Characteristics of Emergency Medicine Residency Programs in Colombia.

INTRODUCTION: Emergency medicine (EM) is in different stages of development around the world. Colombia has made significant strides in EM development in the last two decades and recognized it as a medical specialty in 2005. The country now has seven EM residency programs: three in the capital city of Bogotá, two in Medellin, one in Manizales, and one in Cali. The seven residency programs are in different stages of maturity, with the oldest founded 20 years ago and two founded in the last two years. The objective of this study was to characterize these seven residency programs. METHODS: We conducted semi-structured interviews with faculty and residents from all the existing programs in 2013-2016. Topics included program characteristics and curricula. RESULTS: Colombian EM residencies are three-year programs, with the exception of one four-year program. Programs accept 3-10 applicants yearly. Only one program has free tuition and the rest charge tuition. The number of EM faculty ranges from 2-15. EM rotation requirements range from 11-33% of total clinical time. One program does not have a pediatric rotation. The other programs require 1-2 months of pediatrics or pediatric EM. Critical care requirements range from 4-7 months. Other common rotations include anesthesia, general surgery, internal medicine, obstetrics, gynecology, orthopedics, ophthalmology, radiology, toxicology, psychiatry, neurology, cardiology, pulmonology, and trauma. All programs offer 4-6 hours of protected didactic time each week. Some programs require Advanced Cardiac Life Support, Pediatric Advanced Life Support and Advanced Trauma Life Support, with some programs providing these trainings in-house or subsidizing the cost. Most programs require one research project for graduation. Resident evaluations consist of written tests and oral exams several times per year. Point-of-care ultrasound training is provided in four of the seven programs. CONCLUSION: As emergency medicine continues to develop in Colombia, more residency programs are expected to emerge. Faculty development and sustainability of academic pursuits will be critically important. In the long term, the specialty will need to move toward certifying board exams and professional development through a national EM organization to promote standardization across programs.

Characterizing the limited use of point-of-care ultrasound in Colombian emergency medicine residencies.

BACKGROUND: Emergency medicine (EM) is a growing specialty in Colombia with five residency programs in the country. EM leadership is interested in incorporating point-of-care (POC) ultrasound into a standardized national EM residency curriculum. This study is a nationwide survey of Colombian EM residents designed to explore the current state of POC ultrasound use within EM residencies and examine specific barriers preventing its expansion. METHODS: We conducted a mix-methodology study of all available current EM residents in the five EM residencies in Colombia. The quantitative survey assessed previous ultrasound experience, current use of various applications, desire for further training, and perceived barriers to expanded use. Focus group discussions (FGDs) were conducted with current EM residents to gather additional qualitative insight into their practice patterns and perceived barriers to clinician-performed ultrasound. RESULTS: Sixty-nine EM residents completed the quantitative survey, a response rate of 85% of all current EM residents in Colombia; 52% of resident respondents had previously used ultrasound during their training. Of these, 58% indicated that they had performed <10 scans and 17% reported >40 scans. The most frequently used applications indicated by respondents were trauma, obstetrics, and procedures including vascular access. A quarter indicated they had previously received some ultrasound training, but almost all expressed an interest in learning more. Significant barriers included lack of trained teachers (indicated by 78% of respondents), absence of machines (57%), and limited time (41%). In FGDs, the barriers identified were inter-specialty conflicts over the control of ultrasonography, both institutionally and nationally, and program-specific curriculum decisions to include POC ultrasound. CONCLUSION: While currently limited in their access, EM residents in Colombia have a strong interest in integrating POC ultrasound into their training. Current barriers to expanded use include traditional barriers such as a lack of equipment seen in many developing countries, as well as inter-specialty conflicts typical of developed countries. Further collaboration is underway to help overcome these obstacles and integrate POC ultrasound into Colombian EM residency training.

Major histocompatibility complex and T cell interactions of a universal T cell epitope from Plasmodium falciparum circumsporozoite protein.

A 20-residue sequence from the C-terminal region of the circumsporozoite protein of the malaria parasite Plasmodium falciparum is considered a universal helper T cell epitope because it is immunogenic in individuals of many major histocompatibility complex (MHC) haplotypes. Subunit vaccines containing T* and the major B cell epitope of the circumsporozoite protein induce high antibody titers to the malaria parasite and significant T cell responses in humans. In this study we have evaluated the specificity of the T* sequence with regard to its binding to the human class II MHC protein DR4 (HLA-DRB1*0401), its interactions with antigen receptors on T cells, and the effect of natural variants of this sequence on its immunogenicity. Computational approaches identified multiple potential DR4-binding epitopes within T*, and experimental binding studies confirmed the following two tight binding epitopes: one located toward the N terminus (the T*-1 epitope) and one at the C terminus (the T*-5 epitope). Immunization of a human DR4 volunteer with a peptide-based vaccine containing the T* sequence elicited CD4+ T cells that recognize each of these epitopes. Here we present an analysis of the immunodominant N-terminal epitope T*-1. T*-1 residues important for interaction with DR4 and with antigen receptors on T*-specific T cells were mapped. MHC tetramers carrying DR4/T*-1 MHC-peptide complexes stained and efficiently stimulated these cells in vitro. T*-1 overlaps a region of the protein that has been described as highly polymorphic; however, the particular T*-1 residues required for anchoring to DR4 were highly conserved in Plasmodium sequences described to date.

Protective cellular immunity against P. falciparum malaria merozoites is associated with a different P7 and P8 residue orientation in the MHC-peptide-TCR complex.

Developing a logical and rational methodology for obtaining vaccines, especially against the main parasite causing human malaria (P. falciparum), consists of blocking receptor-ligand interactions. Conserved peptides derived from proteins involved in invasion and having high red blood cell binding ability have thus been identified. Immunization studies using Aotus monkeys have revealed that these peptides were neither immunogenic nor protection inducing. When modified in their critical binding residues, previously identified by Glycine scanning, some of these peptides were immunogenic and non-protection inducers; others induced short-lived antibodies whilst a few were both immunogenic and protection inducing. However, very few of these modified high activity binding peptides (HABPs) reproducibly induced protection without inducing antibody production, but with high cytokine liberation, suggesting that cellular mechanisms had been activated in the protection process. The three-dimensional structure of these peptides inducing protection without producing antibodies was determined by 1H-NMR. Their HLA-DRbeta1* molecule binding ability was also determined to ascertain association between their 3D structure and ability to bind to Major Histocompatibility Complex Class-II molecules (MHC-II). 1H Nuclear Magnetic Resonance analysis and structure calculations clearly showed that these modified HABPs inducing protective cellular immune responses (but not producing antibodies against malaria) adopted special structural configuration to fit into the MHC II-peptide-TCR complex. A different orientation for P7 and P8 TCR contacting residues was clearly recognized when comparing their structure with modified peptides, which induced high antibody titers and protection, suggesting that these residues are involved in activating the immune system associated with antibody production and protection.

Effectiveness of a simple Internet-based disaster triage educational tool directed toward Latin-American EMS providers.

BACKGROUND: A previous survey demonstrated a lack of standardization related to disaster triage among Latin-American providers. OBJECTIVE: To assess the effectiveness of a short Internet-based educational intervention in disaster and mass-casualty triage. Using three Spanish Internet emergency medical services (EMS) forums, Latin-American providers were invited to participate in the study. The tool consisted of two educational modules: an introduction to disaster triage module and a START (simple triage and rapid treatment) module. Pre- and post-intervention tests were administered, each consisting of five standardized scenarios. Factorial analysis was used to measure the weight of each scenario. The first and fifth scenarios were identical for intraclass correlation. Skill retention was assessed through a one-month follow-up survey. Statistical analysis was performed using chi-square and Fisher's exact test. A total of 55 EMS providers participated in the study. Five of 55 (9.1%) participants correctly answered four or more scenarios on the pretest intervention, compared with 53 of 55 (96.4%) on the posttest [p < 0.001, relative risk 10.60 (95% CI 4.59-24.49)]. Similar findings were obtained for those accurately triaging all five scenarios, with zero of 55 (0%) in the pretest compared with 49 of 55 in the posttest (p < 0.001). Follow-up at one month was 69%. Four or more scenarios were correctly answered at follow-up by 34 of 38 (89.5%) respondents. No significant difference was noted compared with the immediate post-course survey (p = 0.18). Although initial ability of the cohort to accurately triage patients was suboptimal, a short Internet-based educational tool significantly impacted the cohort's ability to perform triage in a simulated patient environment. This improvement was maintained after one month.

Peptides inducing short-lived antibody responses against Plasmodium falciparum malaria have shorter structures and are read in a different MHC II functional register.

The search for a rational method of developing an antimalarial vaccine (malaria caused by Plasmodium falciparum) consists of blocking receptor-ligand interaction. Conserved peptides derived from proteins involved in invasion and having strong red blood cell binding ability have thus been identified; immunization studies using Aotus monkeys revealed that these peptides were neither immunogenic nor protection-inducing. Some of these peptides induced long-lasting and very high antibody titers and protection when their critical red blood cell binding residues were replaced to change their immunological properties. Others induced short-lived antibodies that were not associated with inducing protection. The three-dimensional structure of the short-lived antibody-inducing peptide was determined by (1)H NMR. Their HLA-DRbeta1* molecule binding ability was also determined to ascertain the relationship among three-dimensional structure, their ability to bind to major histocompatibility complex class II molecules (MHC II), and possible short-lived antibody production. These short-lived antibody-inducing peptides were 6.8 +/- 0.5 A shorter between those residues theoretically coming into contact with pocket 1 and pocket 9 of HLA-DRbeta1* molecules to which they bind than immunogenic and protection-inducing peptides. These more compact alpha-helical structures suggest that these short-lived antibody-inducing peptides could have a structure more similar to those of native peptides than immunogenic and protective ones. Such shortening was associated with a shift in HLA-DRbeta1* molecule binding and a consequent shift in functional register reading, mainly by alleles of the same haplotype when compared with immunogenic protection-inducing HABPs, suggesting an imperfect and different conformation of the MHC II peptide-TCR complex.

Ventriculectomia parcial esquerda: ponte para transplante? / Partial left ventriculectomy: bridge to transplantation?

OBJETIVO: Analisar os resultados e a viabilidade da ventriculectomia parcial esquerda (VPE) como ponte para transplante cardíaco (TX). DELINEAMENTO: Estudo de coorte histórica e prospectivo. CASUISTICA E MÉTODOS: Cinquenta e três pacientes (pts) foram submetidos a VPE em um período de 5 anos. Destes, 7 pts com contra-indicação inicial ao TX, idades variando de 37 a 64 anos, 5 homens e 2 mulheres, com miocardiopatia dilatada, foram subseqüentemente relistados e transplantados. Foram analisados a fração de ejeção (FE), o diâmetro diastólico final do ventrículo esquerdo (DDFVE), a CF da NYHA, o consumo máximo de oxigênio (VO2 máx) e os escores de qualidade de vida (QV) antes da VPE, aos 3 e 6 meses, e pré-transplante...

Três anos de ventriculectomia parcial esquerda: resultados globais e tardios em 41 pacientes / Three years of partial left ventriculectomy: overall and late results in 41 patients

Objetivos: Avaliar a indicação, sobrevida, qualidade de vida e arritmias após Ventriculectomia Parcial Esquerda (VPE) e relatar seu uso como ponte para transplante. Casuística e Métodos: Quarenta e um pacientes (pt) operados no período de dezembro de 1994 a dezembro de 1997,com idades de 32 a 70 anos, com miocardiopatia dilatada, classe funcional IV-92,6 por cento e III-7,3 por cento com contra-indicação para transplante e má qualidade de vida. Ecocardiogramas e estudos eletrofisiológicos (EEF) pré e pós-operatórios foram realizados. Clinicamente, agrupados pela NYHA e pelo Protocolo de Qualidade de Vida (QV). Resultados: Em 15 pacientes examinados aos 30 e 90 dias de pós-operatório por ecocardiograma obtivemos os dados da tabela abaixo: Sobrevida de 66 por cento, 53 por cento, 40 por cento e 36,6 por cento aos 3, 6, 12 e 24 meses, respectivamente. Aos 3 anos a mortalidade imediata e tardia é de 21,5 por cento e 42,1 por cento, com total de 63,6 por cento. Menor mortalidade relacionada a arritmia quando não se conseguiu induzí-la no pós-operatório. A qualidade de vida melhorou (72,7 por cento em NYHA I e II e 81,8 por cento em QV I e II) e dois foram transplantados posteriormente. Conclusões: Melhoraram a dinâmica cardíaca, a QV e a classe funcional (NYHA). O EEF identificou pacientes com maior risco de arritmias pós-operatórias. A sobrevida de 36 por cento em 3 anos é encorajadora, levando-se em conta a gravidade dos casos. A seleção de pacientes não tem ainda critérios inequívocos.