The COMET framework: A novel approach to design an escape room workshop for interprofessional objectives.

While recreational escape rooms have gained momentum across education and team training in multiple professions, few published escape room designs have been truly interprofessional. A major obstacle faced by educators and team leaders alike is the lack of any practical design framework for escape room development that is specific to meeting learning objectives. The COMET Framework (Context, Objectives, Materials, Execution, and Team Dynamics) was developed as a step-by-step approach to escape room design using general terminology and piloted in a one-hour workshop at a regional interprofessional conference. Surveys completed by participants suggest that application of the COMET framework increased understanding and confidence regarding escape room design regardless of prior experience with the format. The generality of the COMET framework may allow it to be utilized for team exercise design more broadly in the contexts of interprofessional training and faculty development.

A treatment program for babies with esophageal atresia in Belize.

BACKGROUND: Children born with congenital anomalies in low- and middle-income countries often face a multitude of challenges. Access to pediatric surgical services is limited because of a lack of medical facilities, an adequate transportation system, and a lack of trained surgeons, anesthesiologists, and nurses, all of which leads to a high mortality rate. METHODS: This is a report of a 5-y collaborative effort between the World Pediatric Project, the Children's Hospital of Richmond at Virginia Commonwealth University, and multiple organizations within the country of Belize to provide care for infants born with esophageal atresia, with or without associated tracheoesophageal fistula. RESULTS: A total of six infants were transferred to our institution in Richmond, VA for operative correction of their esophageal atresia. CONCLUSIONS: Caring for infants with congenital anomalies can be challenging, especially children from low- and middle-income countries. Through collaboration between countries and nonprofit organizations, life-saving international care can be provided to children for these conditions.

Phagotrophic protist diversity in the groundwater of a karstified aquifer - morphological and molecular analysis.

To clarify the structure of microbial food webs in groundwater, knowledge about the protist diversity and feeding strategies is essential. We applied cultivation-dependent approaches and molecular methods for further understanding of protist diversity in groundwater. Groundwater was sampled from a karstified aquifer located in the Thuringian Basin (Thuringia, Germany). Cultivable protist abundance estimated up to 8,000 cells/L. Eleven flagellates, 10 naked amoebae, and one ciliate morpho-species were detected in groundwater enrichment cultures. Most of the flagellates morpho-species, typically < 10 µm, were sessile or free swimming suspension feeders, e.g., Spumella spp., Monosiga spp., and mobile, surface-associated forms that grasp biofilms, e.g., Bodo spp. Naked amoebae, typically < 35 µm, that grasp biofilms were represented by, e.g., Vahlkampfia spp., Vannella spp., and Hartmanella spp. The largest fraction of the 18S rRNA gene sequences was affiliated with Spumella-like Stramenopiles. Besides, also sequences affiliated with fungi and metazoan grazers were detected in clone libraries of the groundwater. We hypothesize that small sized protist species take refuge in the structured surface of the fractures and fissures of the karstified aquifer and mainly feed on biofilm-associated or suspended bacteria.

Evaluation of Postoperative Pain Management Using an Opioid-Sparing Protocol in Pediatric Surgical Patients.

BACKGROUND: Since the 1990s, the U.S. has faced increasing rates of opioid overuse, misuse, and overdose deaths. To combat the opioid epidemic, there have been national initiatives to limit prescribing of opioids. At our institution, we implemented an opioid-sparing protocol in pediatric surgical patients and sought to evaluate its impact on postoperative opioid prescribing patterns. METHODS: A retrospective chart review of the electronic medical record was performed for 9- to 18-year-old patients who underwent a laparoscopic appendectomy or cholecystectomy before and after the implementation of an opioid-sparing protocol. Data on postoperative opioids administered during the hospitalization and prescribed at discharge, postoperative pain control, use of non-opioid analgesics, and safety were collected. RESULTS: A total of 81 patient charts were analyzed. The median amount of opioids administered during hospitalization was 8 MMEs and 15 MMEs in the pre-implementation and post-implementation, respectively (P = 0.310). The median amount of opioids prescribed at discharge was 150 MMEs and 60 MMEs in the pre-implementation and post-implementation, respectively (P = 0.006). Patients reported mild pain scores throughout the hospitalization in both groups. DISCUSSION: Among young patients who underwent laparoscopic appendectomy or cholecystectomy, the administration of opioids during hospitalization for postoperative pain was minimal. The opioid sparing protocol did not reduce the amount of inpatient postoperative opioids administered but found a decrease in the amount of opioids prescribed at discharge. The study findings identified further areas of intervention and education to optimize postoperative opioid prescribing after these common pediatric surgical procedures.

Telehealth Training for Surgeons to Empathetically Deliver Bad News Via Video-Mediated Communication.

BACKGROUND: The COVID-19 pandemic resulted in a sudden increase in the need to effectively use telehealth in all realms of health care communication, including the delivery of bad news. METHODS: A single arm, unblinded, feasibility study was performed at a tertiary care center located in Central Virginia to explore the value and utility of providing a telehealth training program based on SPIKES to teach surgical residents and faculty best practice for disclosing difficult news via video-mediated communication (VMC). Surgical interns (categorical and preliminary), surgical residents, and surgical faculty from General, Neuro, Pediatric, Plastics, Oncology, Urology, and Vascular surgical specialties were recruited via email to voluntarily participate in a telehealth simulation-based workshop, with 33 surgical learners participating in the training and 28 completing evaluation surveys. RESULTS: Only six respondents (22%) indicated they had prior formal training on telehealth communication with patients or families, while 13 (46%) said they had prior experience giving bad news via telehealth. Comments about improving the training focused on providing more scenarios to practice and more time for feedback. Overall, 25 learners (86%) agreed the activity was a valuable learning experience and the majority (61%) of responses were positive for future use of telehealth for breaking bad news. DISCUSSION: Practicing communication skills with VMC was found to be valuable by surgical interns, residents, and faculty. Formal training should be provided for surgeons at every stage of training and practice to improve skill in the delivery of bad news to patients and their families.

Adapting Compassionate Conversations for Virtual Mediated Communication.

OBJECTIVE: The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions. DESIGN: The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed. SETTING: Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated. PARTICIPANTS: Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators. RESULTS: A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall. CONCLUSIONS: This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

From chaos to creativity: Designing collaborative communication training for the delivery of bad news.

BACKGROUND: Before the COVID-19 pandemic, teaching communication skills in health care focused primarily on developing skills during face-to-face conversation. Even experienced clinicians were unprepared for the transition in communication modalities necessitated due to physical distancing requirements and visitation restrictions during the COVID-19 pandemic. We aimed to develop and pilot a comprehensive video-mediated communication training program and test its feasibility in multiple institutional settings and medical disciplines. METHODS: The education team, consisting of clinician-educators in general surgery and emergency medicine (EM) and faculty specialists in simulation and coaching, created the intervention. Surgery and EM interns in addition to senior medical students applying in these specialties were recruited to participate. Three 90-minute sessions were offered focusing on 3 communication topics that became increasingly complex and challenging: breaking bad news, goals of care discussions, and disclosure of medical error. This was a mixed-methods study using survey and narrative analysis of open comment fields. RESULTS: Learner recruitment varied by institution but was successful, and most (75%) learners found the experience to be valuable. All of the participants reported feeling able to lead difficult discussions, either independently or with minimal assistance. Only about half (52%) of the participants reported feeling confident to independently disclose medical error subsequent to the session. CONCLUSION: We found the program to be feasible based on acceptability, demand, the ability to implement, and practicality. Of the 3 communication topics studied, confidence with disclosure of medical error proved to be the most difficult. The optimal length and structure for these programs warrants further investigation.

Teaching technical skills to medical students during a surgery clerkship: results of a small group curriculum.

BACKGROUND: Opportunities for medical students to learn and perform technical skills during their clinical years have decreased. Alternative means to provide instruction are increasingly important. METHODS: Third-year students were assigned to three weekly small group tutorial sessions during their surgery clerkship. One hour sessions covered the following: suturing/knot tying, tubes (Foley catheter/NG tube), and lines (i.v. placement/arterial puncture). Students used a self-reported checklist to report their experience performing these procedures in the hospital after being exposed to them in the skills sessions. These data were compared with results prior to the implementation of the skills curriculum. Results were compared by Fisher's exact test. RESULTS: Seventy-seven students had evaluable checklists during the control period, and 69 were evaluable during the study period. Participations in four specific skills were compared: Foley catheter placement, nasogastric tube insertion/removal, i.v. placement, and arterial stick. In all four skills, students were more likely to have performed the task after having been introduced to it in the skills sessions. For both Foley catheter placement (96% versus 90%; P = 0.05) and NG tube insertion/removal (70% versus 53%; P = 0.06) there was a trend toward a higher incidence of participation, although statistical significance was not met. However, for both IV placement (64% versus 18%; P = 0.0001) and arterial puncture (48% versus 18%; P = 0.0002) there were significant increases in participation between the study periods. CONCLUSIONS: These results suggest that a small group technical skills curriculum facilitates learning of specific technical skills and appears to increase participation in all of the skills taught and assessed. This may be one strategy to introduce students to technical skills during the surgery clerkship and improve participation of these skills in the hospital setting.

Laparoscopic Excision of Congenital Hepatic Cysts in the Pediatric Population: A Case Series and Literature Review.

PURPOSE: Congenital hepatic cysts are rare. Surgical excision is indicated for symptoms, complications, and to rule out malignancy. Laparoscopic management in the pediatric population has not been extensively documented. We present a series involving laparoscopic excision of pediatric congenital hepatic cysts and review the literature. METHODS: Data were collected over 15 years from two pediatric surgeons at three medical centers. Presence of a hepatic cyst excised laparoscopically was the only inclusion criterion. Data were collected on the cyst size, type, pathology, and location, as well as on length of hospital stay, complications, and 1 year recurrence rate. RESULTS: Four patients were identified: a 7-week-old male presenting with feeding intolerance due to a hepatic cyst; a 6-year-old male presenting with a hepatic cyst identified by ultrasound during evaluation for appendicitis; a male neonate diagnosed at birth with a left thoracic cyst that communicated through the diaphragm with a hepatic cystic lesion; and a 14-year-old male presenting with a 25 cm × 11 cm hepatic cyst. All lesions were excised laparoscopically. CONCLUSION: Our series is the largest documenting complete laparoscopic excision of congenital solitary hepatic cysts in the pediatric population. Laparoscopic excision is a safe and effective approach for the pediatric population.

Preoperative Bowel Preparation before Elective Bowel Resection or Ostomy Closure in the Pediatric Patient Population Has No Impact on Outcomes: A Prospective Randomized Study.

The role of preoperative bowel prep in the pediatric surgical population is uncertain. We performed a randomized prospective study to evaluate noninferiority between the presence or absence of a preoperative bowel prep in elective pediatric bowel surgery on postoperative outcomes. Patients aged three months to 18 years were recruited and randomized to the bowel prep group or the no bowel prep group. Patients were evaluated in-hospital and at postoperative clinic visits. Thirty-two patients were recruited; 18 in the bowel prep group and 14 in the no bowel prep group. There was no statistical difference (P > 0.05) in complications between the groups. Complications were observed in five patients in each group (27.8% and 35.7%, respectively). In the bowel prep group, two (11.1%) had wound infection (vs three, 21.4%), 0 had an intra-abdominal abscess (vs one, 7.1%), one (5.6%) had sepsis (vs one, 7.1%), one (5.6%) had an anastomotic leak (vs 0), and three (16.7%) had a bowel obstruction (vs one, 7.1%). There were no extra-abdominal complications. There were no significant differences in complications between the two groups. Further research is warranted, but may require a multi-institutional trial to recruit sufficient numbers to make conclusions about the significance of the need for bowel prep.

The use of extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia.

The use of extracorporeal membrane oxygenation (ECMO) has revolutionized the care of the critical infant born with a congenital diaphragmatic hernia (CDH). In some respects, this is surprising given our current lack of understanding regarding optimal preoperative ventilation strategy, identification of patients most likely to benefit from ECMO, and the correct timing of hernia repair for the infant treated with ECMO. Historically, repair of CDH was considered one of the few true pediatric surgical emergencies. Mortality, however, was high. In the 1970s, ECMO was first utilized as a rescue therapy following repair of CDH when conventional methods failed. In the 1980s, advancements in neonatal intensive care and an understanding of the pathophysiology of pulmonary hypertension associated with CDH led to a strategy involving preoperative stabilization and delayed surgical intervention. Historical reviews demonstrate an improvement of survival in infants treated with ECMO from 56% to 71%. This paper will outline the advances in the care of the CDH patient and the approach used for treatment with ECMO.

TNF alpha-induced hepatocyte apoptosis is associated with alterations of the cell cycle and decreased stem loop binding protein.

BACKGROUND: Inhibition of nuclear factor kappa B (NF kappa B) during liver regeneration induces hepatocyte apoptosis associated with normal DNA synthesis but decreased mitosis, suggesting that inhibition of NF kappa B impairs progression from S-phase through the G(2)/M phase of the cell cycle. Our aim was to determine if inhibition of NF kappa B alters cell cycle characteristics in hepatocytes treated with tumor necrosis factor alpha (TNF alpha). METHODS: Primary hepatocytes from BALB/c mice were infected with adenoviruses expressing luciferase (control; AdLuc) or the I kappa B super-repressor (AdI kappa B) and treated with or without TNF alpha (30 ng/ml). Flow cytometry was performed (0 to 40 hours) to determine apoptosis and cell cycle progression. Reverse transcriptase-polymerase chain reaction and immunoblots assessed changes in cell cycle mediators and antiapoptotic factors. RESULTS: Primary hepatocytes treated with AdI kappa B and TNF alpha demonstrated significantly more S-phase cells (14% +/- 3% vs 6% +/- 2%, P<.05) at 14 hours compared with controls. Inhibition of NF kappa B with or without TNFalpha was associated with decreased expression of stem loop bind protein, a marker of cell cycle progression through S-phase. The NF kappa B-induced antiapoptotic proteins, iNOS and TRAF2, had decreased message at 9 and 12 hours, respectively, in TNF alpha- and AdI kappa B-treated cells. CONCLUSION: Inhibition of NF kappa B in TNF alpha-treated primary mouse hepatocytes is associated with increased S-phase cell cycle retention and decreased stem loop bind protein.

Transforming growth factor-beta1 induces hepatocyte apoptosis by a c-Jun independent mechanism.

BACKGROUND: During hepatic regeneration, transforming growth factor (TGF)-beta1 messenger RNA increases after the initial cycle of DNA synthesis, and it may control hepatocyte growth by inducing apoptosis. TGF-beta1 also induces c-Jun, a potential proapoptotic transcription factor. We hypothesized that autocrine expression of activated TGF-beta1 (Ad5aTGF-beta1) would increase c-jun expression in rat liver and limit hepatic regeneration by inducing apoptosis. METHODS: Male rats (175 to 200 g) received portal venous injections with adenoviruses expressing either luciferase (Ad5Luc), as a control, or Ad5aTGF-beta1 at a dose of 6 x 10(9) plaque-forming units. Livers were harvested 24 or 48 hours after injection and nuclear extracts and total RNA isolated. TGF-beta1 expression was confirmed by Northern blot analysis in all TGF-beta1-injected rats. RESULTS: A 2.5-fold increase in c-jun mRNA expression was detected in Ad5aTGF-beta1-infected rats compared with control rats. Transcriptional activity was assessed with an AP-1-responsive-reporter gene that increased 3-fold in rat primary hepatocytes infected with Ad5aTGF-beta1. C-Jun N-terminal kinase activity also increased 6- to 7-fold in Ad5aTGF-beta1-treated rats 24 and 48 hours after injection. Ad5aTGF-beta1-injected rats demonstrated increased AP-1 binding activity compared with Ad5Luc rats. Hepatocytes infected in vitro with Ad5aTGF-beta1 demonstrated increased apoptosis compared with Ad5Luc-infected hepatocytes (47% vs 27%) 36 hours after infection. Dual adenoviral infection with Ad5aTGF-beta1 and a dominant-negative c-Jun (Ad5TAM67) decreased AP-1-induced Ad5Luc activity but not hepatocyte apoptosis (46% with dominant-negative c-Jun and 47% without). CONCLUSIONS: These data demonstrate that TGF-beta1 induces c-Jun, but c-Jun is not proapoptotic in hepatocytes.

Differential responses of herbivores and herbivory to management in temperate European beech.

Forest management not only affects biodiversity but also might alter ecosystem processes mediated by the organisms, i.e. herbivory the removal of plant biomass by plant-eating insects and other arthropod groups. Aiming at revealing general relationships between forest management and herbivory we investigated aboveground arthropod herbivory in 105 plots dominated by European beech in three different regions in Germany in the sun-exposed canopy of mature beech trees and on beech saplings in the understorey. We separately assessed damage by different guilds of herbivores, i.e. chewing, sucking and scraping herbivores, gall-forming insects and mites, and leaf-mining insects. We asked whether herbivory differs among different forest management regimes (unmanaged, uneven-aged managed, even-aged managed) and among age-classes within even-aged forests. We further tested for consistency of relationships between regions, strata and herbivore guilds. On average, almost 80% of beech leaves showed herbivory damage, and about 6% of leaf area was consumed. Chewing damage was most common, whereas leaf sucking and scraping damage were very rare. Damage was generally greater in the canopy than in the understorey, in particular for chewing and scraping damage, and the occurrence of mines. There was little difference in herbivory among differently managed forests and the effects of management on damage differed among regions, strata and damage types. Covariates such as wood volume, tree density and plant diversity weakly influenced herbivory, and effects differed between herbivory types. We conclude that despite of the relatively low number of species attacking beech; arthropod herbivory on beech is generally high. We further conclude that responses of herbivory to forest management are multifaceted and environmental factors such as forest structure variables affecting in particular microclimatic conditions are more likely to explain the variability in herbivory among beech forest plots.

Traumatic rupture of a choledochal cyst masking as a duodenal hematoma.

Choledochal cysts are rare, congenital malformations of the intra and/or extrahepatic biliary tree. We describe a case in which a patient was transferred to our hospital with a reported duodenal hematoma. The patient ultimately required exploration when his condition deteriorated. Laparotomy resulted in the discovery and successful treatment of a ruptured type IV-A choledochal cyst.

NFkappaB inhibition decreases hepatocyte proliferation but does not alter apoptosis in obstructive jaundice.

INTRODUCTION: Cholestasis activates nuclear factor kappa B (NFkappaB), which is involved in both hepatocyte proliferation and apoptosis, depending on the cellular microenvironment. We hypothesized that NFkappaB inhibition would decrease hepatocyte proliferation and potentiate hepatocyte apoptosis in a rat model of extrahepatic biliary obstruction. AIM: To determine if NFkappaB inhibition concomitantly decreases hepatocyte proliferation and increases apoptosis in obstructive jaundice. MATERIALS AND METHODS: Male Sprague-Dawley rats underwent either sham operation or bile-duct ligation (BDL) combined with portal vein injection of vehicle or 6 x 10(9) particles of an adenovirus carrying either the control luciferase or the IkappaB super-repressor (AdIkappaBSR) transgenes. Liver was harvested 3, 5, and 7 days after sham operation or BDL, and immunohistochemistry for proliferating cell nuclear antigen and terminal dUTP nick end-labeling was performed for detection of DNA synthesis and apoptosis, respectively. RESULTS: Increased serum total bilirubin and hematoxylin and eosin-stained liver sections confirmed cholestasis in BDL animals. Western blot analysis demonstrated IkappaBSR protein expression in AdIkappaBSR-infected animals only. At day 7, NFkappaB inhibition decreased hepatocyte DNA synthesis in BDL rats compared to both adenovirus carrying the control luciferase and vehicle-treated controls. Apoptosis was increased in BDL vehicle-treated animals compared to sham-operation animals, but NFkappaB inhibition did not alter hepatocyte apoptosis in the BDL group. CONCLUSION: In obstructive cholestasis, NFkappaB is required for hepatocyte proliferation, but does not augment apoptosis.

Cirrhotic hepatocytes exhibit decreased TGFbeta growth inhibition associated with downregulated Smad protein expression.

TGFbeta controls hepatocyte growth through cell cycle arrest and apoptosis, and resistance to TGFbeta is a mechanism of malignant transformation. The aim of this study was to assess differences in TGFbeta-mediated growth inhibition in normal and cirrhotic hepatocytes. Cirrhosis was induced in mice and normal and cirrhotic hepatocytes were isolated by collagenase perfusion and treated with or without TGFbeta (5 ng/ml). DNA synthesis, Smad protein expression, and DNA binding activity were determined. TGFbeta reduced DNA synthesis to a greater degree in normal hepatocytes than in cirrhotic hepatocytes (87% vs. 68%; p<0.05). Smad protein expression was decreased in cirrhotic hepatocytes and Smad 2/3/4 complex formation was suppressed. Furthermore, cirrhotic hepatocytes had decreased DNA binding activity at 120 min following TGFbeta treatment. In conclusion, decreased Smad protein expression may impair TGFbeta-mediated growth inhibition in cirrhotic hepatocytes.