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3D Visualization of Lung Anatomy: New Approaches to Medical Education
No full textContext 3-Dimensional (3D) imaging is utilized in a variety of ways in medicine, including ultra-sound facial scanning in utero, breast cancer detection, and mapping blood vessels. 3D imaging can also be used to educate both students and patients. Oftentimes, it can prove difficult to visualize the spatial relationships between blood vessels and territories they supply or drain, but through the use of 3D-image rendering software we can improve the way this information is presented to enhance medical student and patient education. All images and videos produced in this research project were produced at Marian University College of Osteopathic Medicine in the 3D Visualization Laboratory. Anony-mized CT image studies were evaluated with the 3D analytical software Amira. This allowed for the identification and discrimination of anatomical structures such as blood vessels, lung tissue, and airways. Using the video and animation editing software Camtasia Studio, the 3D images were composed into an educational video to be presented for further clarity. This research project used CT images to provide a clear demonstration of the pulmonary vasculature and its corresponding territories. In anatomy lab, students may find it difficult to find basic anatomical structures. For example, visualization of the pulmonary artery’s branches and vascular territories within the lung requires tedious dissection. Figures generated throughout the project show the paths of the various pulmonary artery branches which supply the different lobes of the lung, allowing viewers to appreciate the vascular territories much more easily. This project includes a YouTube video, complete with 3D imaging for each pulmonary artery and vein branches, to help portray functional pulmonary anatomy and vascular territories so as to mitigate any confusion students or patients may have
Cryotherapy: Don\u27t freeze out the cardiovascular consequences of cold pain
No full textINTRODUCTION: Cold limb immersion, a form of cryotherapy, can cause cardiovascu-lar changes due to cold-pain induced autonomic reflex. OBJECTIVE: This cryotherapy treatment side-effect has received less attention, and could have direct implications for the physical rehabilitation of individuals who have cardiovascular co-morbidities. METHODS: To test hypotheses related to the pressor effects of limb and surface area of cryotherapy, two common lower limb injury sites (the ankle and knee) were immersed into cold water for 15 min at 1-3°C and then referenced to a standard cold pressor test (CPT). Beat-by-beat arterial blood pressure (finger photoplethysmogra-phy), heart rate (ECG), systemic vascular conductance (SVC; Modelflow), and calf VC (venous occlusion plethysmography) were measured in 14 healthy participants. RESULTS: At 2 min, CPT increased mean arterial pressure (MAP; 21±4 mmHg) to a greater degree than either ankle or leg immersion (15±4 and 15±5 mmHg, respective-ly; P=0.015). SVC and calf VC decreased but were not different across treatments (P=0.713). MAP and SVC were not different from 2 min to 15 min of immersion (P=0.164 and P=0.522), but calf VC decreased further by the end of immersion (3.1±0.5 to 2.8±0.4 and 2.7±3 to 1.7±0.2 units; P=0.028). MAP increases to CPT were similar on CPT day and when CPT followed ankle or leg immersion (27±5 and 23±4 mmHg, respectively; P=0.199). CONCLUSION: These data indicate ankle and leg immersion cause a significant but equivalent increase in arterial blood pressure, but immersion of the hand causes a greater pressor response. Thus, the location but not the precise surface area of immersion of cryotherapy appears to be an important factor. No cold-pain habituation or progressive change of MAP was observed from the initial immersion, but significant decreases in non-immersed calf VC were observed during the duration of cryotherapy. Rehabilitative specialists should consider the effect of these responses when recommending cryotherapy to patients with cardiovascular conditions
Augmented Reality in Nurse Anesthesia Education
Get PDFResearch shows that the addition of extended reality (XR) in healthcare education is advantageous as it enhances the learning experience and improves students’ knowledge and motivation to learn. Its use has been documented in nearly all areas of healthcare education but is much less explored in the realm of anesthesia. This research project focuses on a branch of XR known as augmented reality (AR) and its use as an adjunct learning tool in the curricula for nurse anesthesia. Keller’s Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Motivation guided the design of this project to understand the impact AR technology had on second year student registered nurse anesthetists’ (SRNA) motivation towards learning. Students used an AR mobile application to interact with a realistic anatomical structure of the human larynx and completed a related worksheet. A post-assessment Likert-type Instructional Materials Motivation Survey (IMMS) was used to assess AR’s impact on learner motivation as it relates to each of the four ARCS model constructs. Each construct yielded a high average score amongst participants, thereby indicating a positive learning experience. The results imply that AR enhances current learning modalities and may directly influence students’ motivation to learn. The evidence is supportive for the use of AR as an adjunct learning tool in nurse anesthesia education. Future studies are needed to evaluate the efficacy of AR as a result of its integration into curricula
Role of Bradykinin in Human Sweating During Stimulated and Actual Heat Stress
No full textBradykinin, a local dermal kallikrein-kinin system product, increases skin blood flow via a cyclic GMP mechanism but is not the active cutaneous vasodilation molecule associated with cholinergic stimulation. However, the precise role of bradykinin in sweating and thermoregulation is unclear. We tested the hypothesis that bradykinin increases eccrine sweating via increases in cutaneous capillary permeability and fluid extravasation. Protocol #1: physiological sweating was induced in 10 healthy subjects via perfusing warm (46-48°C) water through a high-density tube-lined suit to induce heat stress. During heating a bradykinin type 2 (B2) receptor antagonist (HOE-140; 40μM) and the vehicle (lactated Ringer’s) were perfused intradermally via microdialysis, while sweating (capacitance hygrometry) and cutaneous vascular conductance (CVC; Doppler flux/ mean arterial pressure) were obtained directly superficial to the membrane. In addition, both microdialysis membranes were then perfused with bradykinin (1mM). Protocol #2: pharmacological sweating was induced in 6 healthy subjects via intradermally perfusing a cholinergic agonist (pilocarpine; 1.67 mg/ml) to mimic heat stress and steady state sweating conditions and was followed by the same B2 antagonist and agonist approach. Increases in internal (37.1±0.1 to 37.9±0.1°C) and uncovered local skin (30.1±0.4 to 32.9±0.4°C) temperature caused increases in sweat rate (+0.79±0.12 and +0.64±0.10 mg/cm2/min) and CVC (63±11 to 181±22 and 85±15 to 204±19 flux/ mmHg for HOE-140 and vehicle, respectively), while HOE-140 and control sites were not different. Heart rate increased (62±3 to 94±6 bpm) with whole-body heating but arterial blood pressure was not significantly altered. Pilocarpine induced sweating (+0.38±0.16 and +0.32±0.12 mg/cm2/min) and increases in CVC (88±36 to 183±55 and 73±25 to 208±66 flux/mmHg for HOE-140 and vehicle, respectively) but again, no changes between sites were noted. These data indicate that B2 receptor antagonists do not modulate physiological or pharmacological sweating. HOE-140 delivered during normothermia was also identified not to be sudorific. The addition of exogenous bradykinin also did not modulate sweating during whole-body heating or pilocarpine perfusion in either control or HOE-140 sites. These data indicate HOE-140 does not affect sweating independently and B2 agonists do not modulate absolute sweat output. Although the kallikrein-kinin system is present in eccrine sweat glands, its precise role remains to be elucidated. Current data do not support a mechanism related to absolute in vivo sweat output and evaporative cooling but rather its role may be more conditionspecific or supportive to epithelial transport and the alteration of the interstitial milieu around the gland
The Relationship Between Delayed Vasopressor Usage and Mortality in Sepsis
No full textIntroduction Delayed vasopressor initiation can occur with septic patients who arrive to the emergency department (ED) hemodynamically stable but decompensate later in their ED or hospital course. The relationship between delayed vasopressor initiation and mortality among septic patients is not well understood. Methods We performed a retrospective review of ED visits for sepsis by adult patients at two urban institutions from January 2010 - March 2015. Included patients were diagnosed with sepsis in the ED and had initial (\u3c 3 hours) lactate in the “pre-shock” range of 2-4 mmol/L. Patients who received delayed (\u3e3- but \u3c 48-hours following ED arrival) vasopressors were compared to those who did not. Data were collected on patient demographics, vital signs, laboratory tests, medications given, length of ED and hospital stay, and mechanical ventilation status. Descriptive data analysis and group-wise comparisons were performed, including logistic regression. Results A total of 407 patients were included, with a mean age 65 years (SD 17.3). Mortality rate was 31% (61/197) among patients receiving delayed vasopressors [vs. 9.5% (20/210) for patients receiving no vasopressors (p=.0001)], and 38% (54) for those receiving mechanical ventilation [vs. 10% (27) among non-intubated patients]. Vasopressor usage (p=.0080; OR 2.32) and mechanical ventilation (p=.0001; OR 3.75) were both significant predictors of mortality. The majority (58%) of patients receiving delayed vasopressors were also mechanically ventilated. Median survival from time of ED arrival for those who died was 96 hours (Q1, Q3: 48, 240). Other variables, such as MAP, age, sex, lactate, and creatinine did not appear to predict mortality. Conclusions In this data set, we found that delayed initiation of vasopressors and mechanical ventilation were both independently associated with increased mortality for “pre-shock” septic patients. A significant proportion of those patients who received delayed vasopressors also received mechanical ventilation. Further study is needed, including larger data sets
The Role of Quorum Sensing and Stringent Response in Vibrio cholerae Antibiotic Resistance
No full textVibrio cholerae is a Gram-negative bacterium that is the cause of the diarrheal disease cholera. Many strains have developed antibiotic resistance which allows these mutated strains to elude traditional treatment. Among the mechanisms that are proposed to contribute to antibiotic resistance are the quorum sensing genes and the stringent response. The stringent response is a bacterial defense mechanism in response to environmental stress in which gene expression is modified to divert resources from growth and division instead to long-term survival. Quorum sensing is a means of determining how many bacteria are present nearby and regulating genes according to that information, using the transcription factor HapR to activate or repress gene transcription. In our experiments, we explored how two closely related patient-derived cholera strains (C6706 and N16461), with combinations of deletions of the stringent response genes, responded to a large spectrum of antibiotics. On initial exploration, we discovered that stringent response played a role in resistance to antibiotics, but the C6706 strains seemed to demonstrate less antibiotic resistance than the N16461 strains. One of the major differences between these two strains is the presence of the quorum sensing transcription factor hapR in the C6706 strains, while N16961 contains a natural non-sense mutation in hapR and lacks quorum sensing regulation. To explore if the differences in antibiotic resistance profiles of C6706 and N16961 strains was due to quorum sensing, we created a deletion of hapR in C6706. We exposed C6706ΔhapR to the same initial antibiotics and found that there was little difference in antibiotic resistance between C6706ΔhapR and C6706. This indicated that the difference in resistance to antibiotics seen in C6706 and N16961 was not due to quorum sensing. Future experiments will test whether the stringent response regulatory system acts differently in N16961 and C6706, and if that plays a role in the different antibiotic resistance profiles of the strains
Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients (POISED-CPCIP)
No full textThe United States spends well over $100 billion for millions of people affected by Alzheimer’s disease and related dementias (ADRD) and for their family caregivers. Most people with ADRD have multiple chronic comorbid conditions requiring help from family members for proper management. A lack of optimal care for the cognitive, behavioral and functional needs of persons with dementia further compounds the challenge of managing chronic comorbid disease. Family caregivers of persons with dementia have many unmet needs as well. This adversely affects caregivers’ ability to manage the chronic medical conditions of the person with dementia and may explain the greater use of emergency departments (EDs) and more return visits for those with dementia compared to those without dementia. How best to support family caregivers in preventing the need for emergency care has not been tested. The goal of this study is to test whether a novel care management program for family caregivers of persons with dementia can reduce the need for ED use. We will also test whether this intervention will lead to more activated caregivers who may also benefit by having fewer symptoms of depression and anxiety, and experiencing greater social support. This study focuses on family and friends who serve as caregivers of people with probable dementia who reach the crisis of needing emergency department care. The proposed intervention, the Program of Intensive Support in Emergency Departments for Care Partners of Cogni-tively Impaired Patients (POISED-CPCIP), will start in the emergency departments of two medical centers at academic institutions, New York University (NYU) and Indiana University (IU) and will recruit family caregivers and their care recipients (dyads) among patients who perform poorly on cognitive testing (indicating a high likelihood of dementia) and who are going to be discharged to home. We will randomize dyads to either the POISED intervention or to usual care. POISED will use typical dementia care management procedures provided by nurse care managers and care manager assistants who will additionally employ an intensive focus on understanding and supporting the needs of chronic disease management and on caregiver activation. In POISED, we will apply the principles of root cause analysis, a well-known quality improvement technique (that was started in the NASA space industry and later applied to health care) to understand what led to the ED visit and then apply what is learned to six months of care management. If this randomized controlled trial demonstrates reduced rates of ED use and a decrease in caregiver psychosocial symptoms, we will have validated a scalable program for supporting caregivers of people with dementia that should lead to significant healthcare cost reductions while providing much needed support for persons with dementia and for their family caregivers
Role of cyclooxygenase inhibitors in blocking Coxiella burnetii intracellular growth
No full textCoxiella burnetii is an obligate intracellular bacterial pathogen and a causative agent of culture-negative endocarditis. While Coxiella initially infects alveolar macrophages, it may disseminate and cause endocarditis up to 20 years after initial infection, which can be fatal if untreated. Even for those receiving treatment, the mortality rate is 19%. Further the treatment has several restrictions and poses significant side effects. Hence, designing better treatments is crucial. To this end, it is important to determine the pathogenesis of Coxiella endocarditis. The occurrence of Coxiella endocarditis several years after initial infection suggests that the bacterium survives long term by subverting host immune response. Our overall goal is to elucidate the specific host immune pathways Coxiella modulates to achieve long-term intracellular survival and identify potential therapeutic targets. Previous studies in endocarditis patients demonstrated an increase in lipid immune mediator prostaglandin E2 (PGE2) which contributed to immunosuppression and promoted bacterial growth suggesting PGE2 importance in Coxiella survival. Our preliminary ELISAs in Coxiella-infected mouse alveolar macrophages demonstrated increased PGE2 production. Since PGE2 production directly correlates to the enzyme cyclooxygenase (Cox) expression and activity, we determined expression of constitutive Cox-1 and inducible Cox-2 genes. Compared to uninfected cells, our gene expression analysis revealed Cox-2 but not Cox-1 upregulation in Coxiellainfected alveolar macrophages. Hence, we hypothesize that inhibition of Cox-2 activity blocks Coxiella intracellular growth. To test this, we are currently treating Coxiellainfected cells with FDA-approved Cox-2 inhibitor celecoxib and pan-Cox inhibitor aspirin. Compared to untreated cells, our preliminary qualitative microscopic analysis suggests Coxiella growth inhibition in celecoxib and aspirin-treated cells. Ongoing studies are quantifying changes in Coxiella growth after celecoxib and aspirin treatment. Future studies will elucidate the mechanisms Coxiella employs to regulate Cox-2 expression and PGE2 production to induce immunosuppression
Experience with and perception of research among third year osteopathic medical students
No full textThere is a lack of data regarding real and perceived barriers to research participation among osteopathic medical students (OMS’s). We have previously addressed this open question by surveying incoming first-year OMS1’s and found that the possibility of negative impact upon performance in coursework was the predominant concern among respondents at MU-COM. Here, we held a series of three focus groups with third-year OMS’s (n=23), which have completed preclinical training, to gather current perceptions and evaluate how those perceptions may have shifted throughout their preclinical experience. Focus group sessions were facilitated by two OMS2’s and audio recorded for transcription; participants were anonymized and the transcripts analyzed for themes. Participation was voluntary and incentivized by a raffle for Amazon gift cards. This study was deemed exempt by the MU Institutional Review Board. Focus group participants expressed that the importance of research relied heavily upon intrinsic motivations for research or the desire to further their career via establishment of a professional network with their mentor or improving competitiveness for residency positions. Unlike our prior survey findings among incoming OMS1’s, OMS3’s reported monetary compensation was of little importance and possibly would discourage them from performing research due to the perceived added pressure that money would generate. Some perceptions, however, remained consistent throughout the medical training thus far. Both incoming and post-preclinical students placed a great deal of value upon time and establishing themselves academically. This proved to possibly preclude students from undertaking research. Another robust theme observed between both incoming OMS1’s and OMS3’s is the strong desire for clinical research opportunities. This longitudinal approach to research perceptions will prove valuable in enacting change to the research culture and opportunities provided here at MUCOM
Prevalence of Impairing Behavioral Health Problems in ED Patients and Association with ED Utilization
No full textBackground: It has been observed that patients with poor mental health are relatively frequent users of the Emergency Departments (ED). The objective of this study was to evaluate the prevalence of numerous behavioral health domains (depression, anxiety, PTSD, substance abuse, and suicidality) in patients presenting to the IU Health Methodist Emergency Department. Methods: This study seeks to enroll 1000 English-speaking adults presenting to Methodist and Eskenazi ED. Patients were assessed for behavioral health problems using the CAT-MHTM, PHQ-8 and GAD-7 screening tools. Data on disposition medical history, discharge diagnoses, and ED utilization in the 12 months before and 30 days after enrollment from EMR and INPC will be reviewed. Results: 375 patients have been enrolled. Of those 59.4% were female with an overall mean age of 46.1 (SD ± 16.4). CAT-MH results showed 216 (57.8%) had no depression, 158 (42.2%) had mild-severe depression, while 263 (70.3%) had no anxiety and 111 (29.7%) had mild-severe anxiety. Inter-rater reliability for CAT-MH, GAD-7 and PHQ-8 was about 0.80 for a 95% CI. Conclusion: In our sample, almost half of patients that visit the ED have screened positive for mental health problems. We believe that early identification and appropriate referral may reduce inappropriate ED utilization