A peer-to-peer handoff tool to ease clerkship transitions.

EDUCATIONAL CHALLENGE: Frequent transitions between core clinical rotations in medical school increase anxiety and cognitive load. Few formalized programs exist to ease these transitions. Our institutional needs-assessment found that approximately 85% of students believed that additional rotation-specific information prior to starting a new rotation would reduce anxiety and increase success. PROPOSED SOLUTION AND IMPLEMENTATION OF SOLUTION: We developed a novel web-based peer-to-peer handoff tool available to all clerkship students at a single, large academic institution. The tool contains the names and contact information of students who most recently completed rotations on each service for all clerkships. A handoff checklist was also created with suggested discussion points for handoffs. Students were encouraged to schedule a handoff 1-2 weeks before starting a new rotation. LESSONS LEARNED: Overall, 83 students (66%) utilized the handoff tool, with use and efficacy decreasing with time during the clinical year. Of tool users, 65% expressed that having access to the tool prior to starting a new rotation helped to reduce anxiety, and 74% felt that the information gained helped to ease transitions. Our peer-to-peer handoff tool may help students feel more prepared to start a new rotation, decrease anxiety during clerkship year, and ease transitions. NEXT STEPS: This low-resource intervention may be implemented at other institutions to provide students with equal opportunities to receive valuable information prior to starting new rotations, regardless of pre-existing peer connections. An automated update system, which we are implementing at our institution, could greatly decrease the time required to maintain a handoff tool and improve sustainability.

The Antiparallel Dimerization of Myosin X Imparts Bundle Selectivity for Processive Motility.

Myosin X is an unconventional actin-based molecular motor involved in filopodial formation, microtubule-actin filament interaction, and cell migration. Myosin X is an important component of filopodia regulation, localizing to tips of growing filopodia by an unclear targeting mechanism. The native α-helical dimerization domain of myosin X is thought to associate with antiparallel polarity of the two amino acid chains, making myosin X the only myosin that is currently considered to form antiparallel dimers. This study aims to determine if antiparallel dimerization of myosin X imparts selectivity toward actin bundles by comparing the motility of parallel and antiparallel dimers of myosin X on single and fascin-bundled actin filaments. Antiparallel myosin X dimers exhibit selective processivity on fascin-bundled actin and are only weakly processive on single actin filaments below saturating [ATP]. Artificial forced parallel dimers of myosin X are robustly processive on both single and bundled actin, exhibiting no selectivity. To determine the relationship between gating of the reaction steps and observed differences in motility, a mathematical model was developed to correlate the parameters of motility with the biochemical and mechanical kinetics of the dimer. Results from the model, constrained by experimental data, suggest that the probability of binding forward, toward the barbed end of the actin filament, is lower in antiparallel myosin X on single actin filaments compared to fascin-actin bundles and compared to constructs of myosin X with parallel dimerization.

Thermal QST Phenotypes Associated with Response to Lumbar Epidural Steroid Injections: A Pilot Study.

OBJECTIVE: Response to lumbar epidural steroid injection in lumbar radicular pain varies. The purpose of this study is to characterize the changes in quantitative sensory testing (QST) phenotypes of subjects and compare the QST characteristics in patients who do respond to treatment of radicular pain with a lumbar epidural steroid injection (ESI). DESIGN: Prospective, observational pilot study. SETTING: Outpatient pain center. METHODS: Twenty subjects with a lower extremity (LE) radicular pain who were scheduled to have an ESI were recruited. At the visit prior to and four weeks following an ESI, subjects underwent QST measurements of both the affected LE and the contralateral unaffected UE. RESULTS: Following an ESI, nine subjects reported a greater than 30% reduction in radicular pain and 11 reported a less than 30% reduction in radicular pain. Subjects who had less than 30% pain reduction response (nonresponders) to an ESI had increased pre-injection warm sensation threshold (37.30 °C, SD = 2.51 vs 40.39, SD = 3.36, P = 0.03) and heat pain threshold (47.22 °C, SD = 1.38, vs 48.83 °C, SD = 2.10, P = 0.04). Further, the nonresponders also showed increased pre-injection warm sensation threshold as measured in the difference of warm sensation detection threshold difference in the affected limb and the unaffected arm (2.68 °C, SD = 2.92 vs 5.67 °C, SD = 3.22, P = 0.045). Other QST parameters were not affected. CONCLUSIONS: The results show that the nonresponders to ESIs have increased detection threshold to heat pain and warm sensation, suggesting that a preexisting dysfunction in the C fibers in this group of subjects who can be detected by QST. Such altered QST characteristics may prognosticate the response to ESIs.

Donor and recipient polygenic risk scores influence the risk of post-transplant diabetes.

Post-transplant diabetes mellitus (PTDM) reduces allograft and recipient life span. Polygenic risk scores (PRSs) show robust association with greater risk of developing type 2 diabetes (T2D). We examined the association of PTDM with T2D PRS in liver recipients (n = 1,581) and their donors (n = 1,555), and kidney recipients (n = 2,062) and their donors (n = 533). Recipient T2D PRS was associated with pre-transplant T2D and the development of PTDM. T2D PRS in liver donors, but not in kidney donors, was an independent risk factor for PTDM development. The inclusion of a combined liver donor and recipient T2D PRS significantly improved PTDM prediction compared with a model that included only clinical characteristics: the area under the curve (AUC) was 67.6% (95% confidence interval (CI) 64.1-71.1%) for the combined T2D PRS versus 62.3% (95% CI 58.8-65.8%) for the clinical characteristics model (P = 0.0001). Liver recipients in the highest quintile of combined donor and recipient T2D PRS had the greatest risk of PTDM, with an odds ratio of 3.22 (95% CI 2.07-5.00) (P = 1.92 × 10-7) compared with those in the lowest quintile. In conclusion, T2D PRS identifies transplant candidates with high risk of PTDM for which pre-emptive diabetes management and donor selection may be warranted.

Accuracy of real-time delivery room resuscitation documentation.

OBJECTIVE: To assess the accuracy of real-time delivery room resuscitation documentation. DESIGN: Retrospective observational study. SETTING: Level 3 academic neonatal intensive care unit. PARTICIPANTS: Fifty infants with video recording of neonatal resuscitation. MAIN OUTCOME MEASURES: Vital sign assessments and interventions performed during resuscitation. The accuracy of written documentation was compared with video gold standard. RESULTS: Timing of initial heart rate assessment agreed with video in 44/50 (88%) records; the documented heart rate was correct in 34/44 (77%) of these. Heart rate and oxygen saturation were documented at 5 min of life in 90% of resuscitations. Of these, 100% of heart rate and 93% of oxygen saturation values were correctly recorded. Written records accurately reflected the mode(s) of respiratory support for 89%-100%, procedures for 91%-100% and medications for 100% of events. CONCLUSION: Real-time documentation correctly reflects interventions performed during delivery room resuscitation but is less accurate for early vital sign assessments.

Visual attention patterns of team leaders during delivery room resuscitation.

AIM: To assess visual attention of neonatal team leaders during delivery room resuscitation of preterm infants using eye tracking glasses. METHODS: Prospective observational eye tracking study. Gaze fixations and sequences were captured, categorized, and mapped during the first 5 min of the resuscitations. Gaze fixation metrics of total gaze duration, visit count, and visit duration were summarized and compared based on interventions performed and provider training level. Fixation sequences were compared between attending neonatologists and fellows. RESULTS: During 18 eye tracking recordings, practitioners focused most of their cumulative visual attention on the infant (median total gaze duration 57%, interquartile range [IQR] 38-61%), followed by monitors (24%, IQR 13-46%), clinical staff (5%, IQR 1-8%), other physical objects (4%, IQR 3-6%), T-piece resuscitator (2%, IQR 0-4%) and the Apgar timer (1%, IQR 0-2%). Visual attention parameters varied according to intervention, with higher visit counts on the infant during corrective ventilation steps than during Continuous Positive Airway Pressure (CPAP) or Positive Pressure Ventilation (PPV), and longer visit durations on monitors during PPV. Time and frequency-based measures of visual attention did not significantly differ by provider training level, but patterned fixation sequences were identified among attending neonatologists that were not observed in fellows. CONCLUSION: Team leaders predominantly gazed upon the infant and monitors during resuscitation, and visual attention parameters varied depending on the respiratory interventions performed. Attending neonatologists exhibited patterned fixation sequences that were not observed in fellows. Study results may have implications for optimizing delivery room design and training novice providers.

Provider visual attention on a respiratory function monitor during neonatal resuscitation.

BACKGROUND: A respiratory function monitor (RFM) provides real-time positive pressure ventilation feedback. Whether providers use RFM during neonatal resuscitation is unknown. METHODS: Ancillary study to the MONITOR(NCT03256578) randomised controlled trial. Neonatal resuscitation leaders at two centres wore eye-tracking glasses, and visual attention (VA) patterns were compared between RFM-visible and RFM-masked groups. RESULTS: 14 resuscitations (6 RFM-visible, 8 RFM-masked) were analysed. The median total gaze duration on the RFM was significantly higher with a visible RFM (29% vs 1%, p<0.01), while median total gaze duration on other physical objects was significantly lower with a visible RFM (3% vs 8%, p=0.02). Median total gaze duration on the infant was lower with RFM visible, although not statistically significantly (29% vs 46%, p=0.05). CONCLUSION: Providers' VA patterns differed during neonatal resuscitation when the RFM was visible, emphasising the importance of studying the impact of additional delivery room technology on providers' behaviour.

Visual attention on a respiratory function monitor during simulated neonatal resuscitation: an eye-tracking study.

OBJECTIVE: A respiratory function monitor (RFM) may improve positive pressure ventilation (PPV) technique, but many providers do not use RFM data appropriately during delivery room resuscitation. We sought to use eye-tracking technology to identify RFM parameters that neonatal providers view most commonly during simulated PPV. DESIGN: Mixed methods study. Neonatal providers performed RFM-guided PPV on a neonatal manikin while wearing eye-tracking glasses to quantify visual attention on displayed RFM parameters (ie, exhaled tidal volume, flow, leak). Participants subsequently provided qualitative feedback on the eye-tracking glasses. SETTING: Level 3 academic neonatal intensive care unit. PARTICIPANTS: Twenty neonatal resuscitation providers. MAIN OUTCOME MEASURES: Visual attention: overall gaze sample percentage; total gaze duration, visit count and average visit duration for each displayed RFM parameter. Qualitative feedback: willingness to wear eye-tracking glasses during clinical resuscitation. RESULTS: Twenty providers participated in this study. The mean gaze sample captured wa s 93% (SD 4%). Exhaled tidal volume waveform was the RFM parameter with the highest total gaze duration (median 23%, IQR 13-51%), highest visit count (median 5.17 per 10 s, IQR 2.82-6.16) and longest visit duration (median 0.48 s, IQR 0.38-0.81 s). All participants were willing to wear the glasses during clinical resuscitation. CONCLUSION: Wearable eye-tracking technology is feasible to identify gaze fixation on the RFM display and is well accepted by providers. Neonatal providers look at exhaled tidal volume more than any other RFM parameter. Future applications of eye-tracking technology include use during clinical resuscitation.

Genome-Wide Study Updates in the International Genetics and Translational Research in Transplantation Network (iGeneTRAiN).

The prevalence of end-stage renal disease (ESRD) and the number of kidney transplants performed continues to rise every year, straining the procurement of deceased and living kidney allografts and health systems. Genome-wide genotyping and sequencing of diseased populations have uncovered genetic contributors in substantial proportions of ESRD patients. A number of these discoveries are beginning to be utilized in risk stratification and clinical management of patients. Specifically, genetics can provide insight into the primary cause of chronic kidney disease (CKD), the risk of progression to ESRD, and post-transplant outcomes, including various forms of allograft rejection. The International Genetics & Translational Research in Transplantation Network (iGeneTRAiN), is a multi-site consortium that encompasses >45 genetic studies with genome-wide genotyping from over 51,000 transplant samples, including genome-wide data from >30 kidney transplant cohorts (n = 28,015). iGeneTRAiN is statistically powered to capture both rare and common genetic contributions to ESRD and post-transplant outcomes. The primary cause of ESRD is often difficult to ascertain, especially where formal biopsy diagnosis is not performed, and is unavailable in ∼2% to >20% of kidney transplant recipients in iGeneTRAiN studies. We overview our current copy number variant (CNV) screening approaches from genome-wide genotyping datasets in iGeneTRAiN, in attempts to discover and validate genetic contributors to CKD and ESRD. Greater aggregation and analyses of well phenotyped patients with genome-wide datasets will undoubtedly yield insights into the underlying pathophysiological mechanisms of CKD, leading the way to improved diagnostic precision in nephrology.