Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

OBJECTIVE: To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED. METHODS: A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). RESULTS: Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8). CONCLUSIONS: Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

Recurrent horizontal transfer identifies mitochondrial positive selection in a transmissible cancer.

Autonomous replication and segregation of mitochondrial DNA (mtDNA) creates the potential for evolutionary conflict driven by emergence of haplotypes under positive selection for 'selfish' traits, such as replicative advantage. However, few cases of this phenomenon arising within natural populations have been described. Here, we survey the frequency of mtDNA horizontal transfer within the canine transmissible venereal tumour (CTVT), a contagious cancer clone that occasionally acquires mtDNA from its hosts. Remarkably, one canine mtDNA haplotype, A1d1a, has repeatedly and recently colonised CTVT cells, recurrently replacing incumbent CTVT haplotypes. An A1d1a control region polymorphism predicted to influence transcription is fixed in the products of an A1d1a recombination event and occurs somatically on other CTVT mtDNA backgrounds. We present a model whereby 'selfish' positive selection acting on a regulatory variant drives repeated fixation of A1d1a within CTVT cells.

Somatic evolution and global expansion of an ancient transmissible cancer lineage.

The canine transmissible venereal tumor (CTVT) is a cancer lineage that arose several millennia ago and survives by "metastasizing" between hosts through cell transfer. The somatic mutations in this cancer record its phylogeography and evolutionary history. We constructed a time-resolved phylogeny from 546 CTVT exomes and describe the lineage's worldwide expansion. Examining variation in mutational exposure, we identify a highly context-specific mutational process that operated early in the cancer's evolution but subsequently vanished, correlate ultraviolet-light mutagenesis with tumor latitude, and describe tumors with heritable hyperactivity of an endogenous mutational process. CTVT displays little evidence of ongoing positive selection, and negative selection is detectable only in essential genes. We illustrate how long-lived clonal organisms capture changing mutagenic environments, and reveal that neutral genetic drift is the dominant feature of long-term cancer evolution.

Interprofessional Collaborative Practice: Use of Simulated Clinical Experiences in Medical Education.

CONTEXT: Mastering the art of assessing interprofessional outcomes has been a topic of interest in academic research. Specifically, the Interprofessional Education Collaborative has been publishing thorough bodies of work that aim to strengthen teamwork among health professionals and reinforce competencies that will lead to better patient care. OBJECTIVE: To determine osteopathic medical students' perceived effectiveness of simulated clinical experiences in cultivating interprofessional competencies with nursing students. METHODS: Second-year osteopathic medical students (classes of 2016 and 2017) and nursing students participated in a simulated clinical experience using a simulated patient mannequin. Students were assessed on clinical and humanistic skills using graded evaluations performed by faculty and actors portraying family members and given feedback on their performance. Evaluation grades were not analyzed. Students were asked to complete an anonymous survey that assessed their attitudes toward the collaborative experience. RESULTS: A total of 743 medical students participated in the study-371 from the class of 2016 and 372 from the class of 2017. Incomplete surveys (1 from the class of 2016 and 3 from the class of 2017) were included in the analysis. Statistically significant differences were found between the 2 classes of medical students in their responses to 2 items. With regard to appropriate patient data collection, the ranked distribution of scores was significantly greater for the class of 2014-2015 than for the class of 2013-2014 (mean rank, 389.3 vs 354.64, respectively; U=75,445.50; P=.017). For the item on effective communication with family members, the ranked distribution of scores was significantly greater for the class of 2014-2015 than for the class of 2013-2014 (mean rank, 390.61 vs 353.34, respectively; U=75,928.50; P=.006). Overall, medical students reported feeling better prepared to care for real patients after the simulation. CONCLUSION: Simulated interprofessional experiences during the second year of medical school may help prepare students to collaborate with other health care professionals in a clinical setting, take care of patients, and communicate with patients' family members.

A tool for evaluating the potential for cost-effective outcomes measurement.

Cost related to higher-level outcomes measurement is often very high. However, the cost burden is felt even more by smaller, less well-funded continuing medical education (CME) programs. It is possible to overcome financial and participant-related barriers to measuring Level 6 outcomes, which are patient health outcomes. The Temple University School of Medicine's Office for Continuing Medical Education developed a sequential tool for attaining cost-effective outcomes measurement for determining the likelihood of a CME intervention to produce significant changes in physician performance. The appropriate selection of the CME topic and specific practice change indictors drive this tool. This tool walks providers through a simple YES or NO decision-making list that guides them toward an accurate prediction of potential programmatic outcomes. Factors considered during the decision-making process include whether: (a) the intended change(s) will have a substantial impact on current practice; (b) the intended practice change(s) are well supported by clinical data, specialty organization/government recommendations, expert opinion, etc; (c) the potential change(s) affects a large population; (d) external factors, such as system pressures, media pressures, financial pressures, patient pressures, safety pressures, etc, are driving this intended change in performance; (e) there is a strong motivation on the part of physicians to implement the intended change(s); and (f) the intended change(s) is relatively easy to implement within any system of practice. If each of these questions can be responded to positively, there is a higher likelihood that the intended practice-related change(s) will occur. Such change can be measured using a simpler and less costly methodology.

Differential suppression of tumor-specific CD8+ T cells by regulatory T cells.

In the CT26 BALB/c murine model of colorectal carcinoma, depletion of regulatory T cells (Tregs) prior to tumor inoculation results in protective immunity to both CT26 and other BALB/c-derived tumors of diverse histological origin. In this paper, we show that cross-protection can be conferred by adoptively transferred CD8(+) CTLs. Other schedules for inducing immunity to CT26 have been described, but they do not lead to cross-protection. We show that Treg ablation facilitates the development of new CTL specificities that are normally cryptic, and have mapped the root epitope of one of these responses. This work has allowed us to demonstrate how the specificity of CTL responses to tumor Ags can be controlled via differential suppression of CTL specificities by Tregs, and how this can result in very different physiological outcomes.

Limited use of the human patient simulator by nurse faculty: an intervention program designed to increase use.

Underutilization of human patient simulators (HPS) is not only a curricular issue but also a resource allocation problem. The study explored factors contributing to the limited HPS by faculty in a large ADN program. There is limited empirical evidence published to address this phenomenon. The researchers surveyed the faculty to identify their beliefs and challenges with implementing simulation based upon the constructs (attitudes, subjective norms, perceived behavioral control and intent to use) of the Theory of Planned Behavior (TPB). An educational intervention to address these specific challenges was implemented. The intervention had a positive influence on all TPB construct means (attitudes, p < .01; subjective norms, p < .01; perceived behavioral control, p < .01; intent, p < .05). Attitude (beta = .896) was the strongest predictor in explaining intent to use the HPS. This evidenced-based study offers an approach to increasing the use of the HPS by faculty.