Informal Peer Support and Intentional Acts of Kindness May Attenuate the Impact of Work-Related Stressors on Compassion Satisfaction, Secondary Traumatic Stress, and Burnout of Emergency Medical Services Clinicians.

OBJECTIVE: Emergency medical services (EMS) Code Lavender was developed to support EMS clinicians after stressful events via consistent recognition of events, informal peer support, and intentional acts of kindness. This study evaluated changes in burnout screening tool responses of EMS clinicians in response to program implementation and the coincidental start of coronavirus disease 2019. METHODS: Anonymous surveys with demographic questions and 2 burnout screening tools were distributed before program implementation (spring 2020) and 20 months later (fall 2021). Analysis included t-tests, Fisher exact tests, and multivariable linear regression. RESULTS: Seventy-seven preprogram (59% response rate) and 108 intraprogram (88% response rate) survey responses were included. No changes existed between preprogram and intraprogram responses across all subscale scores. Sex was associated with depersonalization subscale scores, with men having scores 1.53 (95% confidence interval [CI] 0.11-2.95) higher than women. Compared with emergency medical technicians, paramedics had higher compassion satisfaction (OR 3.50; 95% CI 1.79-5.70) and personal accomplishment scores (OR 2.40; 95% CI 1.08-3.71). Transport nurses had higher personal accomplishment (OR 3.29; 95% CI 1.18-5.40), depersonalization (OR 3.73; 95% CI 1.19-6.26), and rates of burnout symptoms (OR 0.54; 95% CI 0.09-0.98) than emergency medical technicians. CONCLUSION: The organizational commitment, peer support, and authentic leadership of EMS Code Lavender may attenuate work-related stressors among EMS clinicians.

Supporting Emergency Medical Services Clinicians Through Acute and Sustained Crises With Informal Peer Support and Intentional Acts of Kindness: The Emergency Medical Services Code Lavender Program.

OBJECTIVE: Given the recommendations against the use of critical incident stress debriefing, the emergency medical services (EMS) Code Lavender program was created as a mechanism to consistently recognize and reach out to EMS clinicians after acute crisis events, offer nonintrusive informal peer support and acts of kindness, and provide stepwise support via mental health professionals as needed. The study aimed to assess program utilization and evaluate the program's impact on EMS clinicians' perceptions of support and resources available to them after an acute crisis event. METHODS: Anonymous surveys were distributed before program implementation and 18 months later. Program utilization was tracked using REDCap (Vanderbilt University, Nashville, TN). Fisher exact tests and logistic regression were used to analyze the survey results. RESULTS: Within 30 months, 87 referrals were made. Seventy-seven preprogram (59% response rate) and 104 intraprogram (88% response rate) surveys were collected. There were no differences between respondents by sex or role. There were significant improvements in knowing where to go for help (from 40% to 85%, P < .001) and willingness to seek help if needed (from 40% to 59%, P = .02). CONCLUSION: The implementation of an EMS Code Lavender program led to significant increases in EMS clinician self-reported knowledge of where to go and willingness to seek help after acute crisis events.

Use of Six Sigma strategies to pull the line on central line-associated bloodstream infections in a neurotrauma intensive care unit.

The creation of a consistent culture of safety and quality in an intensive care unit is challenging. We applied the Six Sigma Define-Measure-Analyze-Improve-Control (DMAIC) model for quality improvement (QI) to develop a long-term solution to improve outcomes in a high-risk neurotrauma intensive care unit. We sought to reduce central line utilization as a cornerstone in preventing central line-associated bloodstream infections (CLABSIs). This study describes the successful application of the DMAIC model in the creation and implementation of evidence-based quality improvement designed to reduce CLABSIs to below national benchmarks.

Acquisition of antigen-presenting functions by neutrophils isolated from mice with chronic colitis.

Active episodes of the inflammatory bowel diseases are associated with the infiltration of large numbers of myeloid cells including neutrophils, monocytes, and macrophages. The objective of this study was to systematically characterize and define the different populations of myeloid cells generated in a mouse model of chronic gut inflammation. Using the T cell transfer model of chronic colitis, we found that induction of disease was associated with enhanced production of myelopoietic cytokines (IL-17 and G-CSF), increased production of neutrophils and monocytes, and infiltration of large numbers of myeloid cells into the mesenteric lymph nodes (MLNs) and colon. Detailed characterization of these myeloid cells revealed three major populations including Mac-1(+)Ly6C(high)Gr-1(low/neg) cells (monocytes), Mac-1(+)Ly6C(int)Gr-1(+) cells (neutrophils), and Mac-1(+)Ly6C(low/neg)Gr-1(low/neg) leukocytes (macrophages, dendritic cells, and eosinophils). In addition, we observed enhanced surface expression of MHC class II and CD86 on neutrophils isolated from the inflamed colon when compared with neutrophils obtained from the blood, the MLNs, and the spleen of colitic mice. Furthermore, we found that colonic neutrophils had acquired APC function that enabled these granulocytes to induce proliferation of OVA-specific CD4(+) T cells in an Ag- and MHC class II-dependent manner. Finally, we observed a synergistic increase in proinflammatory cytokine and chemokine production following coculture of T cells with neutrophils in vitro. Taken together, our data suggest that extravasated neutrophils acquire APC function within the inflamed bowel where they may perpetuate chronic gut inflammation by inducing T cell activation and proliferation as well as by enhancing production of proinflammatory mediators.

Progressive vascular changes in a transgenic mouse model of squamous cell carcinoma.

Phage display was used to identify homing peptides for blood vessels in a mouse model of HPV16-induced epidermal carcinogenesis. One peptide, CSRPRRSEC, recognized the neovasculature in dysplastic skin but not in carcinomas. Two other peptides, with the sequences CGKRK and CDTRL, preferentially homed to neovasculature in tumors and, to a lesser extent, premalignant dysplasias. The peptides did not home to vessels in normal skin, other normal organs, or the stages in pancreatic islet carcinogenesis in another mouse model. The CGKRK peptide may recognize heparan sulfates in tumor vessels. The dysplasia-homing peptide is identical to a loop in kallikrein-9 and may bind a kallikrein inhibitor or substrate. Thus, characteristics of the angiogenic vasculature distinguish premalignant and malignant stages of skin tumorigenesis.

Patient Utilization of Online Information and its Influence on Orthopedic Surgeon Selection: Cross-sectional Survey of Patient Beliefs and Behaviors.

BACKGROUND: Patient attitudes and behavior are critical to understand owing to the increasing role of patient choice. There is a paucity of investigation into the perceived credibility of online information and whether such information impacts how patients choose their surgeons. OBJECTIVE: The purpose of this study was to explore the attitudes and behavior of patients regarding online information and orthopedic surgeon selection. Secondary purposes included gaining insight into the relative importance of provider selection factors, and their association with patient age and education level. METHODS: This was a cross-sectional study involving five multispecialty orthopedic surgery groups. A total of 329 patients who sought treatment by six different orthopedic surgeons were asked to anonymously answer a questionnaire consisting of 25 questions. Four questions regarded demographic information, 10 questions asked patients to rate the importance of specific criteria regarding the selection of their orthopedic surgeon (on a 4-point Likert scale), and 6 questions were designed to determine patient attitude and behaviors related to online information. RESULTS: Patient-reported referral sources included the emergency room (29/329, 8.8%), friend (42/329, 12.8%), insurance company (47/329, 14.3%), internet search/website (28/329, 8.5%), primary care physician (148/329, 45.0%), and other (34/329, 10.3%). Among the 329 patients, 130 (39.5%) reported that they searched the internet for information before their first visit. There was a trend of increased belief in online information to be accurate and complete in younger age groups (P=.02). There was an increased relative frequency in younger groups to perceive physician rating websites to be unbiased (P=.003), provide sufficient patient satisfaction information (P=.01), and information about physician education and training (P=.03). There was a significant trend for patients that found a surgeon's website to be useful (P<.001), with the relative frequency increased in younger age groups. CONCLUSIONS: This study shows that insurance network, physician referrals, appointment availability, and office location are important to patients, whereas advertising and internet reviews by other patients were considered to be not as helpful in choosing an orthopedic surgeon. Future studies may seek to identify obstacles to patients in integrating online resources for decision-making and strategies to improve health-seeking behaviors.

Passively sensing SARS-CoV-2 RNA in public transit buses.

Affordably tracking the transmission of respiratory infectious diseases in urban transport infrastructures can inform individuals about potential exposure to diseases and guide public policymakers to prepare timely responses based on geographical transmission in different areas in the city. Towards that end, we designed and tested a method to detect SARS-CoV-2 RNA in the air filters of public buses, revealing that air filters could be used as passive fabric sensors for the detection of viral presence. We placed and retrieved filters in the existing HVAC systems of public buses to test for the presence of trapped SARS-CoV-2 RNA using phenol-chloroform extraction and RT-qPCR. SARS-CoV-2 RNA was detected in 14% (5/37) of public bus filters tested in Seattle, Washington, from August 2020 to March 2021. These results indicate that this sensing system is feasible and that, if scaled, this method could provide a unique lens into the geographically relevant transmission of SARS-CoV-2 through public transit rider vectors, pooling samples of riders over time in a passive manner without installing any additional systems on transit vehicles.

Smartphone camera oximetry in an induced hypoxemia study.

Hypoxemia, a medical condition that occurs when the blood is not carrying enough oxygen to adequately supply the tissues, is a leading indicator for dangerous complications of respiratory diseases like asthma, COPD, and COVID-19. While purpose-built pulse oximeters can provide accurate blood-oxygen saturation (SpO2) readings that allow for diagnosis of hypoxemia, enabling this capability in unmodified smartphone cameras via a software update could give more people access to important information about their health. Towards this goal, we performed the first clinical development validation on a smartphone camera-based SpO2 sensing system using a varied fraction of inspired oxygen (FiO2) protocol, creating a clinically relevant validation dataset for solely smartphone-based contact PPG methods on a wider range of SpO2 values (70-100%) than prior studies (85-100%). We built a deep learning model using this data to demonstrate an overall MAE = 5.00% SpO2 while identifying positive cases of low SpO2 < 90% with 81% sensitivity and 79% specificity. We also provide the data in open-source format, so that others may build on this work.

A tumor-homing peptide with a targeting specificity related to lymphatic vessels.

Blood vessels of tumors carry specific markers that are usually angiogenesis-related. We previously used phage-displayed peptide libraries in vivo to identify peptides that home to tumors through the circulation and that specifically bind to the endothelia of tumor blood vessels. Here we devised a phage screening procedure that would favor tumor-homing to targets that are accessible to circulating phage, but are not blood vessels. Screening on MDA-MB-435 breast carcinoma xenografts yielded multiple copies of a phage that displays a cyclic 9-amino-acid peptide, LyP-1. Homing and binding to tumor-derived cell suspensions indicated that LyP-1 also recognizes an osteosarcoma xenograft, and spontaneous prostate and breast cancers in transgenic mice, but not two other tumor xenografts. Fluorescein-labeled LyP-1 peptide was detected in tumor structures that were positive for three lymphatic endothelial markers and negative for three blood vessel markers. LyP-1 accumulated in the nuclei of the putative lymphatic cells, and in the nuclei of tumor cells. These results suggest that tumor lymphatics carry specific markers and that it may be possible to specifically target therapies into tumor lymphatics.

Achilles Tendon Rip-Stop SpeedBridge Repair.

Achilles tendon injuries have been on the rise secondary to our increased participation in sports, increase in societal obesity rates, and the growing elderly population. There has been disagreement in recent years about whether to treat injuries such as Achilles tendon ruptures operatively or nonoperatively with aggressive functional rehabilitation. For those opting to surgically manage Achilles tendon ruptures, insertional Achilles tendonitis, or augment the described SpeedBridge Achilles tendon repair, we propose a modified rip-stop technique. The goal of this technique is to provide a biomechanical advantage to our current operative interventions for these injuries, a greater load-to-failure and a speedier, more reliable return to sport in our athletic populations.

A COVID-19 Airway Management Innovation with Pragmatic Efficacy Evaluation: The Patient Particle Containment Chamber.

The unique resource constraints, urgency, and virulence of the coronavirus disease 2019 pandemic has sparked immense innovation in the development of barrier devices to protect healthcare providers from infectious airborne particles generated by patients during airway management interventions. Of the existing devices, all have shortcomings which render them ineffective and impractical in out-of-hospital environments. Therefore, we propose a new design for such a device, along with a pragmatic evaluation of its efficacy. Must-have criteria for the device included: reduction of aerosol transmission by at least 90% as measured by pragmatic testing; construction from readily available, inexpensive materials; easy to clean; and compatibility with common EMS stretchers. The Patient Particle Containment Chamber (PPCC) consists of a standard shower liner draped over a modified octagonal PVC pipe frame and secured with binder clips. 3D printed sleeve portals were used to secure plastic sleeves to the shower liner wall. A weighted tube sealed the exterior base of the chamber with the contours of the patient's body and stretcher. Upon testing, the PPCC contained 99% of spray-paint particles sprayed over a 90s period. Overall, the PPCC provides a compact, affordable option that can be used in both the in-hospital and out-of-hospital environments.

Observation of an antiferromagnetic quantum critical point in high-purity LaNiO3.

Amongst the rare-earth perovskite nickelates, LaNiO3 (LNO) is an exception. While the former have insulating and antiferromagnetic ground states, LNO remains metallic and non-magnetic down to the lowest temperatures. It is believed that LNO is a strange metal, on the verge of an antiferromagnetic instability. Our work suggests that LNO is a quantum critical metal, close to an antiferromagnetic quantum critical point (QCP). The QCP behavior in LNO is manifested in epitaxial thin films with unprecedented high purities. We find that the temperature and magnetic field dependences of the resistivity of LNO at low temperatures are consistent with scatterings of charge carriers from weak disorder and quantum fluctuations of an antiferromagnetic nature. Furthermore, we find that the introduction of a small concentration of magnetic impurities qualitatively changes the magnetotransport properties of LNO, resembling that found in some heavy-fermion Kondo lattice systems in the vicinity of an antiferromagnetic QCP.

Lymphatic zip codes in premalignant lesions and tumors.

Blood vessels in tumors are morphologically and functionally distinct from normal resting blood vessels. We probed lymphatic vessels in premalignant lesions and tumors by in vivo screening of phage-displayed peptide libraries, asking whether they too have distinctive signatures. The resulting peptides begin to define such signatures. One peptide identified the lymphatics in a human melanoma xenograft. Another recognized the lymphatics in prostate cancers but not in premalignant prostate lesions; this peptide similarly identifies human prostate cancer lymphatics. A third was selective for the lymphatics in the premalignant prostate lesions. A fourth identified the lymphatics in dysplasias and squamous carcinomas of the cervix and skin. None recognize lymphatics in normal tissues. Thus, tumor development is associated with organ- and stage-specific changes in lymphatics. Systemic treatment of mice with fusions of a lymphatic homing peptide and a proapoptotic motif reduced the number of tumor lymphatics in prostate tumor and melanoma, forecasting future lymphatic targeting agents for detection and therapeutic intervention.

Unconventional slowing down of electronic recovery in photoexcited charge-ordered La1/3Sr2/3FeO3.

The coupling of ordered electronic phases with lattice, spin, and orbital degrees of freedom are of central interest in strongly correlated systems. Their interplay has been intensively studied from femtosecond to picosecond time scales, while their dynamics beyond nanoseconds are usually assumed to follow lattice cooling. Here, we report an unusual slowing down of the recovery of an electronic phase across a first-order phase transition. Following optical excitation, the recovery time of both transient optical reflectivity and X-ray diffraction intensity from the charge-ordered superstructure in a La1/3Sr2/3FeO3 thin film increases by orders of magnitude as the sample temperature approaches the phase transition temperature. In this regime, the recovery time becomes much longer than the lattice cooling time. The combined experimental and theoretical investigation shows that the slowing down of electronic recovery corresponds to the pseudo-critical dynamics that originates from magnetic interactions close to a weakly first-order phase transition.

Image registration of low signal-to-noise cryo-STEM data.

Combining multiple fast image acquisitions to mitigate scan noise and drift artifacts has proven essential for picometer precision, quantitative analysis of atomic resolution scanning transmission electron microscopy (STEM) data. For very low signal-to-noise ratio (SNR) image stacks - frequently required for undistorted imaging at liquid nitrogen temperatures - image registration is particularly delicate, and standard approaches may either fail, or produce subtly specious reconstructed lattice images. We present an approach which effectively registers and averages image stacks which are challenging due to their low-SNR and propensity for unit cell misalignments. Registering all possible image pairs in a multi-image stack leads to significant information surplus. In combination with a simple physical picture of stage drift, this enables identification of incorrect image registrations, and determination of the optimal image shifts from the complete set of relative shifts. We demonstrate the effectiveness of our approach on experimental, cryogenic STEM datasets, highlighting subtle artifacts endemic to low-SNR lattice images and how they can be avoided. High-SNR average images with information transfer out to 0.72 Å are achieved at 300 kV and with the sample cooled to near liquid nitrogen temperature.

Effect of defects on reaction of NiO surface with Pb-contained solution.

In order to understand the role of defects in chemical reactions, we used two types of samples, which are molecular beam epitaxy (MBE) grown NiO(001) film on Mg(001) substrate as the defect free NiO prototype and NiO grown on Ni(110) single crystal as the one with defects. In-situ observations for oxide-liquid interfacial structure and surface morphology were performed for both samples in water and Pb-contained solution using high-resolution X-ray reflectivity and atomic force microscopy. For the MBE grown NiO, no significant changes were detected in the high-resolution X-ray reflectivity data with monotonic increase in roughness. Meanwhile, in the case of native grown NiO on Ni(110), significant changes in both the morphology and atomistic structure at the interface were observed when immersed in water and Pb-contained solution. Our results provide simple and direct experimental evidence of the role of the defects in chemical reaction of oxide surfaces with both water and Pb-contained solution.

Molecular profiling of heart endothelial cells.

BACKGROUND: Endothelial cells that line the vascular lumen can express cell-surface proteins that are specific to the endothelium of a particular tissue. In this study, we probed the heart vasculature for heart-specific endothelial markers by phage display. METHODS AND RESULTS: We used a novel combination of in vivo phage selection and a bacterial 2-hybridization scheme against a heart cDNA library, which allows simultaneous identification of peptides that specifically bind to the target endothelium, as well as the endothelial molecules (receptors) recognized by the peptides. We found 5 heart-targeting peptides and their receptors. We confirmed and quantified the selective expression of 4 of the proteins in heart endothelial cells by independent methods. The heart specificity of phages was as high as 300-fold greater than that of nonrecombinant control phages. The proteins selectively expressed by the heart endothelium were in most cases also expressed by cardiomyocytes and, at lower levels, in some other tissues. CONCLUSIONS: These findings provide new markers for the endothelium of heart vessels and reveal a commonality between parenchymal and endothelial gene expression in the heart. The heart-homing peptides provide a means of targeting diagnostic and therapeutic agents to the heart, and their receptors are potential drug discovery targets.

Role of reactive metabolites of oxygen and nitrogen in inflammatory bowel disease.

The inflammatory bowel diseases (IBD; Crohn's disease, ulcerative colitis) are a collection of chronic idiopathic inflammatory disorders of the intestine and/or colon. Although the pathophysiology of IBD is not known with certainty, a growing body of experimental and clinical data suggests that chronic gut inflammation may result from a dysregulated immune response to normal bacterial antigens. This uncontrolled immune system activation results in the sustained overproduction of reactive metabolites of oxygen and nitrogen. It is thought that some of the intestinal and/or colonic injury and dysfunction observed in IBD is due to elaboration of these reactive species. This review summarizes the current state-of-knowledge of the role of reactive oxygen species and nitric oxide in the pathophysiology of IBD.

Nitric oxide and chronic gut inflammation: controversies in inflammatory bowel disease.

One of the most consistent and dramatic findings in both experimental and human inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis) is the enhanced expression of the inducible isoform of nitric oxide synthase (iNOS) and the sustained overproduction of the free radical nitric oxide (NO). The role that iNOS-derived NO plays in the pathophysiology of inflammatory bowel disease remains the subject of intense investigation and active debate. Although several different studies using a variety of animal models of acute and chronic gut inflammation suggest that NO may promote intestinal inflammation, an equally impressive number of investigations suggest that iNOS may play no role or may act to attenuate or to limit the extent of inflammatory tissue injury. This review discusses some of the basic concepts related to the immunoregulation of chronic gut inflammation and summarizes the current state of knowledge of the role that NO may play in modulating inflammatory tissue injury.

Interface-induced nonswitchable domains in ferroelectric thin films.

Engineering domains in ferroelectric thin films is crucial for realizing technological applications including non-volatile data storage and solar energy harvesting. Size and shape of domains strongly depend on the electrical and mechanical boundary conditions. Here we report the origin of nonswitchable polarization under external bias that leads to energetically unfavourable head-to-head domain walls in as-grown epitaxial PbZr(0.2)Ti(0.8)O3 thin films. By mapping electrostatic potentials and electric fields using off-axis electron holography and electron-beam-induced current with in situ electrical biasing in a transmission electron microscope, we show that electronic band bending across film/substrate interfaces locks local polarization direction and further produces unidirectional biasing fields, inducing nonswitchable domains near the interface. Presence of oxygen vacancies near the film surface, as revealed by electron-energy loss spectroscopy, stabilizes the charged domain walls. The formation of charged domain walls and nonswitchable domains reported in this study can be an origin for imprint and retention loss in ferroelectric thin films.