Impact of simulation-based training on perceived provider confidence in acute multidisciplinary pediatric trauma resuscitation.

PURPOSE: Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients. METHODS: An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children's hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation. RESULTS: Survey response rate was 49% (n = 93/190) pre-simulation, 22% (n = 42/190) post-simulation, and 79% (n = 150/190) at 2-year follow-up. These providers reported more anxiety (p = 0.01) and less confidence (p = 0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p = 0.02) and greater confidence (p = 0.01), compared to untrained providers. CONCLUSIONS: Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence. LEVEL OF EVIDENCE: II, Prospective cohort.

Acute Hemorrhage on the Playing Field.

Acute hemorrhage in sport is a common issue for the sideline professional. The severity of bleeding ranges from mild to severe and life- or limb-threatening. The mainstay of management of acute hemorrhage is achieving hemostasis. Hemostasis is frequently accomplished via direct pressure but may require more invasive management including tourniquet use or pharmacologic management. With concerns for internal bleeding, dangerous mechanism of injury, or signs of shock, prompt activation of the emergency action plan is required.

Comparing fluoroscopic versus ultrasound guidance in glenohumeral joint aspiration.

BACKGROUND: Joint aspiration is a common technique used to aid in the diagnosis of glenohumeral pathology. Fluoroscopy and ultrasound are both used as image-guidance methods to increase the accuracy of the procedure. There are no prior studies comparing the ability of these two methods to obtain joint fluid. OBJECTIVE: To evaluate whether fluoroscopy or ultrasound-image guidance more often obtains fluid from the glenohumeral joint and which technique obtains a greater amount of fluid. DESIGN: Retrospective cohort study. SETTING: Single academic orthopedic clinic. PATIENTS: A total of 206 patients undergoing glenohumeral aspiration, generally to rule out infection. INTERVENTIONS: Fluoroscopic- or ultrasound-guided joint aspirations, performed by numerous physicians. MAIN OUTCOME MEASURES: Primary was the successful aspiration of at least 0.1 mL of joint fluid; secondary was the total amount of joint fluid obtained. RESULTS: There was no significant difference in rate of successful aspirations between ultrasound (69.4% successful; 95% confidence interval [CI] = 54.4%, 84.5%) and fluoroscopy (70.6% successful; 95% CI = 63.7%, 77.4%). The amounts of fluid obtained by fluoroscopy and ultrasound did not differ significantly (p = .349; mean ± standard deviation [SD] = 7.1 ± 12.6 vs. 10.0 ± 16.8 mL; median [interquartile range [IQR] = 3 [7] vs. 5 [8.75] mL). Sub-analysis showed that significantly more fluid was obtained with fluoroscopy in patients with a >35 body mass index (BMI) (adjusted mean = 7.9 mL; 95% CI = 4.3, 11.5) when compared with ultrasound (2.3 mL; 95% CI = 0.6, 4.0). CONCLUSIONS: Fluoroscopic- and ultrasound-guided aspirations of the glenohumeral joint demonstrate similar success in obtaining fluid. For nonobese patients, ultrasound guidance is typically less expensive, office-based, less uncomfortable, and allows for dynamic visualization. For obese patients, fluoroscopy appears to have an advantage with respect to the amount of fluid obtained. Prospective studies are warranted to make more robust conclusions.

Learning Effect for Large Joint Diagnostic Aspirations With Fluoroscopy and Ultrasound.

OBJECTIVE: The first objective was to identify whether increased experience, gauged by number of procedures performed posttraining, is correlated with greater likelihood of obtaining joint fluid in diagnostic aspirations. The second objective was to identify whether trainee involvement at the time of procedure affected the success rate of the procedure (which in this case was obtaining fluid on aspiration). DESIGN: This was a retrospective analysis of fluoroscopic- and ultrasound-guided large joint aspirations. Logarithmic fit was performed to identify the presence of a learning curve to the successful attainment of fluid with experience. Logistic regression analysis was used to identify whether trainee presence for a procedure affected fluid attainment. RESULTS: Ultrasound did not demonstrate a significant fit to the logarithmic curve ( P = 0.447), whereas fluoroscopy did ( P < 0.001), indicative of a learning curve for fluoroscopy. After adjusting for covariates, joint fluid was successfully attained at a similar rate whether trainees were present or not. Significant independent factors related to successful joint fluid attainment were image guidance technique ( P = 0.001), body mass index ( P = 0.032), and joint aspirated (overall P < 0.001). CONCLUSION: There was a statistically significant learning curve for fluoroscopic-guided joint aspirations, but not with ultrasound guidance. Trainee involvement did not affect the success rate of joint aspirations.

The decreased expression of Beclin-1 correlates with progression to esophageal adenocarcinoma: the role of deoxycholic acid.

Beclin-1 has a central role in the regulation of autophagy. Barrett's esophagus (BE) is associated with a significantly increased risk for the development of esophageal adenocarcinoma (EAC). In the current study, we evaluated the role of Beclin-1 and autophagy in the EAC. Biopsies obtained from patients with BE and EAC, tissues from a rat model of BE and EAC, and esophageal cell lines were evaluated for the expression of Beclin-1 by immunohistochemistry, immunoblotting, or RT-PCR. Since reflux of bile acids is important in EAC, we also evaluated the effect of exposure to deoxycholic acid (DCA) on autophagy and Beclin-1 expression. Beclin-1 expression was high in squamous epithelium and nondysplastic BE, whereas its expression was low in dysplastic BE and EAC. The same pattern of expression was observed in rat tissues and in esophageal cell lines. Normal esophageal epithelium and HET-1A cells (derived from normal squamous epithelium) show high levels of Beclin-1, but lower levels of Beclin-1 were found in BE and EAC cell lines (CP-A, CP-C, and OE33). Acute exposure to DCA led to increased Beclin-1 expression and increased autophagy as evaluated by electron microscopy and counting percentage of GFP-LC3-positive BE cells with punctate pattern. In contrast, chronic exposure to DCA did not result in the alteration of Beclin-1 levels or autophagy. In summary, these data suggest that autophagy is initially activated in response to bile acids, but chronic exposure to bile acids leads to decreased Beclin-1 expression and autophagy resistance.

Hip aspiration: A comparison of ultrasound and fluoroscopic guidance.

Introduction: Hip aspirations are commonly performed for diagnostic purposes using either fluoroscopic or ultrasound guidance. The superiority of one type of image guidance over another for aspiration of a native or replaced hip remains a matter of debate. The questions to be evaluated in this study include 1) to determine if hip aspiration using fluoroscopy or ultrasound guidance more often obtains fluid from native and post-arthroplasty hip joints, and 2) to identify patient-related factors associated with the ability to obtain fluid. Material and methods: A retrospective analysis of all hip aspirations (433) performed at a single institution was undertaken, with the primary outcome variable being successful attainment of joint fluid. Age, body mass index (BMI), sex, presence of a trainee, presence of an arthroplasty at the time of aspiration on the affected side, amount of fluid collected, and type of image guidance were used as independent variables in regression models. Results: 1) The likelihood of obtaining fluid was approximately 2.1 times greater with ultrasound guidance than fluoroscopy guidance (95% CI = 1.382, 3.117; p < 0.001). 2) Ultrasound guidance and lower BMI were independently associated with a significantly higher likelihood of obtaining fluid. Additionally, one unit decrease in BMI was associated with about a 3% increase in the odds of obtaining fluid (95% CI = 0.950, 0.998; p = 0.033). Conclusion: This study demonstrates that the use of ultrasound guidance for hip joint aspiration, when compared to fluoroscopic guidance, is more likely to result in a successful aspiration and the acquisition of a greater volume of fluid. Therefore, ultrasound guidance is the preferred method for hip aspiration in both native and replaced hips.

Characterization of squamous esophageal cells resistant to bile acids at acidic pH: implication for Barrett's esophagus pathogenesis.

Barrett's esophagus (BE) is a premalignant condition, where normal squamous epithelium is replaced by intestinal epithelium. BE is associated with an increased risk of developing esophageal adenocarcinoma (EAC). However, the BE cell of origin is not clear. We hypothesize that BE tissue originates from esophageal squamous cells, which can differentiate to columnar cells as a result of repeated exposure to gastric acid and bile acids, two components of refluxate implicated in BE pathology. To test this hypothesis, we repeatedly exposed squamous esophageal HET1A cells to 0.2 mM bile acid (BA) cocktail at pH 5.5 and developed an HET1AR-resistant cell line. These cells are able to survive and proliferate after repeated 2-h treatments with BA at pH 5.5. HET1AR cells are resistant to acidification and express markers of columnar differentiation, villin, CDX2, and cytokeratin 8/18. HET1AR cells have increased amounts of reactive oxygen species, concomitant with a decreased level and activity of manganese superoxide dismutase compared with parental cells. Furthermore, HET1AR cells express proteins and activate signaling pathways associated with inflammation, cell survival, and tumorigenesis that are thought to contribute to BE and EAC development. These include STAT3, NF-κB, epidermal growth factor receptor (EGFR), cyclooxygenase-2, interleukin-6, phosphorylated mammalian target of rapamycin (p-mTOR), and Mcl-1. The expression of prosurvival and inflammatory proteins and resistance to cell death could be partially modified by inhibition of STAT3 signaling. In summary, our study shows that long-term exposure of squamous cells to BA at acidic pH causes the cells to display the same characteristics and markers as BE.

Qualitative assessment of simulation-based training for pediatric trauma resuscitation.

BACKGROUND: Effective teamwork is critical in the trauma bay, although there is a lack of consensus related to optimal training for these skills. We implemented in situ trauma simulations with debriefing as a possible training methodology to improve team-oriented skills. METHODS: Focus groups were conducted with multidisciplinary clinicians who respond to trauma activations. The focus group questions were intended to elicit discussion on the clinicians' experiences during trauma activations and simulations with an emphasis on confidence, leadership, cooperation, communication, and opportunities for improvement. Thematic content analysis was conducted using Atlas.ti analytical software. RESULTS: Ten focus groups were held with a total of 55 clinicians. Qualitative analysis of focus group feedback revealed the following selected themes: characteristics of a strong leader during a trauma, factors impacting trauma team members' confidence, and effective communication as a key component during trauma response. Participants recommended continued simulations to enhance trauma team trust and efficiency. CONCLUSION: Clinicians responding to pediatric trauma resuscitations valued the practice they received during trauma simulations and supported the continuation of the simulations to improve trauma activation teamwork and communication. Findings will inform the development of future simulation-based training programs to improve teamwork, confidence, and communication between trauma team members.

The Na+/H+ exchanger controls deoxycholic acid-induced apoptosis by a H+-activated, Na+-dependent ionic shift in esophageal cells.

Apoptosis resistance is a hallmark of cancer cells. Typically, bile acids induce apoptosis. However during gastrointestinal (GI) tumorigenesis the cancer cells develop resistance to bile acid-induced cell death. To understand how bile acids induce apoptosis resistance we first need to identify the molecular pathways that initiate apoptosis in response to bile acid exposure. In this study we examined the mechanism of deoxycholic acid (DCA)-induced apoptosis, specifically the role of Na(+)/H(+) exchanger (NHE) and Na(+) influx in esophageal cells. In vitro studies revealed that the exposure of esophageal cells (JH-EsoAd1, CP-A) to DCA (0.2 mM-0.5 mM) caused lysosomal membrane perturbation and transient cytoplasmic acidification. Fluorescence microscopy in conjunction with atomic absorption spectrophotometry demonstrated that this effect on lysosomes correlated with influx of Na(+), subsequent loss of intracellular K(+), an increase of Ca(2+) and apoptosis. However, ethylisopropyl-amiloride (EIPA), a selective inhibitor of NHE, prevented Na(+), K(+) and Ca(2+) changes and caspase 3/7 activation induced by DCA. Ouabain and amphotericin B, two drugs that increase intracellular Na(+) levels, induced similar changes as DCA (ion imbalance, caspase3/7 activation). On the contrary, DCA-induced cell death was inhibited by medium with low a Na(+) concentrations. In the same experiments, we exposed rat ileum ex-vivo to DCA with or without EIPA. Severe tissue damage and caspase-3 activation was observed after DCA treatment, but EIPA almost fully prevented this response. In summary, NHE-mediated Na(+) influx is a critical step leading to DCA-induced apoptosis. Cells tolerate acidification but evade DCA-induced apoptosis if NHE is inhibited. Our data suggests that suppression of NHE by endogenous or exogenous inhibitors may lead to apoptosis resistance during GI tumorigenesis.