Does participation in the European Trauma Course lead to new behaviours and organisational change? A Portuguese experience

BACKGROUND

Medical educational courses can be successful from an immediate feedback perspective but not lead to new behaviour or organisational changes in the workplace. The aim of this study was to assess the self-perceived impact of the European Trauma Course (ETC) on Reanima trainees' behaviour and organisational change.

METHODS

A 40-item questionnaire based on Holton's evaluation model was used to evaluate the candidate's perceptions. The results were analysed with descriptive and inferential statistical analysis using nonparametric tests with α = 0.05.

RESULTS

Out of 295 participants, 126 responded to the survey. Of these, 94% affirmed that the ETC modified their approach to trauma patients, and 71.4% described a change in their behaviour. Postcourse responders changed their behaviour in their initial approach to trauma care in the nontechnical skills of communication, prioritisation and teamwork. Being an ETC instructor strongly influenced the acquisition of new material, and this group was able to implement changes in attitudes. Individuals with no previous trauma course experience identified lack of self-efficacy as a significant obstacle to introducing new work-based learning. In contrast, responders with ATLS training noted a lack of ETC colleagues as the main impediment for moving from conceptualisation to experimentation in the workplace.

CONCLUSIONS

Participation in the ETC led to behavioural changes in the workplace. However, the ability to influence others and bring about wider organisational changes was more difficult to achieve. Major factors were the status of the person, their experience and self-efficacy. National organisational impact was obtained, which went far beyond our aspirations in acknowledging change in individual daily practice. Future research studies will include the effect of implementing the ETC methodology on the outcome of trauma patients.

Laparoscopic Lumen-guided cholecystectomy in face of the difficult gallbladder

BACKGROUND

Where the critical view of safety cannot be established during cholecystectomy, certain salvage techniques are indicated to reduce the likelihood of bile duct injury. The present study describes a salvage technique termed the "laparoscopic lumen-guided cholecystectomy" (LLC) and reports its peri-operative outcomes.

METHOD

A summary of the technique is as follows: (1) Hartmann's pouch is incised and stones are evacuated; (2) the cystic anatomy is inspected from the inside of the gallbladder; (3) the lumen is used to guide retrograde dissection towards the cystic pedicle; (4) cystic duct control is achieved if deemed safe. LLC cases performed between June 2020 and January 2022 in a single health board were included. The operative details and peri-operative outcomes of the technique are reported and compared to cases of similar difficulty where the LLC was not attempted.

RESULTS

LLC was performed in 4.6% (27/587) of cases. In all 27 cases, LLC was performed for a "frozen" cholecystohepatic triangle. Hartmann's pouch was completely excised in all cases (27/27) and cystic duct control was achieved in 85.2% of cases (23/27). No cases of bile leak or ductal injury were reported. Rates of bile leak, post-operative complications and ERCP were lower following LLC compared to the group where LLC was not attempted (p < 0.01).

CONCLUSION

LLC is a safe salvage technique and should be considered in cases where the critical view of safety cannot be established. The technique achieves cystic duct control in the majority of cases and favourable outcomes in the face of a difficult cholecystectomy.

HPB P23 Laparoscopic lumen-guided cholecystectomy in face of the difficult gallbladder

Background

Where the critical view of safety cannot be established during cholecystectomy, certain salvage techniques are indicated to reduce the likelihood of bile duct injury. The present study describes a salvage technique termed the “laparoscopic lumen-guided cholecystectomy” (LLC) and reports its peri-operative outcomes.

Methods

A summary of the technique is as follows: (1) Hartmann's pouch is incised and stones are evacuated; (2) the cystic anatomy is inspected from the inside of the gallbladder; (3) the lumen is used to guide retrograde dissection towards the cystic pedicle; (4) cystic duct control is achieved if deemed safe. LLC cases performed between June 2020 and January 2022 in a single health board were included. The operative details and peri-operative outcomes of the technique are reported and compared to cases of similar difficulty (Nassar ≥4) where the LLC was not attempted.

Results

LLC was performed in 4.6% (27/587) of cases. In all 27 cases, LLC was performed for a “frozen” cholecystohepatic triangle. Hartmann's pouch was completely excised in all cases (27/27) and cystic duct control was achieved in 85.2% of cases (23/27). No cases of bile leak or ductal injury were reported. Rates of bile leak, post-operative complications and ERCP were lower following LLC compared to the group where LLC was not attempted (p&lt;0.01).

Conclusions

LLC is a safe salvage technique and should be considered in cases where the critical view of safety cannot be established. The technique achieves cystic duct control in the majority of cases and favourable outcomes in the face of a difficult cholecystectomy.

Neurobehavioral and neurodevelopmental profiles of a heuristic genetic model of differential schizophrenia- and addiction-relevant features: The RHA vs. RLA rats

The Roman High- (RHA) and Low-(RLA) avoidance rat lines/strains were generated through bidirectional selective breeding for rapid (RHA) vs. extremely poor (RLA) two-way active avoidance acquisition. Compared with RLAs and other rat strains/stocks, RHAs are characterized by increased impulsivity, deficits in social behavior, novelty-induced hyper-locomotion, impaired attentional/cognitive abilities, vulnerability to psychostimulant sensitization and drug addiction. RHA rats also exhibit decreased function of the prefrontal cortex (PFC) and hippocampus, increased functional activity of the mesolimbic dopamine system and a dramatic deficit of central metabotropic glutamate-2 (mGlu2) receptors (due to a stop codon mutation at cysteine 407 in Grm2 -cys407*-), along with increased density of 5-HT2A receptors in the PFC, alterations of several synaptic markers and increased density of pyramidal "thin" (immature) dendrític spines in the PFC. These characteristics suggest an immature brain of RHA rats, and are reminiscent of schizophrenia features like hypofrontality and disruption of the excitation/inhibition cortical balance. RHA rats represent a promising heuristic model of neurodevelopmental schizophrenia-relevant features and comorbidity with drug addiction vulnerability.

Melting and density of MgSiO3 determined by shock compression of bridgmanite to 1254GPa

The essential data for interior and thermal evolution models of the Earth and super-Earths are the density and melting of mantle silicate under extreme conditions. Here, we report an unprecedently high melting temperature of MgSiO3 at 500 GPa by direct shockwave loading of pre-synthesized dense MgSiO3 (bridgmanite) using the Z Pulsed Power Facility. We also present the first high-precision density data of crystalline MgSiO3 to 422 GPa and 7200 K and of silicate melt to 1254 GPa. The experimental density measurements support our density functional theory based molecular dynamics calculations, providing benchmarks for theoretical calculations under extreme conditions. The excellent agreement between experiment and theory provides a reliable reference density profile for super-Earth mantles. Furthermore, the observed upper bound of melting temperature, 9430 K at 500 GPa, provides a critical constraint on the accretion energy required to melt the mantle and the prospect of driving a dynamo in massive rocky planets.

The definite risks and questionable benefits of liberal pre-hospital spinal immobilisation

INTRODUCTION

The routine practice of pre-hospital spinal immobilisation (phSI) for patients with suspected spinal injury has existed for decades. However, the controversy surrounding it resulted in the 2013 publication of a Consensus document by the Faculty of Pre-Hospital Care. The question remains as to whether the quality of evidence in the literature is sufficient to support the Consensus guidelines. This critical review aims to determine the validity of current recommendations by balancing the potential benefits and side effects of phSI.

METHOD

A review of the literature was carried out by two independent assessors using Medline, PubMed, EMBASE and the Cochrane Library databases. Manual searches of related journals and reference lists were also completed. The selected body of evidence was subsequently appraised using a checklist derived from SIGN and CASP guidelines, as well as Crombie's guide to critical appraisal.

RESULTS

No reliable sources were found proving the benefit for patient immobilisation. In contrast there is strong evidence to show that pre-hospital spinal immobilisation is not benign with recognised complications ranging from discomfort to significant physiological compromise. The published literature supports the Consensus guideline recommendations for safely reducing the impact of these side effects without compromising the patient.

CONCLUSION

The literature supports the Consensus Guidelines but raises the question as to whether they go far enough as there is strong evidence to suggest phSI is an inherently harmful procedure without having any proven benefit. These results demonstrate an urgent need for further studies to determine its treatment effect.

Controversies in advanced trauma life support

Since its introduction to the UK in 1988, the Advanced Trauma Life Support (ATLS) course has become the accepted standard for the care of victims of trauma during the ‘golden hour’. Yet despite this success, ATLS has been criticized over the years for its philosophy, the course contents, the rigid regulations, cost to participants and lack of validation. The aim of this article is to explore these and other frequently voiced concerns in the light of evidence gathered over the 20 years since ATLS was first introduced in the USA.

The effect of scene time on survival

A review of the literature was carried out to determine the importance of pre-hospital scene times and how it can be affected. In the UK, and certain centres in North America, mortality and morbidity in critically injured patients appears to be related to scene times. The majority of these patients only require basic life support at the scene. Consequently the possible benefits of more advanced procedure need to be compared with the transportation period, the time needed to mobilize a medical team and skill proficiency. Cardiovascular resuscitation procedures in particular require reappraisal. Though haemostasis is essential, there is little evidence to support the use of fluid resuscitation in nontrapped urban patients with a significant haemorrhage problem. In contrast patients who are not bleeding do appear to benefit from advanced life support procedures even though this increases scene time. There is therefore a need for pre-hospital paramedic workers to triage patients so that appropriate resuscitation can be carried out.

Beating the Odds: Successful Establishment of a Phase II/III Clinical Research Trial in Resource-Poor Liberia during the Largest-Ever Ebola Outbreak

It has been argued that a country such as Liberia, not fully recovered from the devastation of decades of civil unrest, lacked the appropriate ethical and regulatory framework, basic human and health care services, and infrastructure to carry out clinical trials according to international standards of quality during a public health emergency. However, as Liberia, Sierra Leone, and Guinea were being ravaged by the largest and most devastating Ebola Virus Disease (EVD) outbreak ever recorded, the topic of conducting clinical trials of experimental vaccine and treatment candidates in these resource-poor countries generated the keen interest and concern of scientists, researchers, physicians, bioethicists, philanthropists, and even politicians. Decisive action on behalf of the Liberian government, and a timely positive and supportive response from the United States (U.S.) government, led to the formation of PREVAIL (Partnership for Research on Ebola Vaccines in Liberia) – a clinical research partnership between the two governments. Within a span of 12 weeks, this partnership accomplished the unimaginable: the successful initiation of a Phase II/III vaccine clinical trial for EVD in Liberia. This paper will discuss the dynamics of the research collaboration, barriers encountered, breakthroughs realized, key elements of success, and lessons learned in the process.

Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound

OBJECTIVES

International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers.

METHODS

On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces.

RESULTS

Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44% of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below.

CONCLUSIONS

Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: Brachial arterial blood sampling: safe or not?

A shortcut review was carried out to establish whether brachial artery puncture is safe in patients requiring arterial blood sampling. 47 papers were found using the reported searches, of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this paper are tabulated. It is concluded that brachial artery puncture is likely to be safe in the non-shocked patient who is not on concurrent anticoagulant therapy.

Surgical management of emergency and elective giant paraesophageal hiatus hernias

BACKGROUND

Uncertainty exists surrounding the laparoscopic approach to the repair of giant paraesophageal hiatus hernias (GPHHs), in regard to both long-term outcomes and its role in the emergency presentation. The aim of this study was to assess the outcome of laparoscopic GPHH repair, compared with traditional open surgery, in both the elective and emergency setting.

SUBJECTS AND METHODS

Data regarding all patients who underwent GPHH repair between January 1994 and June 2008 were retrieved from the prospectively maintained Lothian Surgical Audit database. Demographic details, surgical approach (open/laparoscopic), conversion to an open procedure, complications, and recurrences were analyzed.

RESULTS

Sixty-four patients had GPHH repair. Attempted laparoscopic repair and conversion rates were 52 of 64 (81.2%) and 12 of 52 (23.1%), respectively. Including these conversions, 24 of 64 patients had an open repair. The mean postoperative hospital stay, complications, and mortality were significantly lower among the laparoscopic cohort. Twenty-five of 64 patients had surgery as an emergency admission. Postoperative mortality after emergency surgery was 5 of 25 (20.0%) compared with 3 of 39 (7.6%) among elective patients (P=.146). The recurrence rate after laparoscopic and open repair was 25.0% (10 of 40) and 8.3% (2 of 24), respectively (P=.184).

CONCLUSIONS

This study has confirmed that surgical repair of GPHH is associated with a significant morbidity and mortality, in both the elective and emergency setting. Although the laparoscopic approach should be attempted in the first instance, the open approach appears to have a lower recurrence rate.

Swiss multidisciplinary and multilingual experience of the Advanced Trauma Life Support course: lessons for Europe

OBJECTIVE

Courses in the Advanced Trauma Life Support are a well-accepted concept throughout the world for training in the emergency treatment of polytraumatized patients. Switzerland, a multilingual country with a long tradition of multidisciplinary collaboration in trauma care, introduced its first student courses in 1998. Unlike some countries where the courses are attended only by surgeons, instructors and students in Switzerland include surgeons, anaesthetists and physicians from other specialties.

METHODS

Course evaluation assessments and instructor and student demographic data were analysed retrospectively using univariate analyses (Pearson correlation), multivariate analysis of variance, with post-hoc analysis and Bonferroni correction, and stepwise linear regression analysis.

RESULTS

Between 1998 and 2003, 922 students attended 58 courses available for evaluation, with 22 338 ratings of different modules. Students rated practical (r=0.076) instruction significantly better than lectures (r=-0.072), gave better rating for women instructors (r=0.026) and for instructors teaching outside their specialty (r=-0.027). Women and participants in French-speaking courses gave better ratings. Ratings by anaesthetists were more critical than by surgeons and students from other specialties.

CONCLUSION

The practical format of Advanced Trauma Life Support courses is appreciated by students, and the involvement of anaesthetists, general practitioners and other specialists as instructors is successful. Course rating was influenced by chosen specialty, sex and language of the students, and this should be taken into consideration when evaluating course modules and instructors.

The European Trauma Course: Using experience to refine an educational initiative

This article is an exploration of the process of the refinement of the instructor cadre development arising from the implementation of the European Trauma Course (ETC). Among the defining characteristics of the ETC is the team management of trauma and mechanisms for enabling information flow were complex and challenging. The article describes the response to this challenge.

'Effectiveness of Continuing Professional Development' project: a summary of findings

This article reports on a study examining continuing professional development (CPD) for consultant doctors. The aim of the study was to identify what promotes or inhibits the effectiveness of CPD and met the following objectives: comparing and contrasting the experiences of CPD across the range of specialties; identifying and describing the range of different models of CPD employed across the different specialties and clinical contexts; considering the educational potential of reflective practice in CPD and its impact on professional practice and exploring how different professionals judge the effectiveness of current CPD practices. Using a mixture of qualitative (interviews, letters, observation) and quantitative (online questionnaire) methods, the views of CPD providers and users were surveyed. Findings suggested that the effectiveness of CPD, as inferred from the comments made by interviewees and questionnaire respondents, relates to the impact on knowledge, skills, values, attitudes, behaviours and changes in practice in the work place. The quality of CPD was seen as inextricably linked to any improvements in the quality of the professional practices required for service delivery. There was widespread consensus as to the value of learning in professional settings. There was recognition that there needs to be a move away from tick boxes to the in-depth identification of learning needs and how these can be met both within and external to the work place, with learning being adequately enabled and assessed in all locations. In conclusion, it can be said that CPD is valued and is seen as effective when it addresses the needs of individual clinicians, the populations they serve and the organisations within which they work. However, the challenge for CPD may lie in the dynamic interaction between educational opportunities and service delivery requirements, as there may be occasions where they vie with each other for resources.

The European Trauma Course (ETC) and the team approach: past, present and future

The European Trauma Course (ETC) was officially launched during the international conference of the European Resuscitation Council (ERC) in 2008. The ETC was developed on behalf of ESTES (European Society of Trauma and Emergency Surgery), EuSEM (European Society of Emergency Medicine), the ESA (European Society of Anaesthesiology) and the ERC. The objective of the ETC is to provide an internationally recognised and certified life support course, and to teach healthcare professionals the key principles of the initial care of severely injured patients. Its core elements, that differentiates it from other trauma courses, are a strong focus on team training and a novel modular design that is adaptable to the differing regional European requirements. This article describes the lessons learnt during the European Trauma Course development and provides an outline of the planned future development.

Unlearned anxiety predicts learned fear: a comparison among heterogeneous rats and the Roman rat strains

Anxiety-related behaviors were evaluated across five tests in a sample of 277 rats from a genetically heterogeneous stock (N/Nih-HS rats), derived from an eight-way cross of inbred strains, and compared with the performance of RLA-I (high anxious) and RHA-I (low anxious) rats in the same tests. These tests either evoke unlearned (novel-cage activity (NACT), elevated "zero" maze (ZM), baseline acoustic startle response (BAS)) or learned (fear-potentiated startle (FPS), two-way active-shuttle box-avoidance acquisition (SHAV)) anxious/fearful responses. The results overall showed that unlearned anxiety responses/behaviors were predictive of behavior in learned fear (i.e. fear-potentiated startle) and conflict (i.e. two-way active avoidance acquisition) situations. Moreover, it was found that N/Nih-HS rats either resemble RLA-I rat anxiety/fear scores or fall in between those of the RLA-I (high anxious) and the RHA-I (low anxious) rat strains. An additional regression analysis (of N/Nih-HS rat data) showed significant positive influences of (unlearned) baseline startle response, risk assessment (i.e. stretch-attend) behavior and activity (5min) in a novel cage on SHAV acquisition, while baseline startle and entries into the open section of the elevated 'zero' maze test of anxiety were the main variables influencing FPS. This indicates that startle responses may have a facilitating role in the rat's active responses in the two-way active (shuttlebox) avoidance acquisition. The results of this behavioral evaluation of N/Nih-HS rats show that unconditioned anxiety (e.g. in the ZM test) predicts learned fear-related responses (e.g. FPS and SHAV) to some extent, while a positive association is also observed between BAS and SHAV. These findings are discussed in terms of their potential usefulness for present and future neurobehavioral and genetic studies of fearfulness/anxiety.

The advanced life support group's view of HOSPEX

This paper explores some of the principles and intentions behind simulation in medical education and explores the extent to which HOSPEX fits within an accepted design. It further points to the direction that HOSPEX will need to take in order to maximise its capacity to aid the delivery of exemplary patient safety.

Determination of required anatomical knowledge for clinical practice in emergency medicine: national curriculum planning using a modified Delphi technique

OBJECTIVES

To identify the content of the postgraduate anatomy curriculum for trainees in emergency medicine (EM) in the UK.

METHODS

Modified Delphi technique involving 160 randomly sampled consultants in EM. The outcome measure was percentage agreement, based upon a three round iterated Delphi process, of participants to items derived from a standard anatomy text being core knowledge for postgraduate clinical practice in the specialty. A national curriculum document was derived as a result of the data obtained.

RESULTS

Response rates ranged from 61% to 70% after three Delphi rounds. From an initial overall questionnaire content of 808 discrete items, 64% was retained as core required knowledge following iteration. This formed the basis of a national consensus anatomy curriculum both to inform question development in postgraduate EM examinations and to benchmark anatomical knowledge requirements for safe clinical practice.

CONCLUSIONS

Application of a national consensus methodology allows for determination of curricular content in anatomy. The principles can be applied to all aspects of training and curricular policy at national collegiate level to guide the development of robust documentation.

Exposure or expert? Setting standards for postgraduate education through a Delphi technique

OBJECTIVES

The aim of this study was to determine if a syllabus of upper limb anatomy for emergency clinicians composed by an expert panel reflected clinical practice as experienced by those at whom the syllabus would be directed.

METHODS

A three round Delphi study was performed using an expert group. We compared this with a measure of the exposure to anatomical concepts in the day to day practice of trainees in emergency medicine.

RESULTS

In total, 404 separate anatomical facts relating to the upper limb were reviewed by both groups. There was poor agreement (kappa = 0.348) between the expert group and the trainees.

CONCLUSION

We have shown disparity between what an expert group believes trainees should know and what trainees are actually exposed to in clinical practice. We believe this demonstrates that curriculum development must strike a balance between important (expert) and common (exposure) information. We have shown how an expert:exposure matrix may be used to inform curriculum development.

The European Trauma Course--from concept to course

The Advanced Trauma Life Support (ATLS) course, developed by the American College of Surgeons, has revolutionised in-hospital management of major trauma patients and is now accepted as a standard of care in many countries worldwide. However, within Europe, there are significant differences in both the aetiology of trauma and the specialties involved in its initial management compared to the American model. Over the past 4 years, there have been a number of initiatives aimed at producing a trauma management course that was evidence based, practical and flexible enough to meet regional European needs and team oriented. Initial attempts tried to incorporate both pre- and in-hospital trauma care. This was eventually rationalised to the production of an in-hospital course and the first pilot course was run in Malta in November 2006. This article describes the evolution of the course, its current structure and plans for the future following the feedback received from candidates and instructors who participated in the first course.

Peptide selection by class I molecules of the major histocompatibility complex

Class I molecules of the major histocompatibility complex (MHC) bind peptides derived from cytoplasmic proteins. Comparison of over 100 such peptides reveals the importance of the carboxy-terminal residue in selective binding. Recent evidence implicates the proteases and transporters of the processing pathway in providing peptides with the correct residues at the carboxyl terminus.

Inter-individual vs line/strain differences in psychogenetically selected Roman High-(RHA) and Low-(RLA) Avoidance rats: neuroendocrine and behavioural aspects

Inter-individual differences in neuroendocrine and behavioural responses to environmental challenges will be considered within the context of psychogenetic selection, using the Roman High-(RHA) and Low-(RLA) Avoidance rat lines as an example. We assume that the selected genotypes, by interacting with environmental factors, determine specific 'biobehavioural profiles'. Practical and theoretical problems regarding the measurement of inter-individual vs line/strain differences, the definition of 'traits' vs experimental variables, and possible correlations between physiological and behavioural parameters will be discussed. We will argue that environmental influences are the main cause of inter-individual variability, and that the genotype only constitutes a 'blueprint' from which typical biobehavioural profiles are established, notably under the influence of early environmental factors. These biobehavioural profiles may correspond in part to human categories known as 'types', 'temperaments' or 'personality traits'. Within each category (including those which can be obtained by psychogenetic selection), more individual personality traits can evolve, notably as a result of social interactions and particular life events.

The psychogenetically selected Roman rat lines differ in the susceptibility to develop amphetamine sensitization

The mesolimbic dopamine system is considered to play a pivotal role in the locomotor activation produced by psychostimulants and in the augmentation of this effect observed upon repeated drug administration, a process denominated behavioral sensitization. The selective breeding of Roman high- (RHA) and low-avoidance (RLA) rats, respectively, for rapid versus poor active avoidance acquisition has resulted in two phenotypes that differ in the functional properties of the mesolimbic dopamine system and in their behavioral and neurochemical responses to addictive drugs, including psychostimulants and opiates. Hence, the present study was designed to compare the ability of these lines to develop behavioral sensitization to psychostimulants. To this aim, the acute effects of amphetamine (0.125 or 0.25 mg/kg, s.c.) on locomotion were assessed in RHA and RLA rats prior to and subsequent to 10 daily doses of either amphetamine (1 mg/kg, s.c.) or saline (1 ml/kg, s.c.). In the RHA line, the locomotor activation produced by either challenge dose of amphetamine was more pronounced in rats that had been repeatedly treated with amphetamine versus the respective saline treated controls. In contrast, no significant change in locomotor activity was observed in RLA rats. Likewise, repeated amphetamine caused an increased frequency of sniffing, rearing, licking/gnawing, and grooming versus the control, repeated saline, group only in the RHA line. The results show that the repeated treatment regimen used in this study induced behavioral sensitization to amphetamine in RHA rats, but not in their RLA counterparts, and underscore the utility of these lines for studying the influence of neural substrates and genetic make up on the individual vulnerability to addiction.

A differential activation of dopamine output in the shell and core of the nucleus accumbens is associated with the motor responses to addictive drugs: a brain dialysis study in Roman high- and low-avoidance rats

Addictive substances like morphine and psychostimulants induce a preferential increase in dopamine (DA) output in the nucleus accumbens (NAC), a major terminal field of the mesolimbic dopaminergic projection. Two subregions of the NAC, the dorsolateral core and the ventromedial shell, are thought to subserve different functions related to the reinforcing properties of natural and drug rewards. The selective breeding of Roman high- (RHA) and low-avoidance (RLA) rats, respectively, for rapid vs. extremely poor active avoidance acquisition in a shuttle-box has resulted in two phenotypes that differ in their behavioural and neurochemical responses to addictive drugs. We used brain dialysis to assess whether such differences in the responsiveness to drugs of abuse are related to differences in mesolimbic DA neuron function. In RHA rats, morphine, cocaine, and amphetamine caused a larger increase in DA efflux in the NAC shell vs. the NAC core, whereas the profile for the drug-induced increases in DA output was almost completely superimposable in the NAC shell and NAC core of RLA rats. Moreover, morphine, cocaine, and amphetamine caused a larger increment in basal DA output in the NAC shell of RHA rats vs. the NAC shell of RLA rats. These drugs also elicited a more robust increase in locomotion, rearing, sniffing, and grooming in RHA than in RLA rats. These results demonstrate that genetically determined differences in the functional properties of DA neurons projecting to the NAC shell may critically influence the behavioural response patterns to addictive drugs that distinguish the Roman lines.

A confidential study of deaths after emergency medical admission: issues relating to quality of care

In this retrospective pilot study we examine the feasibility of establishing a confidential enquiry into why some patients die after emergency admission to hospital. After excluding those who died in the first hour or who were admitted for palliative care, pairs of physicians were able to collect quantitative and qualitative data on 200 consecutive deaths. Both physicians reported shortfalls of care in 14 patients and one of the pair in 25 patients whose deaths would not have been the expected outcome. In 25, the shortfalls of care may have contributed to their deaths. Major problems were delays in seeing doctors, inaccurate diagnoses, delays in investigations and initiation of treatment. They occurred mostly in those admitted at night. It is possible that establishing the correct diagnosis and starting appropriate treatment may have been delayed in 64% of the 200 patients. The headline figures appear worse than some previous external assessment studies but this study did concentrate on those in whom problems were more likely. Nevertheless, the frequency is too high to be overlooked. In this feasibility study we have demonstrated that it is practicable for local staff to collect and assess data in hospitals and that the types of problems identified are relevant to anyone planning how to organise emergency care. A larger definitive study should be performed.

Differential neurochemical properties of central serotonergic transmission in Roman high- and low-avoidance rats

The selective breeding of Roman high- (RHA/Verh) and low-avoidance (RLA/Verh) rats for rapid versus poor acquisition of active avoidant behaviour has produced two behavioural phenotypes with different performances in a variety of animal models of anxiety, in which RLA/Verh rats are consistently more fearful than RHA/Verh rats. In addition, these two lines display different functional properties of brain neurotransmitters like serotonin (5-HT), known to be involved in the expression of anxiety- and depression-related behaviours. Therefore, we used brain microdialysis and [3H]-citalopram binding autoradiography to characterize further the neurochemical properties of 5-HTergic transmission in the two lines. No significant line-related differences were detected in the basal 5-HT output in the frontoparietal cortex (FPCx). In contrast, the increase in the cortical 5-HT output elicited by the systemic administration or the local application, via reverse dialysis, of chlorimipramine and fluoxetine was more robust in RHA/Verh than in RLA/Verh rats. Moreover, the binding signal of [3H]-citalopram to 5-HT re-uptake sites was more intense in the FPCx of RHA/Verh rats than in their RLA/Verh counterparts. These findings suggest that the functional tone of the 5-HTergic projection to the FPCx is stronger in the RHA/Verh line relative to the RLA/Verh line. It is proposed that RLA/Verh rats may be used as a model with heuristic value for studying the role of 5-HTergic transmission in anxiety and in the anxiolytic effects of monoamine re-uptake inhibitors.

Effect of cellular telephone conversations and other potential interference on reaction time in a braking response

This experiment studied the effect of phone conversations and other potential interference on reaction time (RT) in a braking response. Using a laboratory station which simulated the foot activity in driving, 22 research participants were requested to release the accelerator pedal and depress the brake pedal as quickly as possible following the activation of a red brake lamp. Mean reaction time was determined for five conditions: (a) control, (b) listening to a radio, (c) conversing with a passenger, (d) conversing using a hand-held phone, and (e) conversing using a hands-free phone. Results indicated that conversation, whether conducted in-person or via a cellular phone caused RT to slow, whereas listening to music on the radio did not.

Dissociation between mesocortical dopamine release and fear-related behaviours in two psychogenetically selected lines of rats that differ in coping strategies to aversive conditions

The mesocortical and mesolimbic dopaminergic (DAergic) pathways are activated by either aversive or rewarding stimuli. The functional tone of these DAergic neurons also increases during the execution of cognitive tasks. The present study was designed to examine the relationship between mesocortical and mesolimbic DAergic function and the expression of fear-related behaviours as compared with attention- and cognition-related mechanisms (e.g. coping strategies), in response to aversive conditions. To this aim, we used two psychogenetically selected rat lines, Roman high-avoidance (RHA/Verh) and Roman low-avoidance (RLA/Verh), which display drastically different emotion- and coping-related behaviours in response to stressors: RLA/Verh rats are 'reactive copers' and more fearful than RHA/Verh rats, which are 'proactive copers'. Brain dialysis experiments demonstrated that tail-pinch (TP) and the anxiogenic compounds pentylenetetrazol (PTZ) and ZK 93426 increased DA output in the medial prefrontal cortex (PFCX) of RHA/Verh but not RLA/Verh, rats. In contrast, in the shell compartment of the nucleus accumbens (NAC shell), TP caused a small increase in DA output only in RLA/Verh rats, whereas PTZ and ZK 93426 had no significant effect on either line. RHA/Verh rats displayed more robust and longer lasting coping activity and less frequent freezing and self-grooming episodes than did RLA/Verh rats after TP, PTZ or ZK 93426. This dissociation between fear-related behaviour and cortical DAergic activation argues against the view that the latter may be involved in the control of fear-like responses. We therefore propose that the activation of mesocortical DAergic projections by aversive stimuli underlies the cognitive mechanisms that are triggered in an attempt to gain control over the stressor.

Divergent stress responses and coping styles in psychogenetically selected Roman high-(RHA) and low-(RLA) avoidance rats: behavioural, neuroendocrine and developmental aspects

The Swiss sublines of Roman high-(RHA/Verh) and low-(RLA/Verh) avoidance rats have been genetically selected for good vs. poor performance in two-way active avoidance since 1972. RLA/Verh rats show increased stress responses (e.g. freezing behaviour, ACTH, corticosterone and prolactin secretion) and adopt a more passive (or reactive) coping style when confronted with a novel environment. In the open field, elevated plus-maze, black/white box test, and in a new light/dark open field test, RLA/Verh rats appear to be more anxious than their RHA/Verh counterparts. Anxiety may result from their particular psychophysiological profile, i.e. increased emotionality combined with a passive coping style. In contrast, RHA/Verh rats are less responsive to stress, they show little anxiety in novel situations and tend to be impulsive and novelty (sensation) seekers. Some behavioural differences are already noticeable shortly after birth, but the full pattern appears to stabilize only after puberty. Gene-environment interactions are critical in establishing this pattern. The data reviewed indicate that the differences between RHA/Verh and RLA/Verh rats probably result from a complex interaction among divergent anxiety/emotionality characteristics, differences in locomotor activity and novelty/reward seeking, as well as active vs. passive coping styles. It is proposed further that these divergent personality types are to be found not only in other selective breeding programs but in the form of individual differences in most populations of rats used for this type of research.

Fearfulness and sex in F2 Roman rats: males display more fear though both sexes share the same fearfulness traits

The pattern of sex differences in a large sample (about 400 for each sex) of F2-generation rats, derived from inbred Roman high- and low-avoidance strains differing in fearfulness and brain functioning, was investigated. We obtained measures from responses to a battery of novel/threatening tests [open field (OF), plus maze (PM), hole board (HB), activity (A), and acoustic startle reflex (ASR)] as well as learned fear paradigms [classical fear conditioning (CFC) and shuttlebox avoidance conditioning (SAC)]. The results showed that almost all behaviors assessed fit with a pattern of unidirectional sex effects characterized by male rats as being more fearful than females: males defecated more than females in the OF, PM, HB, ASR, and CFC; ambulated less in the OF, PM, A, and SAC; showed more self-grooming in PM and HB; explored the open arms of the PM and the holes of the HB less; displayed enhanced ASR; and showed poorer performance in the SAC task. We applied two factor analyses to each sex showing that, in general, they shared a common three-factor structure: a Learned Fear Factor comprising SAC and CFC responding, a Fear of Heights/Open Spaces Factor with the highest loadings for open arm behavior in the PM, and an Emotional Reactivity Factor, mainly grouping defecations, ambulation, and self-grooming. These results indicate that the essential components of fearful behavior are similar for both sexes in an inbred but genetically heterogeneous population.