A Novel Think Tank Program to Promote Innovation and Strategic Planning in Ophthalmic Surgery.

BACKGROUND: Continuous quality improvement is a pillar of all surgical groups. Innovation is a critical aspect to continuously improve, but traditional staff retreats have several disadvantages which limit their utility in identifying needs and developing innovative solutions. To address these challenges, we designed the novel Think Tank Program to spur innovation and strategic planning for an academic ophthalmology department including the Kellogg Eye Center 6 operating rooms. METHODS: The Think Tank program is a structured seven-phase program for faculty in small teams to identify, innovate, and implement meaningful change. Participants brainstormed problems and possible solutions to those problems, formed teams, acquired data, and implemented meaningful change in clinical care, research, education, and administration. RESULTS: The program generated 19 novel proposals and significant faculty engagement and discussion in improving the department. A case example of improving the operating room (OR) utilization resulted in improved OR utilization from 63.8% to 74.6% over a 3 month period before and after implementation. It also resulted in a reduction of cancelled or rescheduled surgeries within 2 weeks or surgery from 29.8% to 15.2%. This resulted in an estimated positive financial margin of over $141,000 to the institution in addition to improvement in patient, surgeon, and staff satisfaction with the quality of care. CONCLUSIONS: Engaged faculty, critical data analysis, and value proposition analysis with data-driven metrics and accountability can result in a significant increase in OR utilization and reduction in surgical cancellations. Think Tank serves as a model transformative program to assist practices and institutions to best fulfill their mission while actively engaging and retaining their members.

Steroid-Induced Psychosis after EUS-Guided Celiac Plexus Blockade.

A 46-year-old female with no previous personal or family psychiatric history underwent endoscopic ultrasound (EUS)-guided celiac plexus blockade (CPB) to treat pain related to cystic fibrosis transmembrane conductance regulator-associated chronic pancreatitis. She had excellent response to her first three CPBs using bupivacaine and triamcinolone. The patient's subsequent CPBs were complicated by symptoms of racing thoughts, delusional thinking, and insomnia. She was diagnosed with acute psychosis secondary to triamcinolone. This is the first reported case of steroid-induced psychosis caused by EUS-guided CPB. Optimal treatment for steroid-induced psychiatric symptoms include dose reduction or discontinuation of steroids and administration of lithium, valproic acid, or atypical antipsychotics.

The Challenge of Clostridium difficile Infection.

Clostridium difficile infection is a major problem in the United States, resulting in significant morbidity, mortality, and financial costs to the health care system. This commentary provides an update regarding the epidemiology, diagnosis, current recommended management, and challenges surrounding C. difficile infection.

Salivary gland genetic vaccination: a scalable technology for promoting distal mucosal immunity and heightened systemic immune responses.

Use of plasmid DNA for vaccination has been demonstrated quite successfully in small rodents. However, some of the many challenges of DNA vaccine development are the relatively low performance obtained in larger animals and a generally weak mucosal immune response. Vaccination through salivary gland (SG) cannulation and delivery of aqueous solutions of DNA is one potential solution. The scalability of SG DNA vaccination was tested in multiple animal models; antigen specific titers above 10,000 were demonstrated in dogs and rats. Immune responses were also present at a variety of mucosal sites. In conclusion, our data demonstrate that DNA vaccination to the SG presents a unique and advantageous method for eliciting systemic and mucosal immune responses.

Systemic and mucosal antibody responses following retroductal gene transfer to the salivary gland.

Gene transfer to salivary glands by retrograde perfusion of the salivary duct has been shown to result in production of the encoded protein. We sought to determine if this technique would be useful for genetic immunization. In studies that compare delivery of DNA to either the salivary gland (SG) or muscle (im), mean plasma IgG and IgA titers obtained following SG delivery were 46- and 86-fold greater, respectively, than those following im delivery. We also tested the hypothesis that SG vaccination could generate mucosal responses in sites proximal and distal to DNA administration. SG-treated animals produced specific antibodies within saliva, vaginal fluid, and lung washes as well as demonstrating robust specific responses in Peyer's patches. In a test of functional immunity, animals vaccinated with DNA by SG retrograde perfusion were significantly more resistant to the effects of lethal anthrax challenge than im DNA-vaccinated animals. These data suggest that SG genetic immunization may offer advantages over conventional routes of vaccination.

Zinc enhancement of nonviral salivary gland transfection.

Gene transfer to exocrine glands, including the major salivary glands, presents an attractive method to deliver proteins for therapeutic applications. Previous efforts using nonviral gene delivery to these glands have resulted in limited success. In this report, zinc and other divalent transitions were coadministered with plasmid DNA in an effort to improve nonviral salivary gland transfection efficiency. The inclusion of zinc into plasmid DNA solutions resulted in a 20-fold enhancement in transgene expression without noticeable inflammation compared to a solution of plasmid DNA only. This observed enhancement in transgene expression was dependent upon the DNA dose and correlated with the accumulation of plasmid DNA by salivary gland tissues.