessment Scale (GAS) before and after the IPGC experience. At the conclusion, improvements in attitudes toward older adults in the GAS and its four domains - social value, medical care, compassion, and societal resources-were observed across a wide spectrum of students. Students with the lowest initial attitudes improved the most, as did the scores of the youngest students. Older students improved more than younger students in the social value domain (i.e., the perceived social value of older adults). Among disciplines, occupational therapy and social work students improved the most in the social value domain. This study demonstrates improvement in attitudes toward older adults from student involvement in IPGC that combines didactic and experiential learning through community partnerships in a home-based setting.

Occupational Therapy Student Learning on Interprofessional Teams in Geriatric Primary Care.

IMPORTANCE: Geriatric, interprofessional primary care training for occupational therapy students is needed. OBJECTIVE: To measure occupational therapy student-reported knowledge, attitudes, and skills after participation in interprofessional geriatric educational programs. DESIGN: Prospective, observational study with pre- and posttests for the three programs. PARTICIPANTS: Fifty-nine entry-level and postprofessional occupational therapy master's students. OUTCOMES AND MEASURES: Self-reported familiarity with other professionals' roles, perceptions of interprofessional training, capabilities to conduct assessments, and attitudes of older adults. RESULTS: Students of the three programs (Interprofessional Geriatrics Curriculum [IPGC], Student Senior Partnership Program [SSPP], and Geriatric Assessment Program [GAP]) reported different improvements in familiarity of roles, capabilities of assessment, and Geriatric Attitudes Scale (GAS) scores. For example, IPGC and SSPP students had changes in total GAS score (3.91-4.08, p = .002, and 3.84-3.99, p = .003, respectively), but no change was found for GAP students (3.85-3.91, p = .523). CONCLUSIONS AND RELEVANCE: More structured interprofessional education with older adults appeared to help prepare occupational therapy students to work on geriatric interprofessional teams in primary care. WHAT THIS ARTICLE ADDS: This article expands on growing evidence to support occupational therapy's role in primary care by addressing the need to train future generations to work on interprofessional geriatric primary care teams.

AGGRESSIVE ENACTMENTS: CONTAINING THE "NO" IN CLINICAL WORK WITH SURVIVORS OF ABUSE.

Identity development depends on the ability to say 'no.' Setting limits enables a relationship between two separate individuals to develop. Early trauma can leave the individual so vigilant to others' demands that internal prohibitions against intrusion remain silenced, which we conceptualize as a 'no' that could not be sufficiently articulated to keep the person safe. For those who have not been able to assert this fundamental limit, the consulting room provides a potential anchoring point to formulate and work through unconscious meanings. Being able to articulate and register the legitimacy of one's own no becomes an important challenge, as tensions regarding power and powerlessness, trust and distrust, are acted out within the consulting room. Case material illustrates how psychoanalytic ideas regarding transference, countertransference, and enactment help the clinician tolerate the intrusion of past into present, inviting the type of mentalization that moves towards repair rather than merely reenacting the trauma.

National Trends in Indicators of a Medical Home for Children.

OBJECTIVES: The patient centered medical home is now widely supported as a strategy for delivering high quality primary care. The objective of this study was to examine whether children's primary care experiences nationally have become more aligned with the medical home model over time, and how this may have varied for vulnerable children. METHODS: This study analyzed data on 289,672 children, aged 0-17 years, of families responding to one of three iterations of National Survey of Children's Health from 2003, 2007 and 2011-2012. Each year, we assessed indicators of four medical home features (access, continuity, comprehensiveness, and family-centeredness) and a total medical home score for children nationally and for those with a set of social and demographic risk factors. RESULTS: Indicators of access and continuity, and total medical home scores fluctuated but improved overall from 2003 to 2012 (7.1, 6.7 and 1.4 % point increases, respectively), while indicators of comprehensiveness and family-centered care measures declined (2.4 and 1.8 % point decreases, respectively). Children with the highest levels of social and demographic risk experienced larger fluctuations in these measures over time. CONCLUSIONS FOR PRACTICE: There were improvements in the extent to which children's primary care experiences aligned with a medical home model, though not linearly or for all component features. Children with more risk factors experienced more volatile changes, suggesting a particular need to attend to the primary care experiences of the most vulnerable children.

An evaluation of organ dose modulation on a GE optima CT660-computed tomography scanner.

Organ Dose Modulation or ODM (GE Healthcare, Milwaukee, WI) was evaluated to characterize changes in CTDIvol, image noise, effective dose, and organ dose saving to patients. Three separate investigations were completed: a tube current modulation phantom was scanned with and without ODM, a CTDIvol phantom was scanned with ODM, and Monte Carlo simulations were performed. ODM was found to reduce the CTDIvol by approximately 20% whilst increasing the noise by approximately 14%. This was reflected in the dose distribution, where the anterior peripheral dose was reduced by approximately 40% whilst the identical poste-rior dose remained largely unaffected. Enabling ODM for the entire scan would reduce the effective dose by approximately 24%; however, this saving reduces to 5% if the images are matched for CTDIvol. These savings mostly originated from reductions in dose to the stomach, breasts, colon, bladder, and liver. ODM has the effect of a global reduction in CTDIvol with an associated increase in image noise. The benefit of ODM was found to be reduced when the dose-saving contribution from the reduced CTDIvol was removed. Given that there is a higher contribution to effective dose throughout the body from the anterior projections, consideration should be given to applying ODM throughout.

Primary care medical home experience and health-related quality of life among adult medicaid patients with type 2 diabetes.

PURPOSE: To examine whether patient-reported indicators of medical home performance are associated with health-related quality of life (HRQOL) among adults with type 2 diabetes. METHODS: Cross-sectional survey of 540 patients with Medicaid insurance and type 2 diabetes in Los Angeles County. The Primary Care Assessment Tool was used to measure seven features of medical home performance. The EuroQol EQ-5D-3L (EQ-5D) was used to measure HRQOL. RESULTS: Higher total medical home performance was correlated with better overall HRQOL. A one-point change in total medical home score was associated with a 0.06-point higher score on the EQ-5D index [95 % confidence interval (CI): 0.01-0.11], which is a clinically meaningful difference. The total score was also significantly associated with a lower likelihood of problems on one domain of the EQ-5D (pain). Longitudinality was the only medical home feature associated with better general health status (ordered odds ratio = 1.78; 95 % CI: 1.04-3.03). The positive relationship of medical home with the EQ-5D appears to be present predominantly among women. CONCLUSION: Overall medical home experience is favorably associated with HRQOL among vulnerable adult patients with type 2 diabetes. Provider efforts to improve the overall medical home experience for patients may contribute to improvements in HRQOL.

miR-208a as a biomarker of isoproterenol-induced cardiac injury in Sod2+/- and C57BL/6J wild-type mice.

This investigation examined microRNA-208a (miR-208a) as a potential biomarker of isoproterenol (ISO)-induced cardiac injury in superoxide dismutase-2 (Sod2(+/-) ) and the wild-type mice, and the potential sensitivity of Sod2(+/-) mice to ISO-induced toxicity. A single intraperitoneal injection of ISO was administered to age-matched wild-type and Sod2(+/-) mice at 0, 80, or 160 mg/kg. Plasma miR-208a, cardiac troponin I (cTnI), and ISO systemic exposure were measured at various time points postdose. Hearts were collected for histopathology examination and for tissue expression of miR-208a and myosin heavy chain 7. ISO administration caused increases in cTnI and miR-208a plasma levels that correlated with myocardial damage; however, the magnitude of increase differed according to the types of mice. At similar ISO systemic exposure, the magnitude of cTnI was greater in wild-type mice compared to Sod2(+/) (-) mice; however, the magnitude of miR-208a was greater in Sod2(+/-) mice than that of the wild-type mice. Myocardial degeneration occurred at ≥3 hr in the wild-type and ≥6 hr in Sod2(+/) (-) mice. At ≥24 hr after ISO administration, miR-208a appeared superior to cTnI in indicating myocardial injury in both wild-type and Sod2(+/-) mice. Sod2(+/-) mice were not more sensitive than wild-type mice to ISO-induced toxicity.

Occam's Razor and Prehospital Documentation: When the Simpler Solution Resulted in Better Documentation.

INTRODUCTION: The Tactical Combat Casualty Care (TCCC) card has undergone several changes since its first introduction in 1996. In 2013, updates to the card included more data points to increase prehospital documentation quality and enable performance improvement. This study reviews the proportions of data collected before and after the implementation of the new TCCC card. METHODS: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR) focused on prehospital medical care. In this sub-analysis, we defined the pre-implementation period as 2009-2013 followed by a 1-year run-in with the post-implementation period as 2015-2019. Our primary outcome was documentation of a pulse rate and our secondary outcomes included documentation of other vital signs. We used multivariable logistic regression models to adjust for confounders. RESULTS: There were 18,182 encounters that met inclusion for this analysis-14,711 before and 3,471 after the update. Across all vital signs, there was a peak around 2012-2013 with a drop noted in 2015. Comparing the preimplementation and post-implementation groups, there were higher proportions with documentation of a pulse rate (62% versus 49%), respirations (51% versus 45%), systolic pressure (53% versus 46%), diastolic pressure (49% versus 41%), oxygen saturation (55% versus 46%), and pain score (27% versus 19%, all p is less than 0.001) in the pre-implementation group. When adjusting for injury severity score (ISS), casualty category, and year of injury, the odds ratio of documentation of a pulse after implementation was 0.01 (95% CI: 0.00-0.01). When adjusting for ISS and casualty category, the odds ratio was 0.64 (95% CI: 0.60-0.70). When adjusting for ISS only, the odds ratio was 0.58 (95% CI: 0.54-0.63). CONCLUSIONS: Implementation of the new TCCC card resulted in overall lower documentation proportions which persisted after adjusting for measurable confounders.

Medial Prefrontal Cortex Serotonin Input Regulates Cognitive Flexibility in Mice.

The medial prefrontal cortex (mPFC) regulates cognitive flexibility and emotional behavior. Neurons that release serotonin project to the mPFC, and serotonergic drugs influence emotion and cognition. Yet, the specific roles of endogenous serotonin release in the mPFC on neurophysiology and behavior are unknown. We show that axonal serotonin release in the mPFC directly inhibits the major mPFC output neurons. In serotonergic neurons projecting from the dorsal raphe to the mPFC, we find endogenous activity signatures pre-reward retrieval and at reward retrieval during a cognitive flexibility task. In vivo optogenetic activation of this pathway during pre-reward retrieval selectively improved extradimensional rule shift performance while inhibition impaired it, demonstrating sufficiency and necessity for mPFC serotonin release in cognitive flexibility. Locomotor activity and anxiety-like behavior were not affected by either optogenetic manipulation. Collectively, our data reveal a powerful and specific modulatory role of endogenous serotonin release from dorsal raphe-to-mPFC projecting neurons in cognitive flexibility.

Evaluating Interorganizational Collaborations: Lessons Learned from Five California Geriatric Workforce Enhancement Programs.

BACKGROUND: Five Geriatric Workforce Enhancement Programs (GWEPs) in California, funded for 4 years, worked collaboratively across different organizations to provide education on aging issues and/or training to enhance services for older adults. OBJECTIVES: To investigate characteristics of the collaborations that were associated with perceptions and experiences of success for participating organizations. METHODS: A survey distributed to 37 organizations participating in 5 GWEPs measured the correlation of resources and dimensions of collaboration with perceived sense of success of the collaborations. Interviews with 30 representatives of the participating organizations collected information about perceived barriers, impact, and satisfaction with the collaborations. RESULTS: Overall perceptions of interorganizational collaboration success were associated with provision of physical resources and four key measures of collaboration (governance, administration, mutuality, and norms/trust). Barriers to success were described in terms of organization functioning and resources. Strong communication appeared as a facilitator of success, and reciprocity was described as a key experience of satisfaction. CONCLUSIONS: This study highlights the positive effects of shared goals, the experience of reciprocity, and communication during interorganizational collaborations. It also notes the negative effects of having inadequate resources and organizational dysfunction.

Healthy Kids insurance and experiences of medical home quality for vulnerable children.

OBJECTIVES: To examine the relationship of enrollment in Healthy Kids insurance (locally funded insurance products for low-income children ineligible for other public insurance) with parent-reported experiences of primary care medical home quality. METHODS: A cross-sectional survey of parents of 4011 children stratified by established enrollees in Healthy Kids (enrolled 1 y or longer), new enrollees (less than 1 y), and children on a waitlist. We examined differences across groups in having an ongoing source of primary care, and experiences of 6 features of a medical home-accessibility, continuity, comprehensiveness, contextual knowledge, communication, and coordination-and a summary medical home measure. RESULTS: Compared with waitlisted children, new and established enrollees were more likely to have a regular source of care [odds ratio (OR)=2.49; 95% confidence interval (CI): 1.74-3.57 and OR=6.51; CI: 4.64-9.13, respectively] and a personal doctor or nurse (OR=3.41; CI: 2.42-4.80 and OR=7.00; CI: 5.07-9.66). Among those with a regular source of care and visit in the past year, new and established enrollees reported better medical home experiences in 4 and 6 of the 7 measures, respectively. CONCLUSIONS: Despite many barriers to care for vulnerable children, Healthy Kids enrollment was positively associated with having an ongoing source of primary care and better medical home experiences. As these children are mostly left out of healthcare reform, Healthy Kids programs may be a good model for other counties and states to help to connect such children to primary care.

Individual filamentous phage imaged by electron holography.

An in-line electron hologram of an individual f1.K phage was recorded with a purpose-built low energy electron point source (LEEPS) microscope. Cryo-microscopic methods were employed to prepare the specimen so that a single phage could be presented to the coherent low energy electrons: An aqueous phage suspension was applied to a thin carbon membrane with micro-machined slits. The membrane was rapidly cooled to freeze the remaining water as an amorphous ice sheet, which was then sublimated at low temperatures and pressures to leave individual free-standing phages suspended across slits. An image of a phage particle, depicted as the amplitude of the object wave, was reconstructed numerically from a digitized record of the hologram, obtained using 88 eV coherent electrons. The reconstructed image shows a single phage suspended across a slit in a supporting carbon membrane, magnified by a factor of 100,000. The width and shape in the reconstructed image compared well with a TEM image of the same filament. It is thus possible to record and reconstruct electron holograms of an individual phage. The challenge now is to improve the resolution of reconstructed images obtained by this method and to extend these structural studies to other biological molecules.

Relationship of medical home quality with school engagement and after-school participation among children with asthma.

OBJECTIVES: To examine the relationship between medical home quality and measures of daily life experiences among children with asthma. METHODS: A nationally representative sample of children from the 2007 National Survey of Children's Health (NSCH), aged 6-17 years (n = 6357), who have asthma was used to assess the relationship of a quality medical home and its features with their daily life experiences. Five medical home features - access, continuity, comprehensiveness, family-centered care, and coordination of care - were examined individually and in total in relation to measures of school engagement (missed school days, parents contacted about problems with the child, repeating a grade since kindergarten) and after-school activity participation (physical activity, sports participation, and community service or volunteer work). RESULTS: Before and after adjustment for personal characteristics, health insurance status, family environment, neighborhood variables, and asthma severity, total medical home score was associated with more days exercised [beta (B) = 0.10, p < .05] and a greater likelihood of having performed community service or volunteer work [odds ratio (OR) = 1.16, CI: 1.02-1.31]. Additionally, the medical home features of access, comprehensiveness, and family-centered care remained favorably associated with three of the six measures of school engagement and after-school activity participation, even after adjustment. CONCLUSION: Medical home quality - particularly the features of access, comprehensiveness, and family-centered care - is positively associated with the daily life experiences of children with asthma. Working to enhance these aspects of primary care might be one place to start in improving the management of children's chronic conditions and their quality of life.

National disparities in the quality of a medical home for children.

OBJECTIVES: To examine socio-demographic disparities associated with a quality medical home. METHODS: A nationally representative sample of children ages 0-17 years (n = 102,353) from the 2003 National Survey of Children's Health. Risk factors including non-white race/ethnicity, income <200% of the federal poverty level (FPL), uninsured, parent education lesser than high school, and non-English primary household language, were examined in relation to a quality medical home separately and together as a "profile" of risk. Fourteen questions were used to measure five medical home features: access, continuity, comprehensiveness, family-centered care, and coordination. Quality was defined as a value greater than median for each feature and for an overall score. RESULTS: Before and after adjustment for child demographics and health status, all studied risk factors were associated with poorer quality medical home features. Uninsured [odds ratio (OR) = 0.43, 95% confidence interval (CI): 0.40-0.47] and low-income children (OR = 0.65, CI: 0.62-0.69) had among the lowest odds of a quality medical home overall and across most features, except coordination that showed an opposite trend. Summarized through risk profiles, children experiencing all five risk factors had 93% lower odds of a quality medical home overall (OR = 0.07, CI: 0.04-0.25) compared to zero risk children. CONCLUSION: This study demonstrates large national disparities in the quality of a medical home for children. That disparities were most prevalent for the uninsured and those in or near poverty, both modifiable risk factors, suggests that reforms to increase coverage and to lift families out of poverty are essential to assuring that children have access to the full complement of appropriate health care services including a quality medical home.

Inclusion of the homeless in health equity curricula: a needs assessment study.

Exposure to homeless patients is a potential strategy to teach about social determinants of health and health inequities. Little is known about student attitudes and preferences for learning about the homeless in curricula addressing vulnerable populations. A needs assessment to determine student readiness may inform strategies for teaching. A mixed-methods study of one matriculating physician assistant student class, with a cross-sectional survey and 3 focus groups (FG). The validated 19-item Health Professionals' Attitudes Toward Homelessness inventory (HPATHI) and new 7-item Learning Attitudes scale were administered to explore perceptions and preferences about relevance of caring for the homeless to future practice. FGs were conducted to theme saturation. Verbatim transcripts were independently read and coded by 3 researchers using constant comparison. Survey response rate was 100% (N = 60). Overall HPATHI mean score was 3.97 ± 0.04 of 5, indicating positive attitudes toward the homeless. The highest mean score (4.26 ± 0.04) was for the social advocacy subscale; the lowest (3.02 ± 0.06) for personal advocacy. The Learning Attitude scale (Cronbach's alpha 0.89) mean score was 4.47 ± 0.07 out of 5, showing a positive attitude toward curricular exposure. Older students and those with prior experience with the homeless had higher HPATHI scores (p < 0.05). Four major themes emerged: vulnerable patients cannot advocate for themselves; learning about homelessness is relevant to future practice; preference for multiple teaching strategies and adequate preparation for street rotations; and anticipated anxiety about safety. Students recognize the value of learning from homeless patients as part of gaining skills in caring for vulnerable populations. Experiential learning opportunities focusing on this group are seen as an acceptable and valuable way to gain skills applicable to all vulnerable patients. Students express fear and anxiety around non-traditional settings such as the street. Their anxieties should be adequately addressed when designing clinical rotations.

Improvements in access to care for vulnerable children in California between 2001 and 2005.

OBJECTIVE: We examined population changes in access to care for children in California during a period of major efforts to improve access to care for children. METHODS: We used cross-sectional data on 36,010 children aged 0-19 years from the 2001 and 2005 California Health Interview Survey to assess population changes in access to care. We assessed changes in access by individual risk factors and a composite risk profile. RESULTS: In 2005, a smaller proportion of children were uninsured (8.2% vs. 10.9% in 2001), living in poverty (20.7% vs. 23.2% in 2001), and in families without a high school education (20.8% vs. 23.6% in 2001), all p<0.001. Before and after adjusting for these changes in risk, children were more likely in 2005 to have had a physician visit (odds ratio [OR] = 1.09, 95% confidence interval [CI] 1.07, 1.12) and dental visit (OR=1.11, 95% CI 1.08, 1.14). Children were slightly less likely in 2005 to have a regular source of care (OR=0.94, CI 0.91, 0.96). Children who had the highest risk profiles (> or = 4 risk factors) experienced the largest gains in access. For example, children with three and > or = 4 risk factors had gains in dental visits of 11 and 20 percentage points, respectively (p<0.001 for each), compared with < or = 3 percentage points for children with fewer risk factors. CONCLUSIONS: This study found improvements in physician and dental visits between 2001 and 2005 that were not fully explained by changes in insurance coverage or other demographic risk factors. Vulnerable children fared well during this period, suggesting that California may be making important and potentially replicable strides in reducing disparities.

Scopolamine Toxicity in an Elderly Patient.

We present a case of a 66-year-old female who was to undergo a scheduled operation and placed on our institution's ERAS (Enhanced Recovery After Surgery) protocol. The intraoperative course was unremarkable. The patient developed delayed emergence in the Post-Anesthesia Care Unit. On physical exam, the patient was noted to have a transdermal scopolamine patch adjacent to an area of skin breakdown. She also displayed signs of central anti-cholinergic toxicity including mydriasis and tachycardia. Following removal of the scopolamine patch and administration of physostigmine, her mental status returned to baseline. This interesting case highlights the importance of considering patient specific factors such as age when implementing ERAS protocols perioperatively. It also demonstrates the risks associated with scopolamine and the importance of risk/benefit analysis prior to administration.

Mandated wrapping of airway cart instruments: Limited access without the intended safety benefits.

OBJECTIVES/HYPOTHESIS: Isolated case studies have shown improper sterilization or contamination of equipment from anesthesia carts can lead to transmission of disease and even death. Citing this literature, national accrediting agencies mandated all instruments in the otolaryngology airway carts at San Antonio Military Medical Center be packaged to prevent contamination. This study sought to determine the infection and safety implications of packaged airway cart instruments. STUDY DESIGN: Retrospective chart review. METHODS: A review of upper aerodigestive tract procedures, some of which penetrated mucosa, was performed by analyzing 100 patient records during the unpackaged period and 100 during the packaged period. A comparison of infections, deaths, and length of stay in the hospital was included in the analysis. Additionally, a timed simulation to setup a simple group of instruments for an emergency airway situation from both the unpackaged and packaged airway carts was performed using a total of 11 surgical technologists and nurses. RESULTS: Each group had a total of four airway infections and neither had any deaths. The average length of hospital stay was 0.36 days for the unpackaged period and 0.44 days from the packaged period. None of these variables reached statistical significance. The average time to find and set out the correct instruments for the two groups was 46.6 and 95.5 seconds for the unpackaged and packaged airway carts, respectively (P = .004). CONCLUSIONS: This study suggests individually packaging of instruments used for emergency airway cases may put lives at risk when time matters and fails to decrease the risk of infection. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:715-719, 2019.