Background: The need for peripheral intravenous (IV) access in anatomically challenging patients is becoming a more commonly encountered clinical problem. The significant investment devoted to physician training for ultrasound-guided vascular access has not yet been matched by a similar commitment to nursing. Nurses, paramedics, and physicians are becoming more enthusiastic about peripheral IV access with ultrasound (PIVUS); however, institutional and clinician support has not yet been forthcoming. The learning curve for PIVUS has never been rigorously studied, and may be flatter than previously assumed. Methods: Registered nurses were selected to participate as trainees. Training involved 1:1 sessions consisting of formal orientation to portable ultrasound, mentoring, and practice sessions with a nurse practitioner who has expertise in ultrasound-guided peripheral vascular access; hands-on, supervised practice cannulating vessels on a nonhuman tissue simulator; and supervised attempts on live patients. Results: Seven of 8 trainees completed the training. The average number of patient encounters required to achieve 10 successful IV placements was 25 (range ¼ 18-32). The average time required for successful vessel cannulation was 19.57 minutes (range ¼ 5-62 minutes). An average of 25 attempts was required to achieve proficiency, and average of 50 cases was required to maintain consistency. Conclusions: In today's practice environment, PIVUS skills are increasingly important. The results of our study demonstrate that, with appropriate hands-on training and supervision, these skills can be effectively taught to registered nurses.
Activating transcription factor 5 (ATF5) is a member of the cAMP response element binding protein (CREB)/ATF family of basic leucine zipper transcription factors. We previously reported that ATF5-deficient (ATF5−/−) mice exhibited behavioural abnormalities, including abnormal social interactions, reduced behavioural flexibility, increased anxiety-like behaviours, and hyperactivity in novel environments. ATF5−/− mice may therefore be a useful animal model for psychiatric disorders. ATF5 is highly expressed in the ventricular zone and subventricular zone during cortical development, but its physiological role in higher-order brain structures remains unknown. To investigate the cause of abnormal behaviours exhibited by ATF5−/− mice, we analysed the embryonic cerebral cortex of ATF5−/− mice. The ATF5−/− embryonic cerebral cortex was slightly thinner and had reduced numbers of radial glial cells and neural progenitor cells, compared to a wild-type cerebral cortex. ATF5 deficiency also affected the basal processes of radial glial cells, which serve as a scaffold for radial migration during cortical development. Further, the radial migration of cortical upper layer neurons was impaired in ATF5−/− mice. These results suggest that ATF5 deficiency affects cortical development and radial migration, which may partly contribute to the observed abnormal behaviours.
Vignette A 36-year-old homeless man was brought in to the emergency room with altered mental status and was unable to give a history. Based on prior emergency visits, he has a history of IV drug abuse and alcohol abuse. His vital signs on arrival are the following: HR of 110 (regular), BP of 102/58, temperature of 98.0, and respiratory rate of 8/ min. His Glasgow Coma Scale score is 7. Physical examination results are that he is grossly obtunded, responds only to deep painful stimuli, is nonverbal, and moves all extremities. Pupils are small, 2 to 3 mm, and reactive. His heart reveals regular tachycardia. Lungs are clear to auscultation. Abdomen is within normal limits. His extremities are warm to touch. Skin reveals ecchymosis. His initial head CT finding is negative for bleeding, infarct, or mass. He has severe metabolic acidosis, and the urine toxin screen result is positive for cocaine and opiates. His creatinine kinase enzyme is greater than 20,000 IU/L. Peripheral venous access attempts are unsuccessful. The right internal jugular vein is accessed via a needle with ultrasound guidance, but a guidewire failed to pass on multiple attempts. The emergency physician inserts a right femoral line triple lumen catheter without ultrasound. The patient is intubated via an endotracheal tube for airway protection and admitted to the medical ICU.
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