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Background: Telemedicine focuses on providing medical care to patients in remote locations using telecommunication technologies. It has been shown to be cost-effective, improve health outcomes, and enhance patient satisfaction. This study examines the extent to which medical students and resident physicians are exposed to telemedicine during training. Materials and Methods: The authors accessed the American College of Graduate Medical Education (ACGME) Residency Milestones from specialties and subspecialties mentioned in the 2018 Milestones National Report and searched for key terms, including "Technology," "Telemedicine," "Telehealth," "EMR," "Electronic Medical Record," "EHR," "Electronic Health Record," "Electronics," and "Social Media." The authors also accessed the 2018 American Association of Medical Colleges (AAMC) "Curriculum Inventory and Reports" to retrieve data from surveys of medical schools that included telemedicine in required courses and electives for medical students from 2013 to 2018. Results: From the 104 ACGME specialty milestones, only one specialty (Child and Adolescent Psychiatry) mentioned telehealth in its ACGME Milestone document. According to the AAMC data the number of medical schools surveyed increased every academic year from 140 in 2013/2014 to 147 in 2017/2018, telemedicine education in medical school increased significantly from 41% in 2013/2014 to 60% in 2017/2018 (p = 0.0006). However, the growth in telemedicine education plateaued from 56% in 2015/2016 to 60% in 2017/2018 (p = 0.47). Conclusion: Familiarizing medical students with telemedicine is essential; the next generation of health care providers should be equipped with knowledge of telemedicine as a valuable skill to serve populations that do not have direct access to quality medical care. Methods of implementing telemedicine education into more medical schools and residency programs merits further study.

Asunto(s)

Internado y Residencia , Estudiantes de Medicina , Telemedicina , Adolescente , Niño , Competencia Clínica , Curriculum , Educación de Postgrado en Medicina , Humanos , Estados Unidos

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BACKGROUND: Volume resuscitation has only been demonstrated to be effective in approximately fifty percent of patients. The remaining patients do not respond to volume resuscitation and may even develop adverse outcomes (such as acute pulmonary edema necessitating endotracheal intubation). We believe that point-of-care ultrasound is an excellent modality by which to adequately predict which patients may benefit from volume resuscitation. DATA RESOURCES: We performed a search using PubMed, Scopus, and MEDLINE. The following search terms were used: fluid responsiveness, ultrasound, non-invasive, hemodynamic, fluid challenge, and passive leg raise. Preference was given to clinical trials and review articles that were most relevant to the topic of assessing a patient's cardiovascular ability to respond to intravenous fluid administration using ultrasound. RESULTS: Point-of-care ultrasound can be easily employed to measure the diameter and collapsibility of various large vessels including the inferior vena cava, common carotid artery, subclavian vein, internal jugular vein, and femoral vein. Such parameters are closely related to dynamic measures of fluid responsiveness and can be used by providers to help guide fluid resuscitation in critically ill patients. CONCLUSION: Ultrasound in combination with passive leg raise is a non-invasive, cost- and time-effective modality that can be employed to assess volume status and response to fluid resuscitation. Traditionally sonographic studies have focused on the evaluation of large veins such as the inferior vena cava, and internal jugular vein. A number of recently published studies also demonstrate the usefulness of evaluating large arteries to predict volume status.

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Quantum chemistry computations with a semicontinuum (cluster + continuum) solvation model have been used to cure long-standing misprediction of aqueous carbamate anion energies in the industrially important CO2 + aqueous amine reaction. Previous errors of over 10 kcal mol(-1) are revealed. Activation energies were also estimated with semicontinuum modeling, and a refined discussion of the competing hypothetical mechanisms for CO2 + monoethanolamine (MEA) is presented. Further results are also presented to demonstrate that the basicity of an amine (aqueous proton affinity) correlates only with CO2 affinity within an amine class: secondary amines have an extra CO2 affinity that primary amines do not have.

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Ab initio (coupled-cluster and density-functional) calculations of Gibbs reaction energies in solution, with new entropy-of-solvation damping terms, were performed for the ether-catalyzed hydroboration of alkenes. The goal was to test the accuracy of continuum-solvation models for reactions of neutral species in nonaqueous solvents, and the hope was to achieve an accuracy sufficient to address the mechanism in the "Pasto case": B2H6 + alkene in THF solvent. Brown's SN2/SN1 "dissociative" mechanism, of SN2 formation of borane-ether adducts followed by SN1 alkene attack, was at odds with Pasto's original SN2/SN2 hypothesis, and while Brown could prove his mechanism for a variety of cases, he could not perform the experimental test with THF adducts in THF solvent, where the higher THF concentrations might favor an SN2 second step. Two diboranes were tested: B2H6, used by Pasto, and (9BBN)2 (9BBN = 9-borabicyclo[3.3.1]nonane, C8H15B), used by Brown. The new entropy terms resulted in improved accuracy vs traditional techniques (∼2 kcal mol(-1)), but this accuracy was not sufficient to resolve the mechanism in the Pasto case.

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Ab initio molecular dynamics simulations of up to 210 ps have been performed on various aqueous intermediates postulated in the CO2 + amine reaction, important for CO2 capture. Observations of spontaneous deprotonation of aqueous carbamate zwitterions R1R2NHCOO(±) by bulk water (instead of additional amine, or via umbrella sampling) are reported apparently for the first time. Carbamic acid structures R1R2NCOOH were observed in some simulations, arising from zwitterions not via classical 1,3-H-shifts but via Grotthuss-style multiple-H(+) transfer pathways that involve bulk H2O and require carbamate anions R1R2NCOO(-) as an intermediate stage along the way. H(+)-bridging complexes, including not only Zundel ions [water·H(+)·water](+) but neutral carbamate complexes [carbamate(-)·H(+)·water], were observed in simulation. These results should assist efforts in improving underlying mechanisms for kinetic modeling.