Factors That Affect Legionella Positivity in Healthcare Building Water Systems from a Large, National Environmental Surveillance Initiative.

Legionella growth in healthcare building water systems can result in legionellosis, making water management programs (WMPs) important for patient safety. However, knowledge is limited on Legionella prevalence in healthcare buildings. A dataset of quarterly water testing in Veterans Health Administration (VHA) healthcare buildings was used to examine national environmental Legionella prevalence from 2015 to 2018. Bayesian hierarchical logistic regression modeling assessed factors influencing Legionella positivity. The master dataset included 201,146 water samples from 814 buildings at 168 VHA campuses. Overall Legionella positivity over the 4 years decreased from 7.2 to 5.1%, with the odds of a Legionella-positive sample being 0.94 (0.90-0.97) times the odds of a positive sample in the previous quarter for the 16 quarters of the 4 year period. Positivity varied considerably more at the medical center campus level compared to regional levels or to the building level where controls are typically applied. We found higher odds of Legionella detection in older buildings (OR 0.92 [0.86-0.98] for each more recent decade of construction), in taller buildings (OR 1.20 [1.13-1.27] for each additional floor), in hot water samples (O.R. 1.21 [1.16-1.27]), and in samples with lower residual biocide concentrations. This comprehensive healthcare building review showed reduced Legionella detection in the VHA healthcare system over time. Insights into factors associated with Legionella positivity provide information for healthcare systems implementing WMPs and for organizations setting standards and regulations.

Cytokinin stabilizes WUSCHEL by acting on the protein domains required for nuclear enrichment and transcription.

Concentration-dependent transcriptional regulation and the spatial regulation of transcription factor levels are poorly studied in plant development. WUSCHEL, a stem cell-promoting homeodomain transcription factor, accumulates at a higher level in the rib meristem than in the overlying central zone, which harbors stem cells in the shoot apical meristems of Arabidopsis thaliana. The differential accumulation of WUSCHEL in adjacent cells is critical for the spatial regulation and levels of CLAVATA3, a negative regulator of WUSCHEL transcription. Earlier studies have revealed that DNA-dependent dimerization, subcellular partitioning and protein destabilization control WUSCHEL protein levels and spatial accumulation. Moreover, the destabilization of WUSCHEL may also depend on the protein concentration. However, the roles of extrinsic spatial cues in maintaining differential accumulation of WUS are not understood. Through transient manipulation of hormone levels, hormone response patterns and analysis of the receptor mutants, we show that cytokinin signaling in the rib meristem acts through the transcriptional regulatory domains, the acidic domain and the WUSCHEL-box, to stabilize the WUS protein. Furthermore, we show that the same WUSCHEL-box functions as a degron sequence in cytokinin deficient regions in the central zone, leading to the destabilization of WUSCHEL. The coupled functions of the WUSCHEL-box in nuclear retention as described earlier, together with cytokinin sensing, reinforce higher nuclear accumulation of WUSCHEL in the rib meristem. In contrast a sub-threshold level may expose the WUSCHEL-box to destabilizing signals in the central zone. Thus, the cytokinin signaling acts as an asymmetric spatial cue in stabilizing the WUSCHEL protein to lead to its differential accumulation in neighboring cells, which is critical for concentration-dependent spatial regulation of CLAVATA3 transcription and meristem maintenance. Furthermore, our work shows that cytokinin response is regulated independently of the WUSCHEL function which may provide robustness to the regulation of WUSCHEL concentration.

Two concurrent enteric disease outbreaks among men who have sex with men, minneapolis-st paul area.

Between 1 November 2013 and 31 March 2014, concurrent shigellosis and cryptosporidiosis outbreaks occurred among men who have sex with men in the Minneapolis-St. Paul area, 75% of whom were HIV-infected. Current HIV/AIDS strategy emphasizing treatment as prevention may effectively decrease HIV transmission, but raises concerns about other diseases if safer sex messages are de-emphasized.

Investigation of inhalation anthrax case, United States.

Inhalation anthrax occurred in a man who vacationed in 4 US states where anthrax is enzootic. Despite an extensive multi-agency investigation, the specific source was not detected, and no additional related human or animal cases were found. Although rare, inhalation anthrax can occur naturally in the United States.

Vaccine-derived poliomyelitis 12 years after infection in Minnesota.

A 44-year-old woman with long-standing common variable immunodeficiency who was receiving intravenous immune globulin suddenly had paralysis of all four limbs and the respiratory muscles, resulting in death. Type 2 vaccine-derived poliovirus was isolated from stool. The viral capsid protein VP1 region had diverged from the vaccine strain at 12.3% of nucleotide positions, and the two attenuating substitutions had reverted to the wild-type sequence. Infection probably occurred 11.9 years earlier (95% confidence interval [CI], 10.9 to 13.2), when her child received the oral poliovirus vaccine. No secondary cases were identified among close contacts or 2038 screened health care workers. Patients with common variable immunodeficiency can be chronically infected with poliovirus, and poliomyelitis can develop despite treatment with intravenous immune globulin.

Foodborne outbreak of group a streptococcus pharyngitis associated with a high school dance team banquet--Minnesota, 2012.

BACKGROUND: On 20 March 2012, the Minnesota Department of Health (MDH) was notified of multiple Facebook postings suggestive of a foodborne outbreak of Group A Streptococcus (GAS) pharyngitis occurring among attendees of a high school dance team banquet. An investigation was initiated. METHODS: Associations between GAS pharyngitis and specific food items were assessed among banquet attendees. Pharyngeal swabs were performed on attendees, household contacts, and food workers. Patient GAS isolates from clinical laboratories were also obtained. Pharyngeal and food specimens were cultured for GAS by the MDH Public Health Laboratory. Isolates were further characterized by pulsed-field gel electrophoresis (PFGE) and emm typing. RESULTS: Among 63 persons who consumed banquet food, 18 primary illnesses occurred, yielding an attack rate of 29%. Although no food or beverage items were significantly associated with illness, pasta consumption yielded the highest relative risk (risk ratio, 3.56; 95% confidence interval, .25-50.6). GAS colonies with indistinguishable PFGE patterns corresponding to emm subtype 1.0 were isolated from 5 patients and from leftover pasta. The pasta was prepared at home by a dance team member parent; both parent and child reported GAS pharyngitis episodes 3 weeks before the banquet. CONCLUSIONS: In this foodborne outbreak of GAS pharyngitis, pasta was implicated as the vehicle. Recognition of foodborne GAS illness is challenging because transmission is typically assumed to occur by respiratory spread; foodborne transmission should be considered when clusters of GAS pharyngitis patients are encountered. DNA-based typing can reveal potentially epidemiologically related isolates during GAS disease outbreaks and facilitate understanding and control of GAS disease.

Implementation of a Prevention Bundle to Decrease Rates of Staphylococcus aureus Surgical Site Infection at 11 Veterans Affairs Hospitals.

Importance: While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors. Objective: To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates. Design, Setting, and Participants: This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023. Interventions: Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed. Main Outcomes and Measures: The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods. Results: Among 6696 cardiac surgical procedures and 16 309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found. Conclusions and Relevance: Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time.

Fatal Naegleria fowleri infection acquired in Minnesota: possible expanded range of a deadly thermophilic organism.

BACKGROUND: Primary amebic meningoencephalitis (PAM), caused by the free-living ameba Naegleria fowleri, has historically been associated with warm freshwater exposures at lower latitudes of the United States. In August 2010, a Minnesota resident, aged 7 years, died of rapidly progressive meningoencephalitis after local freshwater exposures, with no history of travel outside the state. PAM was suspected on the basis of amebae observed in cerebrospinal fluid. METHODS: Water and sediment samples were collected at locations where the patient swam during the 2 weeks preceding illness onset. Patient and environmental samples were tested for N. fowleri with use of culture and real-time polymerase chain reaction (PCR); isolates were genotyped. Historic local ambient temperature data were obtained. RESULTS: N. fowleri isolated from a specimen of the patient's brain and from water and sediment samples was confirmed using PCR as N. fowleri genotype 3. Surface water temperatures at the times of collection of the positive environmental samples ranged from 22.1°C to 24.5°C. August 2010 average air temperature near the exposure site was 25°C, 3.6°C above normal and the third warmest for August in the Minneapolis area since 1891. CONCLUSIONS: This first reported case of PAM acquired in Minnesota occurred 550 miles north of the previously reported northernmost case in the Americas. Clinicians should be aware that N. fowleri-associated PAM can occur in areas at much higher latitude than previously described. Local weather patterns and long-term climate change could impact the frequency of PAM.

Impact of USA300 methicillin-resistant Staphylococcus aureus on clinical outcomes of patients with pneumonia or central line-associated bloodstream infections.

BACKGROUND: The USA300 methicillin-resistant Staphylococcus aureus (MRSA) strain, which initially emerged as a cause of community-associated infections, has recently become an important pathogen in healthcare-associated infections (HAIs). However, its impact on patient outcomes has not been well studied. We evaluated patients with invasive MRSA infections to assess differences in outcomes between infections caused by USA100 and those caused by USA300. METHODS: Population-based data for invasive MRSA infections were used to identify 2 cohorts: (1) nondialysis patients with central line-associated bloodstream infections (CLABSIs) and (2) patients with community-onset pneumonia (PNEUMO) during 2005-2007 from 6 US metropolitan areas. Medical records of patients with confirmed MRSA USA100 or USA300 infection were reviewed. Logistic regression and, when appropriate, survival analysis was performed to evaluate mortality, early and late complications, and length of stay. RESULTS: A total of 236 and 100 patients were included in the CLABSI and PNEUMO cohorts, respectively. USA300 was the only independent predictor of early complications for PNEUMO patients (odds ratio [OR], 2.6; P = .02). Independent predictors of CLABSI late complications included intensive care unit (ICU) admission before MRSA culture (adjusted OR [AOR], 2.1; P= .01) and Charlson comorbidity index (AOR, 2.6; P = .003), but not strain type. PNEUMO patients were significantly more likely to die if they were older (P = .02), black (P < .001), or infected with USA100 strain (P = .02), whereas those with CLABSI were more likely to die if they were older (P < .001), had comorbidities (P < .001), or had an ICU admission before MRSA culture (P = .001). CONCLUSIONS: USA300 was associated with early complications in PNEUMO patients. However, it was not associated with mortality for either PNEUMO or CLABSI patients. Concerns regarding higher mortality from HAIs caused by USA300 may not be warranted.

Allocating resources during a crisis: you can't always get what you want.

During a disaster or disease outbreak, health care providers may have to make difficult decisions about how to allocate scarce resources. A committee convened by the Minnesota Department of Health has recently focused on this issue as part of statewide disaster preparedness planning. This article presents the group's recommendation that health care facilities need to plan for shortages and introduces resources and strategies that can be used in planning. It also discusses ethical considerations that must be taken into account when shortages occur and decisions must be made about how to distribute equipment, supplies, or medications in short supply.

A novel ergonomic wheelchair reduces bacterial hand contamination.

OBJECTIVE: To determine whether bacterial contamination of rider's hands is less with a novel ergonomic wheelchair (EW) than a standard wheelchair (SW). EXPERIMENTAL DESIGN: After wheelchair hand rims were disinfected, volunteers wearing nitrile gloves propelled each wheelchair through a standardised "run" in hospital. Post-run cultures were obtained from riders' gloved hands. Bacterial hand counts were compared between runs matched by rider (same rider, different chairs) or time (different riders in each chair, running concurrently), and overall. SETTING: Minneapolis Veterans Affairs Health Care System (MVAHCS), a large tertiary care facility. PARTICIPANTS: Eleven employee volunteers. INTERVENTION: EW, as compared with SW. With SW, co-location of hand rims and tyres potentially exposes the user's hands to tyres, which risks contaminating the user's hands with ground-source bacteria. Our novel ergonomic wheelchair (EW) separates drive wheel and hand rims, potentially reducing hand contamination. MAIN OUTCOME MEASURE: Bacterial hand counts. RESULTS: Post-run bacterial hand counts were over 10-fold lower with the EW than the SW. This was true (i) when the same rider tested both chairs sequentially (n = 8 pairs) (median counts, 40 vs. 1030; p = 0.008), (ii) when different riders tested the two chairs concurrently (n = 9 pairs) (median counts, 40 vs. 660; p = 0.004), and (iii) overall (median counts, 40 [n = 9 runs] vs. 550 [n = 10 runs]; p < 0.001). CONCLUSION: Separation of wheelchair hand rims from tyres significantly reduces bacterial hand contamination. Reduced hand contamination could decrease bacterial infections and dissemination of resistant bacteria, warranting further study.Implications for rehabilitationThe novel design of the ergonomic wheelchair, removing the push rim from proximity to the wheelchair tyre, keeps the hands of wheelchair users cleaner.The re-design of the standard manual wheelchair was implemented initially to improve shoulder ergonomics during manual wheelchair propulsion and has the added benefit of reduction in the transfer of bacteria from floors to hands for manual wheelchair users.Since the ergonomic wheelchair has the potential to decrease rates of bacterial infection in manual wheelchair users, further testing is warranted.

Comparative genome sequencing of an isogenic pair of USA800 clinical methicillin-resistant Staphylococcus aureus isolates obtained before and after daptomycin treatment failure.

We describe here a clinical daptomycin treatment failure in a patient with recurrent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in whom daptomycin was administered after a failed empirical treatment course with vancomycin and piperacillin-tazobactam. We had the opportunity to compare the genome sequences of an isogenic pair of daptomycin-susceptible and -resistant MRSA isolates obtained before and after initiation of daptomycin therapy, respectively. The genotype of both isolates was USA800, ST5, SCCmec type IV, agr type II. There was no increase in cell wall thickness in the daptomycin-resistant strain despite having decreased susceptibility to both vancomycin and daptomycin. By comparing the genome sequences by pyrosequencing, we identified a polymorphism (S337L) in the tenth transmembrane segment of the multiple peptide resistance factor, MprF, encoding lysyl phosphatidylglycerol transferase. This enzyme has been shown previously to promote repulsion of daptomycin at the cell surface by addition of positively charged lysine to phosphatidylglycerol. Also, the hlb open reading frame (ORF) encoding the ß-toxin was interrupted by a prophage in the daptomycin-susceptible strain; this phage was missing in the daptomycin-resistant isolate and the hlb ORF was restored. Loss of the phage in the resistant isolate also resulted in loss of the virulence factor genes clpP, scn, and sak. This is the first study to use pyrosequencing to compare the genomes of a daptomycin-susceptible/resistant MRSA isolate pair obtained during failed daptomycin therapy in humans.

Growth and Behavior of North American Microbes on Phragmites australis Leaves.

Phragmites australis subsp. australis is a cosmopolitan wetland grass that is invasive in many regions of the world, including North America, where it co-occurs with the closely related Phragmites australis subsp. americanus. Because the difference in invasive behavior is unlikely to be related to physiological differences, we hypothesize that interactions with unique members of their microbiomes may significantly affect the behavior of each subspecies. Therefore, we systematically inoculated both plant lineages with a diverse array of 162 fungal and bacterial isolates to determine which could (1) differentiate between Phragmites hosts, (2) infect leaves at various stages of development, or (3) obtain plant-based carbon saprophytically. We found that many of the microbes isolated from Phragmites leaves behave as saprophytes. Only 1% (two taxa) were determined to be strong pathogens, 12% (20 taxa) were weakly pathogenic, and the remaining 87% were nonpathogenic. None of the isolates clearly discriminated between host plant lineages, and the Phragmites cuticle was shown to be a strong nonspecific barrier to infection. These results largely agree with the broad body of literature on leaf-associated phyllosphere microbes in Phragmites.

Risk of surgical site infection after carpal tunnel release performed in an operating room versus a clinic-based procedure room within a Veterans Affairs medical center.

BACKGROUND: Carpal tunnel release (CTR) is increasingly performed in a clinic-based procedure room (PR) environment, which is less restrictive than traditional operating rooms (ORs). It is unknown if there is an impact on surgical site infection (SSI) rates. METHODS: Records of patients who underwent clean, elective CTR from October 2014 to April 2017 at a single site were identified using Current Procedural Terminology codes and charts reviewed using National Healthcare Safety Network SSI criteria. Procedure type and patient characteristics were assessed with multivariate logistic regression and costs compared using administrative data. RESULTS: A total of 312 procedures were included: 221 in OR and 91 in PR. SSI rate, including revisions, was 2.88% (nonrevision rate was 2.30%). Unadjusted SSI rate was 3.2% in OR and 2.2% in PR (P = .64). After adjusting for underlying risk factors, procedure setting was not associated with risk of SSI (P = .53; odds ratio, 0.43; 95% confidence interval, 0.03-5.94). Revision CTR was a predictor of SSI (P = .02; odds ratio, 28.21; 95% confidence interval, 1.84-434.57). The mean total cost of CTR in the OR was $4,254.21 and PR was $416.93. CONCLUSIONS: There was no significant difference in SSI rates for CTR performed in OR and PR environments. CTRs performed in a PR led to a 10-fold cost savings. Based on our findings of PRs as both safe and cost-effective, we recommend that more facilities explore the use of PRs for CTR.

Evaluation of surveillance methods for staphylococcal toxic shock syndrome.

We compared passive surveillance and International Classification of Diseases, 9th Revision, codes for completeness of staphylococcal toxic shock syndrome (TSS) surveillance in the Minneapolis-St. Paul area, Minnesota, USA. TSS-specific codes identified 55% of cases compared with 30% by passive surveillance and were more sensitive (p = 0.0005, McNemar chi2 12.25).

A clustering of immune-mediated polyradiculoneuropathy among swine abattoir workers exposed to aerosolized porcine brains, Indiana, United States.

In November 2007 a novel neuropathy, immune-mediated polyradiculoneuropathy (IP), was identified among workers at a Minnesota swine abattoir where a unique compressed air technique was used to remove porcine brains. An epidemiologic investigation at another abattoir in Indiana that also uses this process was launched to evaluate workers self-reporting neurologic illness compatible with IP. A nested case-control study was performed to identify cases and risk factors. Six confirmed, one probable, and three possible IP cases were detected. IP cases were 28-52 years old, of Latino origin, and 62.5% female. Onset dates ranged from April 2005-December 2007; 60% were hospitalized. IP cases at this plant were similar in clinical presentation and exposure risks to those detected in Minnesota. Swine abattoirs using similar brain extraction methods should discontinue this process.

Explaining the unexplained: identifying infectious causes of critical illness and death in Minnesota.

The Minnesota Department of Health began its unexplained critical illness and death due to possible infectious etiologies (UNEX) project in 1995. In 2006, it also began surveillance for all possible infectious disease-related and unexplained deaths investigated by medical examiners (MED-X). Surveillance for unexplained critical illness and death is focused on determining the etiology of an acute illness in a previously healthy person 50 years of age or younger whose illness is suggestive of an infectious disease. This article describes how the programs operate and how they have been able to identify the causes of a number of unexplained deaths in Minnesota. It also discusses the need for specimen collection, laboratory technologies used to identify infectious agents, and the importance of identifying etiologies of unexplained illnesses and deaths in order to prevent potential outbreaks in the greater population.

Immunohistochemistry and electrophysiological findings in swine abattoir workers with immune-mediated polyradiculoneuropathy.

IMPORTANCE: Workers exposed to aerosolized brain in a swine-processing plant developed immune-mediated polyradiculoneuropathy (IP) possibly triggered by an immune response. OBJECTIVE: Immunohistochemistry results were correlated with electrophysiological variables to examine the immunopathogenesis of this disorder. DESIGN/SETTING: Laboratory studies used normal nerve tissue that was exposed to sera from 12 IP patients; 10 exposed controls; and 10 unexposed controls. Clinical and electrophysiological data from IP patients were obtained from medical record reviews. MAIN OUTCOME MEASURES: Analysis included electromyography results of IP patients and nerve conduction studies examining CMAP amplitude, distal motor latency, motor conduction velocity, F-wave latency, sensory nerve action potential amplitude, and sensory nerve conduction velocity. Case and control results were compared relative to distance from exposure. RESULTS: Electrodiagnostic findings revealed prolongation of the distal and f-wave latencies suggestive of demyelination at the level of the nerve root and distal nerve terminals. Immunohistochemical results identified an antibody to the peripheral nerve, with staining at the level of the axolemma. Thus, IP may be a primary axonopathy with secondary paranodal demyelination causing the conduction changes. Staining of the distal and proximal portions of the nerve appears consistent with easier access through the blood-nerve barrier. CONCLUSIONS AND RELEVANCE: IP is an immune-mediated neuropathy related to antibodies to an axon-based antigen on peripheral nerves. Secondary paranodal demyelination is likely. Further studies to identify the primary axonal antigenic target would be useful.

A Case of Lassa Fever Diagnosed at a Community Hospital-Minnesota 2014.

BACKGROUND: In April 2014, a 46-year-old returning traveler from Liberia was transported by emergency medical services to a community hospital in Minnesota with fever and altered mental status. Twenty-four hours later, he developed gingival bleeding. Blood samples tested positive for Lassa fever RNA by reverse transcriptase polymerase chain reaction. METHODS: Blood and urine samples were obtained from the patient and tested for evidence of Lassa fever virus infection. Hospital infection control personnel and health department personnel reviewed infection control practices with health care personnel. In addition to standard precautions, infection control measures were upgraded to include contact, droplet, and airborne precautions. State and federal public health officials conducted contract tracing activities among family contacts, health care personnel, and fellow airline travelers. RESULTS: The patient was discharged from the hospital after 14 days. However, his recovery was complicated by the development of near complete bilateral sensorineural hearing loss. Lassa virus RNA continued to be detected in his urine for several weeks after hospital discharge. State and federal public health authorities identified and monitored individuals who had contact with the patient while he was ill. No secondary cases of Lassa fever were identified among 75 contacts. CONCLUSIONS: Given the nonspecific presentation of viral hemorrhagic fevers, isolation of ill travelers and consistent implementation of basic infection control measures are key to preventing secondary transmission. When consistently applied, these measures can prevent secondary transmission even if travel history information is not obtained, not immediately available, or the diagnosis of a viral hemorrhagic fever is delayed.

An innovative approach to teaching resuscitation skills.

We report the impact of a monthly educational exercise for residents that emphasized practical skills and equipment usage rather than knowledge of advanced cardiac life support (ACLS) protocols. Residents were divided into groups of approximately four that rotated through three stations. Each station included several objectives, most of which related to specific types of equipment. The exercise was held six times from July 2003 to June of 2004. Sixty-seven residents participated and completed a questionnaire prior to and following the exercise. The questionnaire elicited comfort level with basic tasks including using an automated external defibrillator (AED), attaching leads and paddles to read a cardiac rhythm, delivering unsynchronized shocks with monophasic and biphasic defibrillators and implementing the pacing function on a defibrillator. There were significant differences in the pre- and post-answers to each question. The largest difference was found in the question asking how comfortable participants were delivering unsynchronized shocks with a defibrillator. Importantly, responses for the question 'How comfortable are you being a code leader?' showed significant improvement. Simple skills such as attaching tubing to the oxygen tank, turning on the defibrillator and entering appropriate charge, or positioning paddles and monitor leads properly often caused significant difficulty. Cardiopulmonary arrests tend to generate anxiety among house staff, despite certification in ACLS and adequate knowledge of protocols. Exercises, such as the one presented here, will reduce anxiety by specifically addressing this skill. We conclude that residents benefit from additional teaching and practice in actual performance of basic skills used during cardiac arrests. Furthermore, our data demonstrate that comfort levels among house officers increase when they are given the opportunity to practice these skills.