Effects of Augmented Reality-Based Remote Mentoring on Task Performance and Communication: A Simulation Study in the Context of Emergency Medical Services.

Background: Augmented reality head-worn displays (HWDs) may enable efficient remote support in the prehospital environment due to their hand-free operability, their "see-what-I-see" features, and their ability to superimpose digital content over the environment. Methods: In this simulation-based randomized controlled study, a remote mentor used either a phone or HWD to instruct 23 physicians on how to insert a Multi-Lumen Access Catheter into a mannequin. In the phone condition, information could be exchanged only verbally. In the HWD condition, the mentor could additionally see the participant's first-person view and show reference images. We hypothesized that participants who received instructions via the HWD would achieve better procedural performance (lower task completion times, fewer errors advancing the catheter) and exhibit different communication patterns than participants who received instructions via phone. Results: The HWD did not significantly reduce task completion times or errors during catheter advancement. However, by analyzing the frequency of communication events with a Poisson regression, we could demonstrate that with the HWD, the mentor had to request situation reports less often (p < 0.001) but provided more instructions (p = 0.004) and more feedback (p = 0.008). As a possible consequence, participants in the HWD condition rated their workload as lower than participants who used a phone to communicate (p = 0.45). Conclusion: The study demonstrates that HWD-based telemedicine systems can be rated positively by physicians, can benefit communication, and can provide more opportunities for the detection of clinical errors.

Successful endotracheal intubation following a failed first attempt during aeromedical retrieval.

INTRODUCTION: First attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of this study was to identify changes to intubation technique following a failed intubation attempt. METHODS: LifeFlight Retrieval Medicine provides aeromedical retrieval services in Queensland, Australia. This retrospective study identified cases of failed intubation attempts from an electronic database registry over a 41-month period from March 2015 to July 2018. These data were analysed using descriptive statistics. RESULTS: Of the 762 patients who required intubation 758 (99.5%) were successfully intubated, with 684 intubated at the first attempt (89.8%; 95% CI: 0.87 to 0.92). There was no difference in first attempt success between direct and video laryngoscopy (511/563 (90.8%) vs 172/194 (88.6%) p=0.38), trauma or medical (374/419 (89.3%) vs 310/343 (90.4%), p=0.61), primary or interhospital missions (329/370 (88.7%) vs 355/392 (90.8%), p=0.33). 78 cases of failed first attempt intubations were identified. In 65 of these cases, intubation was successful at the second attempt. A single change was made to the intubation procedure prior to a second successful attempt in 28/78 cases (35.9%), and more than one change was made in 41/78 (52.6%). The changes included the operator, intubation device, patient position, intubating aid and external laryngeal manipulation. No change between attempts was recorded in 9/78 (11.5%). 9 cases were successfully intubated at the third attempt, and changes prior to the third attempt included operator, device and intubating aid. CONCLUSION: Although a high overall intubation success was found, one in ten patients who were intubated had a failed first attempt. The majority of successful subsequent attempts were preceded by at least one change to intubating technique. Intubating clinicians need the ability to identify and correct issues leading to a failed first attempt.

Endotracheal Intubation for Traumatic Cardiac Arrest by an Australian Air Medical Service.

OBJECTIVE: Traumatic cardiac arrest (TCA) has been associated with poor outcome, but there are survivors with good neurological outcome. Treatment of hypoxia plays a key part in resuscitation algorithms, but little evidence exists on the ideal method of airway management in TCA. METHODS: LifeFlight Retrieval Medicine is an aeromedical retrieval service based in Queensland, Australia. Data regarding all intubations performed over a 28-month period were accessed from an electronic airway registry. RESULTS: 13/22 TCA patients were male, age range 2-81 years. 7/22 (31.8%) survived to hospital admission. During the same period 271 patients were intubated due to trauma, but were not in cardiac arrest (N-TCA). There was no difference in the likelihood of difficult laryngoscopy in the TCA group (16/22 (72.7%) compared to N-TCA (215/271 (79.3%); p = 0.46). The first attempt success rate was similar in TCA group (19/22 (86.4%)) and N-TCA (241/271 (88.9%) p = 0.71.). TCA patients were more likely to be intubated while lying on the ground than the N-TCA group (11/22 (50%) versus 17/271 (6.3%) p = <0.001). CONCLUSION: Resuscitation for predominantly blunt TCA is not futile. The endotracheal intubation first attempt success rate for TCA is comparable to that of N-TCA trauma patients.

Profiling helicopter emergency medical service winch operations involving physicians in Queensland, Australia.

OBJECTIVE: To analyse the mission profiles of helicopter emergency medical service (HEMS) winch operations involving LifeFlight Retrieval Medicine physicians in Queensland, Australia, specifically focusing on patients' clinical characteristics, extrication methods and scene times. METHODS: A retrospective analysis was performed to identify all helicopter winch missions involving physicians during 2019. Demographic, clinical and non-clinical data were accessed from an electronic database used to log cases and findings presented using descriptive statistics. RESULTS: Out of 4356 HEMS missions involving physicians, 100 (2.3%) were winch operations. Of these, 31 (31%) occurred overwater and 12 (12%) at night. In total, 106 patients were attended, and eight patient deaths occurred. Most patients were traumatically injured (66%), male (66%) and had a median (interquartile range) age of 43.5 (28-59) years. Thirteen missions (13%) involved drowning victims. This group had a higher burden of injury and comprised half of the patients treated with endotracheal intubation. Median scene time was 30 min (20-40), and the winch stretcher was the predominant patient extrication method. Physician winching occurred in 63 (63%) missions and was associated with increased scene time and increased use of the winch stretcher. CONCLUSIONS: Winch operations involving physicians occur infrequently in Queensland HEMS, although almost a third of missions occur overwater. Drowning victims are encountered more frequently than reported elsewhere in Australian HEMS and comprised half of the patients who underwent endotracheal intubation. Patients' severity of illness and injury may contribute to the associations between winching of physicians, increased scene times and increased use of the winch stretcher.

Viscoelastic haemostatic assays in aeromedical transport.

OBJECTIVE: To assess the feasibility of using rotational thromboelastometry (ROTEM®)-sigma and thromboelastography (TEG®)-6s viscoelastic point-of-care assays during rotary wing aeromedical transport, and to determine the reliability of the results obtained. METHODS: A single centre, prospective, observational, non-interventional feasibility study performed at Gold Coast University Hospital intensive care unit, and in a LifeFlight Retrieval Medicine operated Leonardo AW139 helicopter. Blood was collected from eight healthy volunteers on 18 April 2019 and all testing was performed on that day. Functions measured were ROTEM-sigma extrinsically activated thromboelastometry (EXTEM) clotting time (CT), EXTEM amplitude at 5 min after CT (A5) and fibrin-based extrinsically activated thromboelastometry (FIBTEM) A5, and TEG-6s Kaolin (CK) reaction time (R), functional fibrinogen (CFF) maximal amplitude (MA) and CFF amplitude at 10 min after R (A10). Differences between the results obtained in the helicopter and control results at Gold Coast University Hospital during flight and after flight, and also differences in control results over time up to 3 h were analysed. RESULTS: During flight both the ROTEM-sigma and TEG-6s devices failed to give reliable results. Post flight, the helicopter and control samples correlated well. Repeat testing of control samples at 1 and 3 h also revealed good correlation over time. CONCLUSION: It is feasible to reliably run tests on both the ROTEM-sigma and TEG-6s after the devices have been flown in a rotary wing aircraft. However, testing cannot be performed while in flight conditions. It is also possible to run blood samples collected up to 3 h prior and acquire results which correlate well with initial testing.

Doing our work better, together: a relationship-based approach to defining the quality improvement agenda in trauma care.

BACKGROUND: Trauma care represents a complex patient journey, requiring multidisciplinary coordinated care. Team members are human, and as such, how they feel about their colleagues and their work affects performance. The challenge for health service leaders is enabling culture that supports high levels of collaboration, co-operation and coordination across diverse groups. We aimed to define and improve relational aspects of trauma care at Gold Coast University Hospital. METHODS: We conducted a mixed-methods collaborative ethnography using the relational coordination survey-an established tool to analyse the relational dimensions of multidisciplinary teamwork-participant observation, interviews and narrative surveys. Findings were presented to clinicians in working groups for further interpretation and to facilitate co-creation of targeted interventions designed to improve team relationships and performance. FINDINGS: We engaged a complex multidisciplinary network of ~500 care providers dispersed across seven core interdependent clinical disciplines. Initial findings highlighted the importance of relationships in trauma care and opportunities to improve. Narrative survey and ethnographic findings further highlighted the centrality of a translational simulation programme in contributing positively to team culture and relational ties. A range of 16 interventions-focusing on structural, process and relational dimensions-were co-created with participants and are now being implemented and evaluated by various trauma care providers. CONCLUSIONS: Through engagement of clinicians spanning organisational boundaries, relational aspects of care can be measured and directly targeted in a collaborative quality improvement process. We encourage healthcare leaders to consider relationship-based quality improvement strategies, including translational simulation and relational coordination processes, in their efforts to improve care for patients with complex, interdependent journeys.

Phenylaminopyrimidines as inhibitors of Janus kinases (JAKs).

A series of phenylaminopyrimidines has been identified as inhibitors of Janus kinases (JAKs). Development of this initial series led to the potent JAK2/JAK1 inhibitor CYT387 (N-(cyanomethyl)-4-[2-[[4-(4-morpholinyl)phenyl]amino]-4-pyrimidinyl]-benzamide). Details of synthesis and SAR studies of these compounds are reported.

Intra-articular Treatment of Osteoarthritis with Diclofenac-Conjugated Polymer Reduces Inflammation and Pain.

The most common treatment for osteoarthritis is daily oral administration of a nonsteroidal anti-inflammatory drug such as diclofenac. This daily dosage regime is often associated with severe side effects. In this study, we explored the potential of utilizing a high molecular weight cross-linked polyurethane polymer covalently linked to diclofenac (C-DCF-PU) for intra-articular administration. We aim to exploit the advantages of local drug delivery by developing an implant with improved efficacy and reduced side effects. The polymer was synthesized from a diclofenac-functionalized monomer unit in a simple one-pot reaction, followed by cross-linking. In vitro drug release studies showed zero-order drug release for 4 days, followed by a gradual decline in drug release rate until diclofenac was depleted after 15 days. The cross-linked polymer was triturated to yield an injectable microgel formulation for administration. Whole animal fluorescence imaging of the rhodamine-labeled C-DCF-RH-PU showed good retention of the polymer in the knee joints of healthy rats, with approximately 30% of the injected dose still present 2 weeks post intra-articular administration. In a reactivation arthritis animal model, the C-DCF-RH-PU formulation reduced pain and significantly reduced inflammation after a short lag phase, showing that this drug delivery system warrants further development for long-term treatment of osteoarthritis with the benefit of reduced side effects.

Precise control of drug loading and release of an NSAID-polymer conjugate for long term osteoarthritis intra-articular drug delivery.

A facile synthesis method of polymer diclofenac conjugates (PDCs) based on biocompatible polyurethane chemistry that provides a high drug loading and offers a high degree of control over diclofenac (DCF) release kinetics is described. DCF incorporating monomer was reacted with ethyl-l-lysine diisocyanate (ELDI) and different amounts of polyethylene glycol (PEG) in a one-step synthesis to yield polymers with pendent diclofenac distributed along the backbone. By adjusting the co-monomers feed ratio, the drug loading could be tailored accordingly to give DCF loading of up to 38 w/w%. The release rate could also be controlled easily by changing the amount of PEG in the backbone. Above 10 w/w% of PEG, the in vitro DCF release studies in physiological conditions showed an apparent zero-order profile without an initial burst effect for up to 120 days. The PDCs described may be suitable for long-term intra-articular (IA) delivery for the treatment of osteoarthritis (OA).

The Hydrolysis of Diclofenac Esters: Synthetic Prodrug Building Blocks for Biodegradable Drug-Polymer Conjugates.

Degradation reactions on diclofenac-monoglycerides (3a,b), diclofenac-(p-hydroxybenzoate)-2-monoglyceride (3c), diclofenac (1), and diclofenac lactam (4) were performed at 37 °C in isotonic buffer solutions (apparent pH range 1-8) containing varying concentrations of acetonitrile (ACN). The concentration remaining of each analyte was measured versus time. Diclofenac-monoglycerides and diclofenac-(p-hydroxybenzoate)-2-monoglyceride (3c) were both found to undergo facile and complete hydrolysis in pH 7.4 isotonic phosphate buffer/10% ACN. Under mildly acidic, neutral or alkaline conditions, diclofenac-(p-hydroxybenzoate)-2-monoglyceride (3c) had the fastest hydrolysis rate (t1/2 = 3.23 h at pH 7.4), with simultaneous formation of diclofenac lactam (4) and diclofenac (1). Diclofenac-monoglycerides (3a,b) hydrolyzed more slowly under the same conditions, to again yield both diclofenac (1) and diclofenac lactam (4). There was also transesterification of diclofenac-2-monoglyceride (3b) to its regioisomer, diclofenac-1-monoglyceride (3a) across the pH range. Diclofenac was shown to be stable in neutral or alkaline conditions but cyclized to form the lactam (4) in acidic conditions. Conversely, the lactam (4) was stable under acidic conditions but was converted to an unknown species under alkaline or neutral conditions.

Concise, stereoselective syntheses of cis-nemorensic acid and 4-hydroxy-cis-nemorensic acid via tandem carbonyl ylide formation-cycloaddition.

[reaction: see text] 1,3-Dipolar cycloaddition of propargyl bromide with the carbonyl ylide derived from 6-diazoheptane-2,5-dione is the key step in concise syntheses of cis-nemorensic acid and 4-hydroxy-cis-nemorensic acid.

Diagnosing bipolar disorder in the community setting.

BACKGROUND: Bipolar disorder (BD) is a common psychiatric illness. Diagnosing this condition is challenging, due to the frequent need to make the diagnosis based on historical symptoms, the lack of specificity of many of the symptoms, and the absence of accurate objective measures to confirm the diagnosis. A lack of consensus among psychiatrists as to the breadth of the diagnosis, increasing pressures to make a diagnosis quickly in clinical settings, and the availability of broader spectrum treatments have also served to foster uncertainty in diagnosis. This article examines the process of diagnosing BD, reviews factors that can confound the diagnostic process, and discusses how the sensitivity and specificity of the diagnosis can be improved. METHODS: A MEDLINE search and a manual search of textbooks and abstracts from scientific meetings were conducted. Results were limited to publications in English, but no timeframe limitations were used. RESULTS: The standard for diagnosing BD remains the psychiatric interview, with laboratory, genetic, radiographic, and neuroimaging tests still investigational, and psychological tests and questionnaires serving an ancillary role. The sensitivity and specificity of the BD diagnosis is less than optimal, with the condition being both overlooked and diagnosed when it is not present. CONCLUSIONS: Factors leading to diagnostic uncertainty and approaches to improve the sensitivity and specificity of the BD diagnosis are discussed. A paradigm for differentiating between BD and borderline personality disorder is offered.

First manic episode in a 55-year-old man after initiation of aripiprazole.

Aripiprazole is a novel antipsychotic medication that is used to treat a number of psychiatric conditions, including schizophrenia, bipolar disorder, and major depressive disorder. Although not specifically indicated for this, novel antipsychotics including aripiprazole are also used for treatment of obsessive compulsive disorder. The following case involves a 55-year-old man with refractory obsessive compulsive disorder who developed his first manic episode after taking aripiprazole. The author reviews other cases of aripiprazole-induced mania and discusses the possible pharmacodynamic mechanisms of this reaction.

Legal insanity: assessment of the inability to refrain.

Maryland's test for a finding of legal insanity (not criminally responsible [NCR]) allows a defendant to be found legally insane due to either a lack of appreciation of wrongfulness (cognitive impairment [CI]) or lack of ability to refrain from illegal behavior (volitional impairment [VI]). During a four-year period, 1,446 defendants underwent in-depth (post screening) evaluations for the NCR plea at Maryland state hospitals. Of the 416 defendants assessed as NCR by the hospitals' court-appointed evaluators, 44 (11%) were assessed as NCR due to VI alone. Diagnostically, the VI and CI groups were similar. Criminal charges were also similar, but the VI group was more likely to have been charged with murder. Many of the forensic evaluators concluded that the VI group was unable to refrain from illegal conduct based on considering a number of factors, including psychiatric symptoms and the defendant's behavior as related to the offense. Some evaluators' reports offered an opinion, but did not adequately explain what data they used to arrive at their conclusion. This paper examines the history of and rationale for a volitional test of insanity and how it is assessed by forensic evaluators.

Stereocontrolled syntheses of the nemorensic acids using 6-diazoheptane-2,5-dione in carbonyl ylide cycloadditions.

Levulinic acid-derived 6-diazoheptane-2,5-dione (9) serves as a common precursor in a formal synthesis of frontalin 19, and in syntheses of cis-nemorensic acid 1, 4-hydroxy-cis-nemorensic acid 2, 3-hydroxy-cis-nemorensic acid 3, and nemorensic acid 4. The key step in these syntheses is the Rh(2)(OAc)(4)-catalyzed tandem carbonyl ylide formation-intermolecular 1,3-dipolar cycloadditions of diazodione 9 with formaldehyde, alkynes or allene, which occur with high regioselectivity. Subsequent oxidative cleavage of the ring originally derived from the cyclic carbonyl ylide intermediate provides a straightforward access to polysubstituted tetrahydrofurans, and in particular an efficient entry to the nemorensic acids. Enantioselective cycloadditions with diazodione 9, using chiral rhodium catalysts, gave cycloadducts in up to 51% ee.