Initial Imaging of Pregnant Patients in the Trauma Bay-Discussion and Review of Presentations at a Level-1 Trauma Centre.

Trauma is the leading non-obstetric cause of maternal and fetal mortality and affects an estimated 5-7% of all pregnancies. Pregnant women, thankfully, are a small subset of patients presenting in the trauma bay, but they do have distinctive physiologic and anatomic changes. These increase the risk of certain traumatic injuries, and the gravid uterus can both be the primary site of injury and mask other injuries. The primary focus of the initial management of the pregnant trauma patient should be that of maternal stabilization and treatment since it directly affects the fetal outcome. Diagnostic imaging plays a pivotal role in initial traumatic injury assessment and should not deviate from normal routine in the pregnant patient. Radiographs and focused assessment with sonography in the trauma bay will direct the use of contrast-enhanced computed tomography (CT), which remains the cornerstone to evaluate the potential presence of further management-altering injuries. A thorough understanding of its risks and benefits is paramount, especially in the pregnant patient. However, like any other trauma patient, if evaluation for injury with CT is indicated, it should not be denied to a pregnant trauma patient due to fear of radiation exposure.

Learner reflections on a postgraduate emergency medicine simulation curriculum: a qualitative exploration based on focus group interviews.

OBJECTIVES: To describe postgraduate emergency medicine (EM) residents' perceptions of simulation-based curriculum immediately post-simulation training. METHODS: This interpretive qualitative study explores residents' reflections on a city-wide, adult EM simulation-based curriculum. Focus group interviews gather residents' insights immediately post-simulation. Postgraduate trainees from the University of Toronto EM residency program were eligible to participate. We explored participants' perceptions of how well learning objectives were addressed, helpful/challenging aspects of the simulations, feelings during sessions, debriefing/pre-briefing, simulation integration into the broader EM curriculum, and anticipated changes in practice after the session. RESULTS: Our findings indicate that EM residents' learning goals for the simulation sessions evolve as they progress through residency training. Junior trainees report performance-oriented goals while senior trainees report learning-oriented goals. Differing motivations may affect residents' perceptions of the quality of the simulation experience. Junior residents want to feel prepared for the scenario and primed with the appropriate knowledge to manage the case. Senior residents focus on developing teamwork competencies and on mastering new clinical skills in the simulation environment. CONCLUSIONS: Junior and senior emergency medicine residents differ in their goal orientation during simulation-based training. Educators who develop simulation-based curricula should be mindful that junior residents may benefit from preparatory materials while senior residents prefer to be challenged. Resident reflections may significantly contribute to improvement of simulation-based curricula.

RéSUMé: OBJECTIF: Décrire la perception du programme de formation par simulation des résidents en médecine d'urgence (MU) immédiatement après un entraînement par simulation. MéTHODES: Cette étude qualitative interprétative explore les réflexions des résidents au sujet d'un programme axé sur la simulation en MU pour adultes à travers la ville. Les entretiens des groupes de discussion recueillent les aperçus des résidents immédiatement après la simulation. Les stagiaires de troisième cycle du programme de résidence en MU de l'Université de Toronto étaient admissibles à participer. Nous avons examiné les perceptions des participants sur la manière dont les objectifs d'apprentissage étaient abordés, les aspects utiles / exigeants des simulations, les sentiments pendant les sessions, le débriefing / pré-briefing, l'intégration de la simulation dans le programme plus large de la MU et les changements anticipés dans la pratique après la session. RéSULTATS: Nos résultats indiquent que les objectifs d'apprentissage des résidents en MU pour les séances de simulation évoluent au fur et à mesure qu'ils progressent dans la formation en résidence. Les stagiaires juniors rapportent des objectifs axés sur la performance tandis que les stagiaires avec plus d'ancienneté rapportent des objectifs axés sur l'apprentissage. Des motivations différentes peuvent affecter la perception qu'ont les résidents de la qualité de l'expérience de simulation. Les résidents assistants veulent se sentir préparés pour le scénario et équipés des connaissances appropriées pour gérer le cas. Les résidents avec plus d'ancienneté se concentrent sur le développement des compétences de travail d'équipe et sur la maîtrise de nouvelles compétences cliniques dans l'environnement de simulation. CONCLUSIONS: Les résidents assistants et ceux avec plus d'ancienneté en médecine d'urgence diffèrent dans leur orientation vers les objectifs au cours de la formation par simulation. Les éducateurs qui développent des programmes axés sur la simulation doivent être conscients que les résidents assistants peuvent bénéficier des matériels préparatoires tandis que les résidents avec plus d'ancienneté préfèrent être mis au défi. Les réflexions des résidents peuvent contribuer de manière significative à l'amélioration des programmes axés sur la simulation.

A vapourized Δ(9)-tetrahydrocannabinol (Δ(9)-THC) delivery system part I: development and validation of a pulmonary cannabinoid route of exposure for experimental pharmacology studies in rodents.

INTRODUCTION: Most studies evaluating the effects of Δ(9)-tetrahydrocannabinol (Δ(9)-THC) in animal models administer it via a parenteral route (e.g., intraperitoneal (IP) or intravenous injection (IV)), however, the common route of administration for human users is pulmonary (e.g., smoking or vapourizing marijuana). A vapourized Δ(9)-THC delivery system for rodents was developed and used to compare the effects of pulmonary and parenteral Δ(9)-THC administration on blood cannabinoid levels and behaviour. METHODS: Sprague-Dawley rats were exposed to pulmonary Δ(9)-THC (1, 5, and 10mg of inhaled vapour) delivered via a Volcano® vapourizing device (Storz and Bickel, Germany) or to parenteral Δ(9)-THC (0.25, 0.5, 1.0, and 1.5mg/kg injected IP). Quantification of Δ(9)-THC and its psychoactive metabolite, 11-hydroxy-Δ(9)-THC (11-OH-Δ(9)-THC), in blood was determined by liquid chromatography/mass spectrometry (LC/MS). In order to verify the potential for the vapourization procedure to produce a robust conditioned place preference (CPP) or conditioned place avoidance CPA, classical conditioning procedures were systematically varied by altering the exposure time (10 or 20min) and number of exposed rats (1 or 2) while maintaining the same vapourization dose (10mg). RESULTS: Blood collected at 20min intervals showed similar dose-dependent and time-dependent changes in Δ(9)-THC and 11-OH-Δ(9)-THC for both pulmonary and parenteral administration of Δ(9)-THC. However, vapourized Δ(9)-THC induced CPP under certain conditions whereas IP-administered Δ(9)-THC induced CPA. DISCUSSION: These results support and extend the limited evidence (e.g., in humans, Naef et al., 2004; in rodents, Niyuhire et al., 2007) that Δ(9)-THC produces qualitatively different effects on behaviour depending upon the route of administration.

A vapourized Δ(9)-tetrahydrocannabinol (Δ(9)-THC) delivery system part II: comparison of behavioural effects of pulmonary versus parenteral cannabinoid exposure in rodents.

INTRODUCTION: Studies of the rewarding and addictive properties of cannabinoids using rodents as animal models of human behaviour often fail to replicate findings from human studies. Animal studies typically employ parenteral routes of administration, whereas humans typically smoke cannabis, thus discrepancies may be related to different pharmacokinetics of parenteral and pulmonary routes of administration. Accordingly, a novel delivery system of vapourized Δ(9)-tetrahydrocannabinol (Δ(9)-THC) was developed and assessed for its pharmacokinetic, pharmacodynamic, and behavioural effects in rodents. A commercially available vapourizer was used to assess the effects of pulmonary (vapourized) administration of Δ(9)-THC and directly compared to parenteral (intraperitoneal, IP) administration of Δ(9)-THC. METHODS: Sprague-Dawley rats were exposed to pure Δ(9)-THC vapour (1, 2, 5, 10, and 20mg/pad), using a Volcano® vapourizing device (Storz and Bickel, Germany) or IP-administered Δ(9)-THC (0.1, 0.3, 0.5, 1.0mg/kg), and drug effects on locomotor activity, food and water consumption, and cross-sensitization to morphine (5mg/kg) were measured. RESULTS: Vapourized Δ(9)-THC significantly increased feeding during the first hour following exposure, whereas IP-administered Δ(9)-THC failed to produce a reliable increase in feeding at all doses tested. Acute administration of 10mg of vapourized Δ(9)-THC induced a short-lasting stimulation in locomotor activity compared to control in the first of four hours of testing over 7days of repeated exposure; this chronic exposure to 10mg of vapourized Δ(9)-THC did not induce behavioural sensitization to morphine. DISCUSSION: These results suggest vapourized Δ(9)-THC administration produces behavioural effects qualitatively different from those induced by IP administration in rodents. Furthermore, vapourized Δ(9)-THC delivery in rodents may produce behavioural effects more comparable to those observed in humans. We conclude that some of the conflicting findings in animal and human cannabinoid studies may be related to pharmacokinetic differences associated with route of administration.

New synthetic routes to chain-extended selenium, sulfur, and nitrogen analogues of the naturally occurring glucosidase inhibitor salacinol and their inhibitory activities against recombinant human maltase glucoamylase.

Six heteroanalogues (X = S, Se, NH) of the naturally occurring glucosidase inhibitor salacinol, containing polyhydroxylated, acyclic chains of 6-carbons, were synthesized for structure-activity studies with different glycosidase enzymes. The target zwitterionic compounds were synthesized by means of nucleophilic attack of the PMB-protected 1,4-anhydro-4-seleno-, 1,4-anhydro-4-thio-, and 1,4-anhydro-4-imino-D-arabinitols at the least hindered carbon atom of 1,3-cyclic sulfates. These 1,3-cyclic sulfates were derived from D-glucose and D-galactose, and significantly, they utilized butane diacetal as the protecting groups for the trans 2,3-diequatorial positions. Deprotection of the coupled products proceeded smoothly, unlike in previous attempts with different protecting groups, and afforded the target selenonium, sulfonium, and ammonium sulfates with different stereochemistry at the stereogenic centers. The four new heterosubstituted compounds (X = Se, NH) inhibited recombinant human maltase glucoamylase (MGA), one of the key intestinal enzymes involved in the breakdown of glucose oligosaccharides in the small intestine. The two selenium derivatives each had Ki values of 0.10 microM, giving the most active compounds to date in this general series of zwitterionic glycosidase inhibitors. The two nitrogen compounds also inhibited MGA but were less active, with Ki values of 0.8 and 35 microM. The compounds in which X = S showed Ki values of 0.25 and 0.17 microM. Comparison of these data with those reported previously for related compounds reinforces the requirements for an effective inhibitor of MGA. With respect to chain extension, the configurations at C-2' and C-4' are critical for activity, the configuration at C-3', bearing the sulfate moiety, being unimportant. It would also appear that the configuration at C-5' is important but the relationship is dependent on the heteroatom.