Exploring Combat Tourniquet Application Errors and Duration Among Skilled and Novice Medical Trainees.

INTRODUCTION: The use of tourniquets in combat medicine continues to be a key focus as they have consistently been shown to combat one of the leading causes of preventable death on the battlefield, massive hemorrhage to extremities. The present study analyzed tourniquet application among combat medics (68W) and combat lifesavers (CLSs) in a training environment to determine whether trainees' performance is consistent among one another and whether performance can be associated with participant demographics such as experience or role. MATERIALS AND METHODS: Study participants treated male and female patient simulators within a tactical field care phase, both of which experienced an amputated leg and required the application of a Combat Application Tourniquet (CAT). To assess tourniquet application variability and performance, a series of application subtasks and potential errors were measured via video coding of the scenarios by a team of 5 coders. Time to tourniquet application and tourniquet application duration were also coded to assess correlations between application duration and variability or performance. RESULTS: Results from analyzing tourniquet application subtasks and errors through a series of one-way ANOVA tests showed that application of the CAT first, hasty CAT application, and high tourniquet application were not predictive of participant role, time within the role, and self-reported tourniquet skill, confidence, or experience. Such demographic variables were also not predictive of successful tourniquet application as defined by the number of windlass rod rotations. Results from binomial logistic regressions showed that participant role and self-reported tourniquet skill and experience were predictors of tourniquet application duration. CONCLUSION: The findings suggest that high variability in CAT application methodology and performance exists among CLS and combat medics, which is largely not predictable by various demographics such as role, experience within the designated role, and self-reported confidence, skill, or experience. The observed disconnect between training or experience and CAT application performance suggests substantial variability in the consistency of training for both CLS and 68W soldiers. These inconsistencies may stem from variability in instructor knowledge, teaching styles, or training materials or may be developed through informal methods such as experiences in the field or recommendations from colleagues and experts. These findings highlight a potential need to reassess CAT application training, particularly in regard to consistency and validation. Finally, it should be noted that the study's findings may be limited or fail to capture some study effects because of the sample size and wide range of reported experience among participants.

Synthesis and crystal structures of N,2,4,6-tetra-methyl-anilinium tri-fluoro-methane-sulfonate and N-iso-propyl-idene-N,2,4,6-tetra-methyl-anilinium tri-fluoro-methane-sulfonate.

Two 2,4,6-tri-methyl-aniline-based trifuloro-methane-sulfonate (tri-fluoro-methane-sulfonate) salts were synthesized and characterized by single-crystal X-ray diffraction. N,2,4,6-Tetra-methyl-anilinium tri-fluoro-methane-sulfonate, [C10H14NH2 +][CF3O3S-] (1), was synthesized via methyl-ation of 2,4,6-tri-methyl-aniline. N-Iso-propyl-idene-N,2,4,6-tetra-methyl-anilinium tri-fluoro-meth-ane-sulfonate, [C13H20N+][CF3O3S-] (2), was synthesized in a two-step reaction where the imine, N-iso-propyl-idene-2,4,6-tri-methyl-aniline, was first prepared via a dehydration reaction to form the Schiff base, followed by methyl-ation using methyl tri-fluoro-methane-sulfonate to form the iminium ion. In compound 1, both hydrogen bonding and π-π inter-actions form the main inter-molecular inter-actions. The primary inter-action is a strong N-H⋯O hydrogen bond with the oxygen atoms of the tri-fluoro-methane-sulfonate anions bonded to the hydrogen atoms of the ammonium nitro-gen atom to generate a one-dimensional chain. The [C10H14NH2 +] cations form dimers where the benzene rings form a π-π inter-action with a parallel-displaced geometry. The separation distance between the calculated centroids of the benzene rings is 3.9129 (8) Å, and the inter-planar spacing and ring slippage between the dimers are 3.5156 (5) and 1.718 Å, respectively. For 2, the [C13H20N+] cations also form dimers as in 1, but with the benzene rings highly slipped. The distance between the calculated centroids of the benzene rings is 4.8937 (8) Å, and inter-planar spacing and ring slippage are 3.3646 (5) and 3.553 Å, respectively. The major inter-molecular inter-actions in 2 are instead a series of weaker C-H⋯O hydrogen bonds [C⋯O distances of 3.1723 (17), 3.3789 (18), and 3.3789 (18) Å], an inter-action virtually absent in the structure of 1. Fluorine atoms are not involved in strong directional inter-actions in either structure.

Long-Term Outcomes Following Definitive or Adjuvant Proton Radiotherapy for Adenoid Cystic Carcinoma.

Purpose: Adenoid cystic carcinoma (ACC) is a rare malignancy accounting for 1% of all head and neck cancers. Treatment for ACC has its challenges and risks, yet few outcomes studies exist. We present long-term outcomes of patients with ACC of the head and neck treated with proton therapy (PT). Materials and Methods: Under an institutional review board-approved, single-institutional prospective outcomes registry, we reviewed the records of 56 patients with de novo, nonmetastatic ACC of the head and neck treated with PT with definitive (n = 9) or adjuvant PT (n = 47) from June 2007 to December 2021. The median dose to the primary site was 72.6 gray relative biological equivalent (range, 64-74.4) delivered as either once (n = 19) or twice (n = 37) daily treatments. Thirty patients received concurrent chemotherapy. Thirty-one patients received nodal radiation, 30 electively and 1 for nodal involvement. Results: With a median follow-up of 6.2 years (range, 0.9-14.7), the 5-year local-regional control (LRC), disease-free survival, cause-specific survival, and overall survival rates were 88%, 85%, 89%, and 89%, respectively. Intracranial extension (P = .003) and gross residual tumor (P = .0388) were factors associated with LRC rates. While the LRC rate for those with a gross total resection was 96%, those with subtotal resection or biopsy alone were 81% and 76%, respectively. The 5-year cumulative incidence of clinically significant grade ≥3 toxicity was 15%, and the crude incidence at the most recent follow-up was 23% (n = 13). Conclusion: This is the largest sample size with the longest median follow-up to date of patients with ACC treated with PT. PT can provide excellent disease control for ACC of the head and neck with acceptable toxicity. T4 disease, intracranial involvement, and gross residual disease at the time of PT following either biopsy or subtotal resection were significant prognostic features for worse outcomes.

Outcrossing in Caenorhabditis elegans increases in response to food limitation.

Theory predicts that organisms should diversify their offspring when faced with a stressful environment. This prediction has received empirical support across diverse groups of organisms and stressors. For example, when encountered by Caenorhabditis elegans during early development, food limitation (a common environmental stressor) induces the nematodes to arrest in a developmental stage called dauer and to increase their propensity to outcross when they are subsequently provided with food and enabled to develop to maturity. Here we tested whether food limitation first encountered during late development/early adulthood can also induce increased outcrossing propensity in C. elegans. Previously well-fed C. elegans increased their propensity to outcross when challenged with food limitation during the final larval stage of development and into early adulthood, relative to continuously well-fed (control) nematodes. Our results thus support previous research demonstrating that the stress of food limitation can induce increased outcrossing propensity in C. elegans. Furthermore, our results expand on previous work by showing that food limitation can still increase outcrossing propensity even when it is not encountered until late development, and this can occur independently of the developmental and gene expression changes associated with dauer.

Bridging the Gap: Engaging Black Men in Lung Cancer Research Through Barbershop Collaboration.

Health disparities persist among Black men, notably in the context of lung cancer and stress-related health outcomes. This study explores these disparities through a community-based participatory research (CBPR) approach, citizen science, and social network theory, leveraging the expertise and trust of Black barbers as community leaders. The purpose is to understand the nuanced connections between stress and lung cancer in this demographic. Engaging 161 Black men across four Chicago neighborhoods, the study successfully collected hair samples and survey data, emphasizing the importance of culturally sensitive recruitment strategies. Findings highlight the effectiveness of the collaboration, showcasing the role of barbershops as community hubs for research. The study concludes by advocating for sustained partnerships with community leaders, emphasizing transparency in research communication, and promoting culturally grounded approaches to address health disparities and enhance research participation among underrepresented populations.

Outcrossing increases resistance against coevolving parasites.

Despite substantial costs, biparental sex is the dominant mode of reproduction across plant and animal taxa. The Red Queen hypothesis (RQH) posits that coevolutionary interactions with parasites can favor biparental sex in hosts, despite the costs. In support of the RQH, previous studies found that coevolutionary interactions with virulent bacterial parasites maintained high outcrossing rates in populations of the androdioecious nematode host Caenorhabditis elegans . Here we test three non-mutually exclusive mechanisms that could explain how coevolving parasites maintain outcrossing rates in C. elegans hosts: 1) short-term parasite exposure induces plastic increases in the hosts' propensity to outcross, 2) hosts evolve increased outcrossing propensity in response to selection imposed by coevolving parasites, and 3) outcrossed offspring incur less parasite-mediated fitness loss than selfed offspring, increasing host male frequencies and opportunities for outcrossing. We find no evidence that parasites cause plastic or evolved changes in host outcrossing propensity. However, parental outcrossing significantly increases survival of host offspring in the F2 generation when exposed to a coevolving parasite. Hence, coevolving parasites maintain outcrossing in host populations by selecting against selfed offspring, rather than by inducing changes in the propensity to outcross.

Evaluation of driver navigational errors and acceptance of a simulated J-turn intersection.

The J-turn intersection is a novel roadway design which decreases the points of conflict at an intersection, by restricting straight crossing and left-turning movements from the minor road across the highway. The novelty of the intersection design may lead to driver errors and dissatisfaction. This study provides an examination of how naïve or first-time drivers may initially navigate J-turns during their first and early exposures to the novel intersection design. Thirty-six participants with limited previous experience and knowledge of J-turns participated in a simulation study to examine their acceptance of J-turns and left turning navigational performance at three simulated J-turn intersections in counterbalanced order, each featuring one of three signage levels. Results revealed participants committed slightly more frequent minor errors (e.g., inefficient lane selection) and significantly more major errors (e.g., missed U-turn) during the first J-turn exposure and these errors tended to decline during subsequent exposures, while moderate severity errors (e.g., risky lane change) slightly increased. Participants' J-turn acceptance significantly declined following simulated driving exposure. The decline in J-turn acceptance was found to be greater among participants who experienced major severity errors; however, more frequent minor errors were associated with increased acceptance. Signage level had little effect on errors, but participants preferred improved signage or on-road markings to guide crossing movements. This work suggests that advanced educational programs and community initiatives should be utilized to prepare drivers for how to navigate J-turns rather than only rely on J-turn exposure to improve driver performance and acceptance.

Impact of mandated drug monitoring on opioid use during highly conformal radiotherapy for oropharynx cancer.

BACKGROUND: Prescription drug monitoring programs (PDMPs) have proliferated due to increasing opioid-related deaths. We evaluated acute opioid use changes for 64 patients treated with highly conformal radiotherapy (RT) following a state-mandated PDMP. METHODS: Patients receiving proton therapy (PT) (n=40), intensity-modulated RT (IMRT) (n=14), or both (n=10) were divided into preintervention (n=26) and postintervention cohorts (n=38); records were reviewed retrospectively under an institutional review board (IRB)-approved tracking protocol. Dosages prescribed during acute therapy (during RT-3 months post-RT) and patient-reported pain (Defense and Veterans Pain Rating Scale) were endpoints. Dosages were treated as responses in Chi-square tests (three-level ordinal response). RESULTS: Overall, 72% (n=46) received opioids; of which 22% (n=10) of all patients and 10% (n=2) of opioid-naive patients continued analgesic management 3 months post-RT. Median total doses were 975 and 1,025 morphine milligram equivalents (MME) in pre- and postintervention groups, with no significant differences in MME prescribed (P=0.8) or uncontrolled pain (P=0.3). Statistically significant factors were tonsil primaries (P<0.01) and alcohol use (P=0.02). Uncontrolled pain episodes during and post-RT did not vary per cohort (P=0.19). CONCLUSIONS: PDMP use was not associated with management changes in patient-reported acute pain during RT (IMRT or PT). Following highly conformal RT, few patients remained on narcotics 3 months post-RT.

Three genes controlling streptomycin susceptibility in Agrobacterium fabrum.

Streptomycin (Sm) is a commonly used antibiotic for its efficacy against diverse bacteria. The plant pathogen Agrobacterium fabrum is a model for studying pathogenesis and interkingdom gene transfer. Streptomycin-resistant variants of A. fabrum are commonly employed in genetic analyses, yet mechanisms of resistance and susceptibility to streptomycin in this organism have not previously been investigated. We observe that resistance to a high concentration of streptomycin arises at high frequency in A. fabrum, and we attribute this trait to the presence of a chromosomal gene (strB) encoding a putative aminoglycoside phosphotransferase. We show how strB, along with rpsL (encoding ribosomal protein S12) and rsmG (encoding a 16S rRNA methyltransferase), modulates streptomycin sensitivity in A. fabrum. IMPORTANCE The plant pathogen Agrobacterium fabrum is a widely used model bacterium for studying biofilms, bacterial motility, pathogenesis, and gene transfer from bacteria to plants. Streptomycin (Sm) is an aminoglycoside antibiotic known for its broad efficacy against gram-negative bacteria. A. fabrum exhibits endogenous resistance to somewhat high levels of streptomycin, but the mechanism underlying this resistance has not been elucidated. Here, we demonstrate that this resistance is caused by a chromosomally encoded streptomycin-inactivating enzyme, StrB, that has not been previously characterized in A. fabrum. Furthermore, we show how the genes rsmG, rpsL, and strB jointly modulate streptomycin susceptibility in A. fabrum.

Reassessing rumination: Validity of the Day Reconstruction Method for Rumination (DRM-R) to assess episodes of rumination in daily life.

Rumination is a robust vulnerability to depression and potential treatment target. However, we know relatively little about rumination in daily life. This study tested the validity of a new approach for assessing daily episodes of rumination, the Day Reconstruction Method for Rumination (DRM-R). Participants (N = 127) who were either high or low in neuroticism completed baseline self-report measures (e.g., depression, trait rumination). Next, they completed the DRM-R by reconstructing the previous day into a series of "scenes," identifying discrete episodes of rumination, and responding to follow-up items about each episode. 78.6% of high neuroticism participants reported experiencing discrete periods of rumination, 80.0% reported constant ruminative thoughts in the back of their heads, and 68.6% reported ruminative thoughts of fluctuating intensity. Time spent ruminating was moderately correlated with trait measures of rumination and worry. Findings provide preliminary evidence that the DRM-R is a valid method for assessing discrete episodes of rumination in daily life. The DRM-R may reveal, ideographically, the relationship between specific thought content and features of ruminative episodes (e.g., length, frequency). Further research is needed to establish whether the DRM-R can detect changes in rumination across multiple days and how it corresponds with traditional daily diary methods and ecological momentary assessment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

An Anaplasma phagocytophilum T4SS effector, AteA, is essential for tick infection.

IMPORTANCE: Ticks are the number one vector of pathogens for livestock worldwide and for humans in the United States. The biology of tick transmission is an understudied area. Understanding this critical interaction could provide opportunities to affect the course of disease spread. In this study, we examined the zoonotic tick-borne agent Anaplasma phagocytophilum and identified a secreted protein, AteA, which is expressed in a tick-specific manner. These secreted proteins, termed effectors, are the first proteins to interact with the host environment. AteA is essential for survival in ticks and appears to interact with cortical actin. Most effector proteins are studied in the context of the mammalian host; however, understanding how this unique set of proteins affects tick transmission is critical to developing interventions.

Extensor Tendon Repair: Avoidance and Management of Complications.

Extensor tendon repair can be technically challenging and can lead to suboptimal outcomes and complications even if managed perfectly. This article describes the pertinent clinical anatomy of the extensor mechanism, reviews outcomes and complications following extensor tendon repair, and provides guidance on how to avoid and manage complications when they occur.

Task-Relevant Smartphone Messages Within Work Zones: A Driving Simulation Study.

OBJECTIVE: This study explored the impact of in-vehicle messages relative to roadside messages to alert drivers to events within a simulated work zone, in order to determine if these messages can improve driving performance within the work zone. BACKGROUND: Safety risks in work zones are usually mitigated by design standards and clear signage to communicate work zone information to drivers. Due to distraction and other driving task demands, these signs are not always noticed by motorists, nor are they always followed when they are noticed. METHOD: The driving simulation tested drivers in two different types of work zones, shoulder work, and lane closure. Participants drove through these work zones three times, each with different messaging interfaces to communicate hazardous events to the driver. The interfaces included a roadside, portable changeable message sign, a smartphone presenting only auditory messages, and a smartphone presenting audio-visual messages. RESULTS: There was significantly better driving performance on key metrics including lane deviation for the in-vehicle message conditions relative to the roadside signs. Furthermore, drivers directed visual attention toward the roadway for the in-vehicle message conditions relative to the roadside sign condition. CONCLUSION: The results indicate that in-vehicle messaging could provide benefits to primary task performance in driving if the message content is appropriately designed. APPLICATION: The findings provide support for a design framework to support in-vehicle communication to drivers approaching work zones and other environments to safely alert them to hazards.

Host Association and Spatial Proximity Shape but Do Not Constrain Population Structure in the Mutualistic Symbiont Xenorhabdus bovienii.

To what extent are generalist species cohesive evolutionary units rather than a compilation of recently diverged lineages? We examine this question in the context of host specificity and geographic structure in the insect pathogen and nematode mutualist Xenorhabdus bovienii. This bacterial species partners with multiple nematode species across two clades in the genus Steinernema. We sequenced the genomes of 42 X. bovienii strains isolated from four different nematode species and three field sites within a 240-km2 region and compared them to globally available reference genomes. We hypothesized that X. bovienii would comprise several host-specific lineages, such that bacterial and nematode phylogenies would be largely congruent. Alternatively, we hypothesized that spatial proximity might be a dominant signal, as increasing geographic distance might lower shared selective pressures and opportunities for gene flow. We found partial support for both hypotheses. Isolates clustered largely by nematode host species but did not strictly match the nematode phylogeny, indicating that shifts in symbiont associations across nematode species and clades have occurred. Furthermore, both genetic similarity and gene flow decreased with geographic distance across nematode species, suggesting differentiation and constraints on gene flow across both factors, although no absolute barriers to gene flow were observed across the regional isolates. Several genes associated with biotic interactions were found to be undergoing selective sweeps within this regional population. The interactions included several insect toxins and genes implicated in microbial competition. Thus, gene flow maintains cohesiveness across host associations in this symbiont and may facilitate adaptive responses to a multipartite selective environment. IMPORTANCE Microbial populations and species are notoriously hard to delineate. We used a population genomics approach to examine the population structure and the spatial scale of gene flow in Xenorhabdus bovienii, an intriguing species that is both a specialized mutualistic symbiont of nematodes and a broadly virulent insect pathogen. We found a strong signature of nematode host association, as well as evidence for gene flow connecting isolates associated with different nematode host species and collected from distinct study sites. Furthermore, we saw signatures of selective sweeps for genes involved with nematode host associations, insect pathogenicity, and microbial competition. Thus, X. bovienii exemplifies the growing consensus that recombination not only maintains cohesion but can also allow the spread of niche-beneficial alleles.

Optimizing Respiratory Therapy Resources by De-Implementing Low-Value Care.

BACKGROUND: Our institution was experiencing a respiratory therapy staffing crisis during the COVID-19 pandemic, in part due to excessive workload. We identified an opportunity to reduce burden by limiting use of 3% hypertonic saline and/or N-acetylcysteine nebulizer therapies (3%HTS/NAC). METHODS: Leveraging the science of de-implementation, we established a policy empowering respiratory therapists to discontinue 3%HTS/NAC not meeting the American Association for Respiratory Care (AARC) Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients. After a 3-month period of educating physicians and advanced practice practitioners the policy went to into effect. Outcomes measured included monthly number of treatments, orders, and full-time employees associated with administering nebulized 3%HTS/NAC. RESULTS: Post policy activation, the monthly mean 3%HTS/NAC treatments were significantly reduced to 547.5 ± 284.3 from 3,565.2 ± 596.4 (P < .001) as were the associated monthly mean of full-time employees, 0.8 ± 0.41 from 5.1 ± 0.86 (P < .001). The monthly mean 3%HTS/NAC orders also fell to 93.8 ± 31.5 from 370.0 ± 46.9 (P < .001). Monthly mean non-3%HTS/NAC treatments remained stable; post policy was 3,089.4 ± 611.4 and baseline 3,279.6 ± 695.0 (P = 1.0). CONCLUSIONS: Implementing a policy that empowers respiratory therapists to promote adherence to AARC Clinical Guidelines reduced low-value therapies, costs, and staffing needs.

The Murine Oral Metatranscriptome Reveals Microbial and Host Signatures of Periodontal Disease.

Periodontal disease is accompanied by alterations to cellular profiles and biological activities of both the subgingival microbiome and host tissues. Although significant progress has been made in describing the molecular basis of the homeostatic balance of host-commensal microbe interactions in health compared to the destructive imbalance in disease, particularly with respect to immune and inflammatory systems, few studies have attempted a comprehensive analysis in diverse host models. Here, we describe the development and application of a metatranscriptomic approach to analysis of host-microbe gene transcription in a murine periodontal disease model, based on oral gavage infection using Porphyromonas gingivalis in C57BL6/J mice. We generated 24 metatranscriptomic libraries from individual mouse oral swabs, representing health and disease. On average, 76% ± 11.7% reads in each sample belonged to the murine host genome and the remainder to the microbes. We found 3,468 (2.4% of the total) murine host transcripts differentially expressed between health and disease, of which 76% were overexpressed in periodontitis. Predictably, there were prominent alterations to genes and pathways linked with the host immune compartment in disease-the CD40 signaling pathway being the top enriched biological process in this data set. However, in addition, we observed significant alterations to other biological processes in disease, particularly cellular/metabolic processes and biological regulation. The number of differentially expressed microbial genes particularly indicated shifts in carbon metabolism pathways in disease with potential consequences for metabolic end-product formation. Together, these metatranscriptome data reveal marked changes between the gene expression patterns in both the murine host and microbiota, which may represent signatures of health and disease, providing the basis for future functional studies of prokaryotic and eukaryotic cellular responses in periodontal disease. In addition, the noninvasive protocol developed in this study will enable further longitudinal and interventionist studies of host-microbe gene expression networks.

An Anaplasma phagocytophilum T4SS effector, AteA, is essential for tick infection.

Pathogens must adapt to disparate environments in permissive host species, a feat that is especially pronounced for vector-borne microbes, which transition between vertebrate hosts and arthropod vectors to complete their lifecycles. Most knowledge about arthropod-vectored bacterial pathogens centers on their life in the mammalian host, where disease occurs. However, disease outbreaks are driven by the arthropod vectors. Adapting to the arthropod is critical for obligate intracellular rickettsial pathogens, as they depend on eukaryotic cells for survival. To manipulate the intracellular environment, these bacteria use Type IV Secretion Systems (T4SS) to deliver effectors into the host cell. To date, few rickettsial T4SS translocated effectors have been identified and have only been examined in the context of mammalian infection. We identified an effector from the tick-borne rickettsial pathogen Anaplasma phagocytophilum , HGE1_02492, as critical for survival in tick cells and acquisition by ticks in vivo . Conversely, HGE1_02492 was dispensable during mammalian cell culture and murine infection. We show HGE1_02492 is translocatable in a T4SS-dependent manner to the host cell cytosol. In eukaryotic cells, the HGE1_02492 localized with cortical actin filaments, which is dependent on multiple sub-domains of the protein. HGE1_02492 is the first arthropod-vector specific T4SS translocated effector identified from a rickettsial pathogen. Moreover, the subcellular target of HGE1_02492 suggests that A. phagocytophilum is manipulating actin to enable arthropod colonization. Based on these findings, we propose the name AteA for Anaplasma ( phagocytophilum ) tick effector A. Altogether, we show that A. phagocytophilum uses distinct strategies to cycle between mammals and arthropods. Importance: Ticks are the number one vector of pathogens for livestock worldwide and for humans in the US. The biology of tick transmission is an understudied area. Understanding this critical interaction could provide opportunities to affect the course of disease spread. In this study we examined the zoonotic tick-borne agent Anaplasma phagocytophilum and identified a secreted protein, AteA, that is expressed in a tick-specific manner. These secreted proteins, termed effectors, are the first proteins to interact with the host environment. AteA is essential for survival in ticks and appears to interact with cortical actin. Most effector proteins are studied in the context of the mammalian host; however, understanding how this unique set of proteins affect tick transmission is critical to developing interventions.

Disrupted propionate metabolism evokes transcriptional changes in the heart by increasing histone acetylation and propionylation.

Propiogenic substrates and gut bacteria produce propionate, a post-translational protein modifier. In this study, we used a mouse model of propionic acidaemia (PA) to study how disturbances to propionate metabolism result in histone modifications and changes to gene expression that affect cardiac function. Plasma propionate surrogates were raised in PA mice, but female hearts manifested more profound changes in acyl-CoAs, histone propionylation and acetylation, and transcription. These resulted in moderate diastolic dysfunction with raised diastolic Ca2+, expanded end-systolic ventricular volume and reduced stroke volume. Propionate was traced to histone H3 propionylation and caused increased acetylation genome-wide, including at promoters of Pde9a and Mme, genes related to contractile dysfunction through downscaled cGMP signaling. The less severe phenotype in male hearts correlated with ß-alanine buildup. Raising ß-alanine in cultured myocytes treated with propionate reduced propionyl-CoA levels, indicating a mechanistic relationship. Thus, we linked perturbed propionate metabolism to epigenetic changes that impact cardiac function.

A Pilot Study on the Role of Experience and Patient Gender on MARCH Treatment Sequence.

INTRODUCTION: The brevity of training for soldiers and combat medics to learn how to provide treatment on the battlefield may restrict optimal performance for treating chest and airway injuries, particularly when treating female soldiers. The present study tested treatment performance on patient simulators by battlefield medic trainees to determine whether there is a need for more extensive training on chest and airway procedures on female soldiers. MATERIALS AND METHODS: Battlefield medic trainees treated male and female patient simulators in counterbalanced order. The assessment considered the effects of patient gender and order on procedures performed, particularly critical chest and airway interventions such as needle chest decompression (NCD), and considered the appropriate order of treatment tasks. Four coders rated video footage of three simulated procedures, i.e., tourniquet, chest seal (front and back application), and NCD, using a binary coding system to determine completeness and order correctness according to the Massive hemorrhage, Airway, Respiration, Circulation, and Head injury/Hypothermia (MARCH) mnemonic. RESULTS: Results from analysis of variance showed that when presented with a female patient first, trainees performed significantly fewer total procedures on both the female and male simulators. More experienced trainees completed significantly more procedures compared to trainees with minimal experience. Results from the binary logistic regression showed that trainees with more experience and trainees presented with the male patient simulator first performed significantly more procedures in the correct order. Finally, an examination of the NCD procedure found that trainees presented with the female patient simulator first had more errors and that trainees with less experience were less likely to perform the procedure adequately. CONCLUSIONS: The findings suggest that treating a female patient first may lead to undertreatment of both patients. Furthermore, the observed differences in treating sensitive areas of the body (e.g., near female breasts) suggest providing greater opportunities for trainees to practice often missed or incorrectly performed procedures. Treating a female patient remains a novel experience for many trainees, such that trainees are less likely to fully treat a female patient and are less likely to treat female soldiers for the most life-threatening injuries. In fact, the initial presentation of the female patient simulator appeared to affect experienced trainees, suggesting that removing the experience of novelty and stress requires more extensive exposure and alternative training. The study's small sample size with a wide range of trainee experience may limit the findings, which may fail to capture some study effects. Finally, the study did not request trainees' experience treating female soldiers, so future studies should examine the extent to which experience is predictive of performance. There is a need for more interactive approaches in patient simulations to provide opportunities for practice, especially those that require the treatment of sensitive areas.

The regional and cellular distribution of GABAA receptor subunits in the human amygdala.

GABAergic neurotransmission in the amygdala plays a crucial role in mediating emotional learning, fear, and memory. In this study, expression of five major GABAA receptor subunits (α1, α2, α3, ß2,3, and γ2) was investigated in the normal human amygdala using immunohistochemistry. At the regional level, the amygdala contains a highly heterogeneous distribution of all the subunits investigated. The most intense staining for α1, α2, ß2,3, and γ2 subunits was present in the lateral nucleus (LA), and α3 in the intercalated nuclei (ICM). Six distinct cell populations that express GABAA receptor subunits were identified throughout the amygdala: type 1 aspiny cells in the basolateral nuclear group (BLNG) and superficial cortical-like nuclear region (SCLR) express α1, ß2,3, and γ2; type 2 larger aspiny cells in the paralaminar nucleus (PL) express α1, ß2,3, and γ2; type 3 aspiny cells in the BLNG express α1, ß2,3, and γ2 as well as calcium-binding proteins including parvalbumin (PV), calbindin (CB), and calretinin (CR); type 4 pyramidal cells in the BLNG and SCLR express α2, α3, ß2,3, and γ2 subunits at high levels on proximal specialised spines; type 5 cells in the central nucleus (CE) express α2, α3, and ß2,3; type 6 cells are found closely packed in the intercalated cell masses (ICM) and express α3 and ß2,3. The α1 subunit rarely co-labelled with α2 and α3 in the same cell population, while the α2 and α3 were often expressed within the same type 4 or 5 cell though not at always at the same puncta. The predominant GABAA receptor subunit combinations expressed in the human amygdala are the α1ß2,3γ2 and α2ß2,3γ2. Cells classified as interneuron types (types 1-3) contained GAD and principally expressed α1ß2,3γ2. The major projection neurons of the BLNG (type 4) are non-GABAergic and mainly express α2ß2,3γ2. The α3 subunit was found intracellularly in type 5 cells and decorating the surface of type 6 cells but rarely co-labelled with the subunits investigated. The results reveal a complex and heterogeneous distribution of GABAA receptor subtypes throughout the amygdala as well as on a variety of cell types through which inhibitory processing is carried out to maintain emotional responses, and control anxiety and fear responses in the brain.