How to HEEAL: A Patient and Peer-Centric Simulation Curriculum for Medical Error Disclosure.

Introduction: Medical errors are an unfortunate certainty with emotional and psychological consequences for patients and health care providers. No standardized medical curriculum on how to disclose medical errors to patients or peers exists. The novel HEEAL (honesty/empathy/education/apology-awareness/lessen chance for future errors) curriculum addresses this gap in medical education through a multimodality workshop. Methods: This 6-hour, two-part curriculum incorporated didactic and standardized patient (SP) simulation education with rapid cycle deliberate practice (RCDP). The morning focused on provider-patient error disclosure; the afternoon applied the same principles to provider-provider (peer) discussion. Summative simulations with SPs evaluated learners' skill baseline and improvement. Formative simulations run by expert simulation educators used RCDP to provide real-time feedback and opportunities for adjustment. Medical knowledge was measured through pre- and postintervention multiple-choice questions. Learners' confidence and attitude towards medical errors disclosure were surveyed pre- and postintervention with assistance of the Barriers to Error Disclosure Assessment tool, revised with the addition of several questions related to provider-provider disclosure. Results: Fourteen medical students participated in this pilot curriculum. Statistical significance was demonstrated in medical knowledge (p = .01), peer-disclosure skills (p = .001), and confidence in medical error disclosure (p < .001). Although there was improvement in patient-disclosure skills, this did not reach statistical significance (p = .05). Discussion: This curriculum addresses the need for designated training in medical error disclosure. Learners gained knowledge, skills, and confidence in medical error disclosure. We recommend this curriculum for medical students preparing for transition to residency.

Biosynthesis of Haloterpenoids in Red Algae via Microbial-like Type I Terpene Synthases.

Red algae or seaweeds produce highly distinctive halogenated terpenoid compounds, including the pentabromochlorinated monoterpene halomon that was once heralded as a promising anticancer agent. The first dedicated step in the biosynthesis of these natural product molecules is expected to be catalyzed by terpene synthase (TS) enzymes. Recent work has demonstrated an emerging class of type I TSs in red algal terpene biosynthesis. However, only one such enzyme from a notoriously haloterpenoid-producing red alga (Laurencia pacifica) has been functionally characterized and the product structure is not related to halogenated terpenoids. Herein, we report 10 new type I TSs from the red algae Portieria hornemannii, Plocamium pacificum, L. pacifica, and Laurencia subopposita that produce a diversity of halogenated mono- and sesquiterpenes. We used a combination of genome sequencing, terpenoid metabolomics, in vitro biochemistry, and bioinformatics to establish red algal TSs in all four species, including those associated with the selective production of key halogenated terpene precursors myrcene, trans-ß-ocimene, and germacrene D-4-ol. These results expand on a small but growing number of characterized red algal TSs and offer insight into the biosynthesis of iconic halogenated algal compounds that are not without precedence elsewhere in biology.

Front-Line Health Care Workers' COVID-19 Infection Contamination Risks: A Human Factors and Risk Analysis Study of Personal Protective Equipment.

Infectious risks escalate with complex donning and doffing personal protective equipment (PPE) protocols. Recent studies suggest that PPE donning and doffing behaviors that deviate from protocol during PPE reuse compounded the risks of health care worker (HCW) self-contamination. This study quantified the occurrence of behaviors associated with known risks in PPE use and reuse. We conducted a prospective study of emergency department HCWs and video-recorded PPE donning and doffing 5 times in simulated patient encounters. Trained coders recorded HCW behaviors according to an evidence-based guide. All 28 participants deviated from the Centers for Disease Control and Prevention (CDC) sanctioned donning and doffing protocol order, and most were documented to have (92.85%) self-contaminated at least once during each simulated clinical encounter. Behaviors that compounded self-contamination due to PPE reuse were also observed. Wide variation in PPE donning and doffing behaviors was found among front-line, experienced HCWs. Future work is needed to determine which deviations put HCWs at increased risk for accidental self-contamination and what changes are needed to the CDC protocol for protecting HCW from infections.

Generating high-quality plant and fish reference genomes from field-collected specimens by optimizing preservation.

Sample preservation often impedes efforts to generate high-quality reference genomes or pangenomes for Earth's more than 2 million plant and animal species due to nucleotide degradation. Here we compare the impacts of storage methods including solution type, temperature, and time on DNA quality and Oxford Nanopore long-read sequencing quality in 9 fish and 4 plant species. We show 95% ethanol largely protects against degradation for fish blood (22 °C, ≤6 weeks) and plant tissue (4 °C, ≤3 weeks). From this furthest storage timepoint, we assemble high-quality reference genomes of 3 fish and 2 plant species with contiguity (contig N50) and completeness (BUSCO) that achieve the Vertebrate Genome Project benchmarking standards. For epigenetic applications, we also report methylation frequency compared to liquid nitrogen control. The results presented here remove the necessity for cryogenic storage in many long read applications and provide a framework for future studies focused on sampling in remote locations, which may represent a large portion of the future sequencing of novel organisms.

Development of a simulation technical competence curriculum for medical simulation fellows.

BACKGROUND AND NEEDS: Medical educators with simulation fellowship training have a unique skill set. Simulation fellowship graduates have the ability to handle basic and common troubleshooting issues with simulation software, hardware, and equipment setup. Outside of formal training programs such as this, simulation skills are inconsistently taught and organically learned. This is important to address because there are high expectations of medical educators who complete simulation fellowships. To fill the gap, we offer one way of teaching and assessing simulation technical skills within a fellowship curriculum and reflect on lessons learned throughout the process. This report describes the instructional designs, implementation, and program evaluation of an educational intervention: a simulation technology curriculum for simulation fellows. CURRICULUM DESIGN: The current iteration of the simulation technical skill curriculum was introduced in 2018 and took approximately 8 months to develop under the guidance of expert simulation technology specialists, simulation fellowship-trained faculty, and simulation center administrators. Kern's six steps to curriculum development was used as the guiding conceptual framework. The curriculum was categorized into four domains, which emerged from the outcome of a qualitative needs assessment. Instructional sessions occurred on 5 days spanning a 2-week block. The final session concluded with summative testing. PROGRAM EVALUATION: Fellows were administered summative objective structured exams at three stations. The performance was rated by instructors using station-specific checklists. Scores approached 100% accuracy/completion for all stations. CONCLUSIONS: The development of an evidence-based educational intervention, a simulation technical skill curriculum, was highly regarded by participants and demonstrated effective training of the simulation fellows. This curriculum serves as a template for other simulationists to implement formal training in simulation technical skills.

To tPA or Not to tPA: Two Medical-Legal Misadventures of Diagnosing a Cerebrovascular Accident as a Stroke Mimic.

We present two recent successfully litigated malpractice cases in which patients with cerebrovascular accidents were misdiagnosed as stroke mimics. The first was diagnosed as a hemiplegic migraine, which occurs in only 0.01% of the population. The second was diagnosed as a conversion disorder, which ultimately has a neurologic etiology in 4% of cases. In both cases, issues of poor patient communication and poor documentation were paramount in the legal outcome. We discuss caveats of stroke mimics, tissue plasminogen activator administration liability, and pitfalls in patient and family interactions.

Adding Insult to Injury: Asymptomatic Fat Embolism Identified on Computed Tomography.

Fat embolism (FE) is a classically taught complication of long bone fractures, with the potential to cause high morbidity and mortality; however, it is rarely apparent on emergency department (ED) presentation or imaging. If recognized by the ED clinician, development of symptoms of FE may be avoided by early surgical fixation and potentially by corticosteroid administration.

Scalable Biosynthesis of the Seaweed Neurochemical, Kainic Acid.

Kainic acid, the flagship member of the kainoid family of natural neurochemicals, is a widely used neuropharmacological agent that helped unravel the key role of ionotropic glutamate receptors, including the kainate receptor, in the central nervous system. Worldwide shortages of this seaweed natural product in the year 2000 prompted numerous chemical syntheses, including scalable preparations with as few as six-steps. Herein we report the discovery and characterization of the concise two-enzyme biosynthetic pathway to kainic acid from l-glutamic acid and dimethylallyl pyrophosphate in red macroalgae and show that the biosynthetic genes are co-clustered in genomes of Digenea simplex and Palmaria palmata. Moreover, we applied a key biosynthetic α-ketoglutarate-dependent dioxygenase enzyme in a biotransformation methodology to efficiently construct kainic acid on the gram scale. This study establishes both the feasibility of mining seaweed genomes for their biotechnological prowess.

What emergency physicians should know about informed consent: legal scenarios, cases, and caveats.

The basic concept of obtaining informed consent is familiar to emergency physicians, and many consider themselves well versed on the topic; however, lack of obtaining proper informed consent is a frequent source of lawsuits. The legal definitions and nuances of informed consent might surprise even the most experienced physician. This article will detail the historical legal evolution of the concept of informed consent. It will also report defining and recent court cases that illustrate the current medical-legal status of informed consent. Special scenarios, caveats, and documentation recommendations are discussed. After reading this article the emergency physician will know how to practice and document the appropriate aspects of informed consent in emergency medicine, as well as understand available legal defenses if a lawsuit should arise.

Treating functional impairment of autism with selective serotonin-reuptake inhibitors.

OBJECTIVE: To review literature describing use of selective serotonin-reuptake inhibitors (SSRIs) in the management of functional impairments associated with autistic disorder. DATA SOURCES: EMBASE (1980-3rd quarter of 2003), International Pharmaceutical Abstracts (1970-August 2003), and MEDLINE (1966-August 2003) were searched. Search terms included autism, autistic disorder, citalopram, fluoxetine, fluvoxamine, paroxetine, selective serotonin-reuptake inhibitors, and sertraline. DATA SYNTHESIS: Studies and case reports evaluating treatment outcomes associated with the use of SSRIs in managing impairments of autism were reviewed. Multiple SSRI dosing ranges were evaluated in autistic patients of different ages with various functional impairments. No specific SSRI or dose range has been shown to improve a specific autistic symptom although some patients have demonstrated improvements. CONCLUSIONS: Benefits with SSRIs in treating functional impairments in autism have been observed. Response to therapy and adverse effects are individualized. Current evidence does not support selection of one SSRI over another for any impairment associated with autism.