A Scoping Review of the Literature on Entrustable Professional Activities in Surgery Residency Programs.

OBJECTIVE: Entrustable professional activities (EPAs) are a crucial component of contemporary postgraduate medical education with many surgery residency programs having implemented EPAs as a competency assessment framework to assess and provide feedback on the performance of their residents. Despite broad implementation of EPAs, there is a paucity of evidence regarding the impact of EPAs on the learners and learning environments. A first step in improving understanding of the use and impact of EPAs is by mapping the rising number of EPA-related publications from the field of surgery. The primary objective of this scoping review is to examine the nature, extent, and range of articles on the development, implementation, and assessment of EPAs. The second objective is to identify the experiences and factors that influence EPA implementation and use in practice in surgical specialties. DESIGN: Scoping review. Four electronic databases (Medline, Embase, Education Source, and ERIC) were searched on January 20, 2022, and then again on July 19, 2023. A quasi-statistical content analysis was employed to quantify and draw meaning from the information related to the development, implementation, assessment, validity, reliability, and experiences with EPAs in the workplace. PARTICIPANTS: A total of 42 empirical and nonempirical articles were included. RESULTS: Four thematic categories describe the topic areas in included articles related to: 1) the development and refinement of EPAs, including the multiple steps taken to develop and refine unique EPAs for surgery residency programs; 2) the methods for implementing EPAs; 3) outcomes of EPA use in practice; 4) barriers, facilitators, and areas for improvement for the implementation and use of EPAs in surgical education. CONCLUSIONS: This scoping review highlights the key trends and gaps from the rapidly increasing number of publications on EPAs in surgery residency, from development to their use in the workplace. Existing EPA studies lack a theoretical and/or conceptual basis; future development and implementation studies should adopt implementation science frameworks to better structure and operationalize EPAs within surgery residency programs.

Dendrimer nanotherapy targeting of glial dysfunction improves inflammation and neurobehavioral phenotype in adult female Mecp2-heterozygous mouse model of Rett syndrome.

Rett syndrome is an X-linked neurodevelopmental disorder caused by mutation of Mecp2 gene and primarily affects females. Glial cell dysfunction has been implicated in in Rett syndrome (RTT) both in patients and in mouse models of this disorder and can affect synaptogenesis, glial metabolism and inflammation. Here we assessed whether treatment of adult (5-6 months old) symptomatic Mecp2-heterozygous female mice with N-acetyl cysteine conjugated to dendrimer (D-NAC), which is known to target glia and modulate inflammation and oxidative injury, results in improved behavioral phenotype, sleep and glial inflammatory profile. We show that unbiased global metabolomic analysis of the hippocampus and striatum in adult Mecp2-heterozygous mice demonstrates significant differences in lipid metabolism associated with neuroinflammation, providing the rationale for targeting glial inflammation in this model. Our results demonstrate that treatment with D-NAC (10 mg/kg NAC) once weekly is more efficacious than equivalently dosed free NAC in improving the gross neurobehavioral phenotype in symptomatic Mecp2-heterozygous female mice. We also show that D-NAC therapy is significantly better than saline in ameliorating several aspects of the abnormal phenotype including paw clench, mobility, fear memory, REM sleep and epileptiform activity burden. Systemic D-NAC significantly improves microglial proinflammatory cytokine production and is associated with improvements in several aspects of the phenotype including paw clench, mobility, fear memory, and REM sleep, and epileptiform activity burden in comparison to saline-treated Mecp2-hetereozygous mice. Systemic glial-targeted delivery of D-NAC after symptom onset in an older clinically relevant Rett syndrome model shows promise in improving neurobehavioral impairments along with sleep pattern and epileptiform activity burden. These findings argue for the translational value of this approach for treatment of patients with Rett Syndrome.

Dendrimer-Conjugated Glutamate Carboxypeptidase II Inhibitor Restores Microglial Changes in a Rabbit Model of Cerebral Palsy.

We have previously shown that maternal endotoxin exposure leads to a phenotype of cerebral palsy and pro-inflammatory microglia in the brain in neonatal rabbits. "Activated" microglia overexpress the enzyme glutamate carboxypeptidase II (GCPII) that hydrolyzes N-acetylaspartylglutamate to N-acetylaspartate and glutamate, and we have shown previously that inhibiting microglial GCPII is neuroprotective. Glutamate-induced injury and associated immune signaling can alter microglial responses including microglial process movements for surveillance and phagocytosis. We hypothesize that inhibition of GCPII activity could alter microglial phenotype and normalize microglial process movement/dynamics. Newborn rabbit kits exposed to endotoxin in utero, when treated with dendrimer-conjugated 2-(phosphonomethyl)-pentanedioic acid (D-2PMPA), a potent and selective inhibitor of microglial GCPII, showed profound changes in microglial phenotype within 48 h of treatment. Live imaging of hippocampal microglia in ex vivo brain slice preparations revealed larger cell body and phagocytic cup sizes with less stable microglia processes in CP kits compared to healthy controls. D-2PMPA treatment led to significant reversal of microglial process stability to healthy control levels. Our results emphasize the importance of microglial process dynamics in determining the state of microglial function in the developing brain and demonstrate how GCPII inhibition specifically in microglia can effectively change the microglial process motility to healthy control levels, potentially impacting migration, phagocytosis, and inflammatory functions.

Assessment of laparoscopic skills: comparing the reliability of global rating and entrustability tools.

Background: Competence by design (CBD) residency programs increasingly depend on tools that provide reliable assessments, require minimal rater training, and measure progression through the CBD milestones. To assess intraoperative skills, global rating scales and entrustability ratings are commonly used but may require extensive training. The Competency Continuum (CC) is a CBD framework that may be used as an assessment tool to assess laparoscopic skills. The study aimed to compare the CC to two other assessment tools: the Global Operative Assessment of Laparoscopic Skills (GOALS) and the Zwisch scale. Methods: Four expert surgeons rated thirty laparoscopic cholecystectomy videos. Two raters used the GOALS scale while the remaining two raters used both the Zwisch scale and CC. Each rater received scale-specific training. Descriptive statistics, inter-rater reliabilities (IRR), and Pearson's correlations were calculated for each scale. Results: Significant positive correlations between GOALS and Zwisch (r = 0.75, p < 0.001), CC and GOALS (r = 0.79, p < 0.001), and CC and Zwisch (r = 0.90, p < 0.001) were found. The CC had an inter-rater reliability of 0.74 whereas the GOALS and Zwisch scales had inter-rater reliabilities of 0.44 and 0.43, respectively. Compared to GOALS and Zwisch scales, the CC had the highest inter-rater reliability and required minimal rater training to achieve reliable scores. Conclusion: The CC may be a reliable tool to assess intraoperative laparoscopic skills and provide trainees with formative feedback relevant to the CBD milestones. Further research should collect further validity evidence for the use of the CC as an independent assessment tool.

Contexte: Les programmes de résidence structurés autour de la compétence par conception (CPC) dépendent de plus en plus d'outils qui fournissent des évaluations fiables, nécessitent une formation minimale des évaluateurs et mesurent la progression dans les étapes de la CPC. Pour évaluer les compétences peropératoires, les échelles d'évaluation globale et de confiance sont couramment utilisées mais peuvent nécessiter une formation approfondie. Le Continuum des compétences (CC) est un cadre de la CPC qui peut être utilisé comme outil d'évaluation des compétences laparoscopiques. L'étude visait à comparer le CC à deux autres outils d'évaluation : l'évaluation globale opératoire des compétences laparoscopiques (GOALS) et l'échelle de Zwisch. Méthodes: Quatre chirurgiens experts ont évalué trente vidéos de cholécystectomie laparoscopique. Deux évaluateurs ont utilisé l'échelle GOALS tandis que les deux autres ont utilisé l'échelle Zwisch et le CC. Chacun d'eux avait reçu une formation spécifique à l'échelle utilisée. Des statistiques descriptives, la fiabilité inter-évaluateurs (FIÉ) et des corrélations de Pearson ont été calculées pour chaque échelle. Résultats: Des corrélations positives significatives ont été trouvées entre les échelles GOALS et Zwisch (r=0.75, p<0.001), CC et GOALS (r=0.79, p<0.001), et CC et Zwisch (r=0.90, p<0.001). Le CC avait une fiabilité inter-évaluateurs de 0,74 tandis que les échelles GOALS et Zwisch avaient des fiabilités inter-évaluateurs de 0,44 et 0,43, respectivement. Par rapport aux échelles GOALS et Zwisch, le CC avait la fiabilité inter-évaluateurs la plus élevée et ne nécessitait qu'une formation minimale des évaluateurs pour obtenir des scores fiables. Conclusion: Le CC constituerait un outil fiable pour évaluer les compétences laparoscopiques peropératoires et pour fournir aux stagiaires une rétroaction formatrice pertinente pour les étapes de la CPC. Des recherches supplémentaires devraient être entreprises pour recueillir plus de preuves de validité pour l'utilisation du CC comme outil d'évaluation indépendant.

Reduced activity of adenylyl cyclase 1 attenuates morphine induced hyperalgesia and inflammatory pain in mice.

Opioid tolerance, opioid-induced hyperalgesia during repeated opioid administration, and chronic pain are associated with upregulation of adenylyl cyclase activity. The objective of this study was to test the hypothesis that a reduction in adenylyl cyclase 1 (AC1) activity or expression would attenuate morphine tolerance and hypersensitivity, and inflammatory pain using murine models. To investigate opioid tolerance and opioid-induced hyperalgesia, mice were subjected to twice daily treatments of saline or morphine using either a static (15 mg/kg, 5 days) or an escalating tolerance paradigm (10-40 mg/kg, 4 days). Systemic treatment with an AC1 inhibitor, ST03437 (2.5-10 mg/kg, IP), reduced morphine-induced hyperalgesia in mice. Lumbar intrathecal administration of a viral vector incorporating a short-hairpin RNA targeting Adcy1 reduced morphine-induced hypersensitivity compared to control mice. In contrast, acute morphine antinociception, along with thermal paw withdrawal latencies, motor performance, exploration in an open field test, and burrowing behaviors were not affected by intrathecal Adcy1 knockdown. Knockdown of Adcy1 by intrathecal injection also decreased inflammatory mechanical hyperalgesia and increased burrowing and nesting activity after intraplantar administration of Complete Freund's Adjuvant (CFA) one-week post-injection.

A state-wide education program on opioid use disorder: influential community members' knowledge, beliefs, and opportunities for coalition development.

BACKGROUND: Deep South states, particularly Alabama, experience disproportionately higher opioid prescribing rates versus national rates. Considering limited opioid use disorder (OUD) providers in this region, collaborative efforts between non-healthcare professionals is critical in mitigating overdose mortality. The Alabama Opioid Training Institute (OTI) was created in 2019 to empower community members to take action in combatting OUD in local regions. The OTI included: 1) eight full-day in-person conferences; and 2) an interactive mobile-enabled website ( https://alabamaoti.org ). This study assessed the impact of the OTI on influential community members' knowledge, abilities, concerns, readiness, and intended actions regarding OUD and opioid overdose mitigation. METHODS: A one-group prospective cohort design was utilized. Alabama community leaders were purposively recruited via email, billboards, television, and social media advertisements. Outcome measures were assessed via online survey at baseline and post-conference, including: OUD knowledge (percent correct); abilities, concerns, and readiness regarding overdose management (7-point Likert-type scale, 1 = strongly disagree to 7 = strongly agree); and actions/intended actions over the past/next 6 months (8-item index from 0 to 100% of the time). Conference satisfaction was also assessed. Changes were analyzed using McNemar or Marginal Homogeneity tests for categorical variables and two-sided paired t-tests for continuous variables (alpha = 0.05). RESULTS: Overall, 413 influential community members participated, most of whom were social workers (25.7%), female (86.4%), and White (65.7%). Community members' OUD knowledge increased from mean [SD] 71.00% [13.32] pre-conference to 83.75% [9.91] post-conference (p < 0.001). Compared to pre-conference, mean [SD] ability scale scores increased (3.72 [1.55] to 5.15 [1.11], p < 0.001) and concerns decreased (3.19 [1.30] to 2.64 [1.17], p < 0.001) post-conference. Readiness was unchanged post-conference. Attendees' intended OUD-mitigating actions in the next 6 months exceeded their self-reported actions in the past 6 months, and 92% recommended the OTI to others. CONCLUSIONS: The Alabama OTI improved community leaders' knowledge, abilities, and concerns regarding OUD management. Similar programs combining live education and interactive web-based platforms can be replicated in other states.

Comparison of sustained rate control in atrial fibrillation with rapid ventricular rate: Metoprolol vs. Diltiazem.

OBJECTIVE: The objective of this study was to compare sustained rate control with intravenous (IV) diltiazem vs. IV metoprolol in acute treatment of atrial fibrillation (AF) with rapid ventricular rate (RVR) in the emergency department (ED). METHODS: This retrospective chart review at a large, academic medical center identified patients with AF with RVR diagnosis who received IV diltiazem or IV metoprolol in the ED. The primary outcome was sustained rate control defined as heart rate (HR) < 100 beats per minute without need for rescue IV medication for 3 h following initial rate control attainment. Secondary outcomes included time to initial rate control, HR at initial control and 3 h, time to oral dose, admission rates, and safety outcomes. RESULTS: Between January 1, 2016 and November 1, 2018, 51 patients met inclusion criteria (diltiazem n = 32, metoprolol n = 19). No difference in sustained rate control was found (diltiazem 87.5% vs. metoprolol 78.9%, p = 0.45). Time to rate control was significantly shorter with diltiazem compared to metoprolol (15 min vs. 30 min, respectively, p = 0.04). Neither hypotension nor bradycardia were significantly different between groups. CONCLUSIONS: Choice of rate control agent for acute management of AF with RVR did not significantly influence sustained rate control success. Safety outcomes did not differ between treatment groups.

Patient Handover in Emergency Trauma Situations.

Miscommunication during patient handover can be a major cause of preventable medical errors. Emergency traumas are situations where high stress and cognitive load make communication more difficult. Simulation allows for junior learners to practice emergency scenarios in a low-risk setting. This technical report outlines a simulation involving patient handover in emergency trauma scenarios. The intended group of learners are first-year surgery and emergency medicine residents. The scenarios were developed based on the learning objectives of communication, collaboration, and information transfer. Using a high-fidelity simulation mimicking a tertiary care facility, the skills performed in these scenarios can be applied to everyday practice.

Dendrimer-conjugated glutaminase inhibitor selectively targets microglial glutaminase in a mouse model of Rett syndrome.

Background: Elevated glutamate production and release from glial cells is a common feature of many CNS disorders. Inhibitors of glutaminase (GLS), the enzyme responsible for converting glutamine to glutamate have been developed to target glutamate overproduction. However, many GLS inhibitors have poor aqueous solubility, are unable to cross the blood brain barrier, or demonstrate significant toxicity when given systemically, precluding translation. Enhanced aqueous solubility and systemic therapy targeted to activated glia may address this challenge. Here we examine the impact of microglial-targeted GLS inhibition in a mouse model of Rett syndrome (RTT), a developmental disorder with no viable therapies, manifesting profound central nervous system effects, in which elevated glutamatergic tone, upregulation of microglial GLS, oxidative stress and neuroimmune dysregulation are key features. Methods: To enable this, we conjugated a potent glutaminase inhibitor, N-(5-{2-[2-(5-amino-[1,3,4]thiadiazol-2-yl)-ethylsulfanyl]-ethyl}-[1,3,4]thiadiazol-2-yl)-2-phenyl-acetamide (JHU29) to a generation 4 hydroxyl PAMAM dendrimer (D-JHU29). We then examined the effect of D-JHU29 in organotypic slice culture on glutamate release. We also examined GLS activity in microglial and non-microglial cells, and neurobehavioral phenotype after systemic administration of D-JHU29 in a mouse model of RTT. Results: We report successful conjugation of JHU29 to dendrimer resulting in enhanced water solubility compared to free JHU29. D-JHU29 reduced the excessive glutamate release observed in tissue culture slices in a clinically relevant Mecp2-knockout (KO) RTT mouse. Microglia isolated from Mecp2-KO mice demonstrated upregulation of GLS activity that normalized to wild-type levels following systemic treatment with D-JHU29. Neurobehavioral assessments in D-JHU29 treated Mecp2-KO mice revealed selective improvements in mobility. Conclusion: These findings demonstrate that glutaminase inhibitors conjugated to dendrimers are a viable mechanism to selectively inhibit microglial GLS to reduce glutamate production and improve mobility in a mouse model of RTT, with broader implications for selectively targeting this pathway in other neurodegenerative disorders.

Decay of Competence with Extended Research Absences During Residency Training: A Scoping Review.

A significant number of residents in postgraduate training programs pursue dedicated research training. Currently, no formal curricula exist to transition residents back into clinical roles following dedicated research leave. This scoping review aims to determine what literature exists on the challenges faced by trainees who interrupt their clinical training for extended periods of time for research leave. The Pubmed and Medline databases were searched for all study designs related to postgraduate trainees taking academic or research leave. A three-step selection process including title, abstract and full-article review was employed to identify articles that mentioned decay of knowledge, skill or competence. A narrative review of the literature was generated to present key themes identified within the studies. The search yielded 174 articles of which five investigated resident skill decay during research leave. The five studies included for analysis were cohort studies that used general surgery residents' self-perception and faculty members' perception of residents' skill decay as a measure. Residents and faculty perceived decay of residents' technical skills, leadership skills and knowledge following dedicated research leave. The greatest decay perceived was in technical skills, specifically with more complex tasks and longer periods of non-use. This review identified that residents and faculty perceive a decay of resident skills following dedicated research training. To provide the necessary support to limit this potential decay, as well as to assist in the transition back into clinical training, the needs of and challenges faced by research residents and postgraduate programs must be better understood.

The Inter-Rater Reliability of Technical Skills Assessment and Retention of Rater Training.

BACKGROUND: The inter-rater reliability (IRR) of laparoscopic skills assessment is usually determined in the context of motivated raters from a single subspecialty practice group with significant experience using similar tools. The purpose of this study was to determine the IRR among attending surgeons of different experience and practices, the extent of rater training that is necessary to achieve good IRR, and if rater training is retained over periods of nonuse. METHODS: In Part 1, 5 surgeons of different practice backgrounds assessed 3 laparoscopic cholecystectomy videos using the Global Operative Assessment of Laparoscopic Skills instrument. In Part 2, 2 of the surgeons assessed a total of 33 videos over 5 scoring sessions distributed across 6 months. They participated in 2 different training sessions, and retention was tested in the other 3 sessions. IRR was calculated for Parts 1 and 2 with an intraclass correlation (ICC) in a 2-way random-effects model. RESULTS: The ICC for Part 1 was poor (ICC = 0.26). In Part 2, the ICC was highest after each training session (scoring #1 ICC = 0.76, scoring #3 ICC = 0.74). The ICC was not retained 1.5 months after the brief video-based training session (scoring #2 ICC = -0.17). The ICC was retained 2.5 months after the in-depth discussion training session (scoring #4 ICC = 0.70), but not 4.5 months later (scoring #5 ICC = 0.04). CONCLUSIONS: Good IRR is not implicit among surgeons with varying backgrounds and experience. Good IRR can be achieved with different types of rater training, but the impact of rater training is lost in periods of nonuse. This suggests the need for further study of the IRR of technical skills assessment when performed by the wide variety of surgeon raters as is commonly encountered in the environment of postgraduate resident assessment.

Altered trajectories of neurodevelopment and behavior in mouse models of Rett syndrome.

Rett Syndrome (RTT) is a genetic disorder that is caused by mutations in the x-linked gene coding for methyl-CpG-biding-protein 2 (MECP2) and that mainly affects females. Male and female transgenic mouse models of RTT have been studied extensively, and we have learned a great deal regarding RTT neuropathology and how MeCP2 deficiency may be influencing brain function and maturation. In this manuscript we review what is known concerning structural and coinciding functional and behavioral deficits in RTT and in mouse models of MeCP2 deficiency. We also introduce our own corroborating data regarding behavioral phenotype and morphological alterations in volume of the cortex and striatum and the density of neurons, aberrations in experience-dependent plasticity within the barrel cortex and the impact of MeCP2 loss on glial structure. We conclude that regional structural changes in genetic models of RTT show great similarity to the alterations in brain structure of patients with RTT. These region-specific modifications often coincide with phenotype onset and contribute to larger issues of circuit connectivity, progression, and severity. Although the alterations seen in mouse models of RTT appear to be primarily due to cell-autonomous effects, there are also non-cell autonomous mechanisms including those caused by MeCP2-deficient glia that negatively impact healthy neuronal function. Collectively, this body of work has provided a solid foundation on which to continue to build our understanding of the role of MeCP2 on neuronal and glial structure and function, its greater impact on neural development, and potential new therapeutic avenues.

Progression of Ankle Plantarflexion Contractures and Functional Decline in Duchenne Muscular Dystrophy: Implications for Physical Therapy Management.

PURPOSE: This study characterizes the progressive loss of ankle dorsiflexion range of motion in boys with Duchenne muscular dystrophy (DMD), the relationship to functional decline, and the implications for physical therapy management. METHODS: Longitudinal data for 332 boys with DMD were extracted from medical records and analyzed. Summary statistics for age, number of visits, ankle dorsiflexion measures, and North Star Ambulatory Assessment (NSAA) scores were computed. RESULTS: Ankle dorsiflexion motion ranged from -32.5 to 25 degrees. Progression of ankle contractures is demonstrated by a trend line: slope -1.43 per year. NSAA score was estimated to decline approximately 0.23 points per 1 degree of ankle dorsiflexion lost. CONCLUSIONS: The results of this study describe the progression of ankle contractures and functional decline in DMD. The findings may help inform decisions regarding interventions to support participants with DMD and their families.

The application of incisional negative pressure wound therapy for perineal wounds: A systematic review.

Impaired perineal wound healing is a major source of morbidity after abdominoperineal resection. Incisional negative pressure wound therapy can improve healing, prevent infections, and decrease the frequency of dehiscence. Our objective was to summarise existing evidence on the use of incisional negative pressure wound therapy on perineal wounds after abdominoperineal resection and to determine the effect on perineal wound complications. Electronic databases were searched in January 2017. Studies describing the use of incisional negative pressure wound therapy on primarily closed perineal wounds after abdominoperineal resection were included. Of the 278 identified articles, 5 were retrieved for inclusion in the systematic review (n = 169 patients). A significant decrease in perineal wound complications when using incisional negative pressure wound therapy was demonstrated, with surgical site infection rates as low as 9% (vs 41% in control groups). The major limitation of this systematic review was a small number of retrieved studies with small patient populations, high heterogeneity, and methodological issues. This review suggests that incisional negative pressure wound therapy decreases perineal wound complications after abdominoperineal resection. Further prospective trials with larger patient populations would be needed to confirm this association and delineate which patients might benefit most from the intervention.

Closing the gap: A whole of school approach to Aboriginal and Torres Strait Islander inclusivity in higher education.

The recruitment and retention of Aboriginal and Torres Strait Islander nurses and midwives is key to the delivery of culturally appropriate health care and improving the health outcomes of Aboriginal and Torres Strait Islander people. A working group to address inclusion and engagement of Aboriginal and Torres Strait Islander students at a West Australian University has impacted on the curricula, faculty staff and Aboriginal and Torres Strait Islander students within the School of Nursing and Midwifery. The University's Reconciliation Action Plan was the foundation and catalysed the group to promote cultural safety education for staff and provide inclusive activities for Aboriginal and Torres Strait Islander students. A conceptual framework was developed to demonstrate the action taken within the School of Nursing and Midwifery to address the inequity for Aboriginal and Torres Strait Islander students that could be seen to exist. Through collaboration with staff and students, both Aboriginal and Torres Strait Islander people and non-Aboriginal people, a shared understanding and goal setting has developed to enable positive action to provide ongoing support for these students at all parts of their journey in higher education. This paper will highlight the process involved to promote the recruitment, retention and academic success of these students.

An integrative review of rural and remote nursing graduate programmes and experiences of nursing graduates.

AIMS AND OBJECTIVES: To examine international studies that specifically focus on transition to practice for graduate registered nurses in rural and remote areas. BACKGROUND: Supportive graduate nursing programmes are essential for enabling nursing graduates' transition to practice and reducing attrition rates. Literature examining support measures for nursing graduates within metropolitan areas is abundant. However, there is a paucity of evidence on effective graduate programmes for rural and remote-based nursing graduates. DESIGN: A systematic approach was used to identify robust research within appropriate electronic databases. METHOD: Eligible articles were critically reviewed using the Mixed Method Appraisal Tool critical appraisal tool. Eligible articles were thematically analysed using the Braun and Clark approach. RESULTS: Eight articles met the selection criteria for inclusion. Findings revealed that while most graduate nurses survived the transition process, they often felt overwhelmed and abandoned with intense feelings of frustration. Many suffered transition shock and did not feel ready for the role. Socialisation of graduates to the clinical environment was lacking. Support offered in many graduate programmes was ad hoc and unstructured. Senior staff were inadequately supported in their roles as preceptors to assist with the transition. Critical support measures recommended included both debrief sessions and regular one-on-one support. CONCLUSIONS: Graduate programmes need to be structured yet flexible to accommodate the needs of rural and remote nurse graduates. Graduates need to be transitioned into practice with decremental support processes for both workloads and education. Preceptors require education on how to mentor before they can provide the appropriate support for graduates. Without these measures in place, a decrease in transition shock may not be possible. RELEVANCE TO CLINICAL PRACTICE: Graduate programmes need to be structured yet flexible, including assistance with both clinical skills and socialisation. Senior staff require education before they can adequately support new graduates.

Resource Utilization After Snakebite Severity Score Implementation into Treatment Algorithm of Crotaline Bite.

BACKGROUND: Crotaline envenomation clinical manifestations vary considerably among patients. Current recommendations for treatment with Crotalidae polyvalent immune Fab require assessment of envenomation control. Determining control of envenomation, particularly when patients are evaluated by different providers in separate clinical settings, can be difficult. OBJECTIVE: To determine if a difference in total vials of Crotalidae antivenin therapy exists between pre-protocol and post-Snakebite Severity Score (SSS) protocol. METHODS: Retrospective medical record review at an academic medical and regional Level I trauma center. Resource utilization in patients with a diagnosis of "snakebite" was compared between patients treated pre- and post-SSS protocol implementation. RESULTS: One hundred forty-six patients were included in the evaluation. One hundred twenty-seven (87.0%) patients received antivenin, n = 80 (90.9%) in the pre-protocol group and n = 47 (81.0%) in the post-protocol group. Median total number of antivenin vials per patient was lower in the post-protocol group than the pre-protocol group, 16 (10-24 interquartile range) vs. 12 (10-16 interquartile range), p = 0.006. This decreased utilization correlates to an approximate $13,200 savings per patient. Hospital and intensive care unit length of stay, opioid use, incidence of blood product transfusion, need for surgical intervention, or need for intubation were not different between groups. CONCLUSIONS: A snakebite protocol with SSS utilization to guide antivenin administration results in significantly decreased antivenin therapy in snakebite patients without increase in other health care utilization.

IgM Myeloma with Plasma Cell Leukemia: Case Report and Literature Review.

IgM multiple myeloma (MM) is a rare entity representing approximately 0.5% of all MM. It should be distinguished from malignant neoplasms of B cells with plasmacytic differentiation such as Waldenstrom macroglobulinemia (WM) and marginal zone lymphoma with plasmacytic differentiation. Plasma cell leukemia (PCL) is a rare and aggressive variant of MM characterized by the presence of circulating plasma cells. We present a case report of a patient who presented with IgM MM in primary PCL phase with high-risk cytogenetics. To our knowledge, this is the first reported case of IgM MM with primarily leukemic presentation in the era of novel drugs. We demonstrate that it is important to distinguish IgM MM from WM and review the data from clinical trials that was used to devise a treatment strategy for this high-risk patient. This case adds to the understanding of the diagnosis and management of IgM MM in leukemic phase.

Is faculty practice valuable? The experience of Western Australian nursing and midwifery academics undertaking faculty clinical practice - A discussion paper.

The faculty clinical practice model provides dedicated time for nursing lecturers and educators in a university school of nursing to work with supervision in the clinical environments for an agreed amount of time each year. Allowing academics to partake in faculty clinical practice this way has been shown to update skills and retain clinical competency. Some nursing and midwifery academics believe it is essential to remain clinically current and up-to-date with professional issues in the clinical environments, whereas other academics believe reading current research maintains clinical competency. This discussion paper will explore the authors' own experiences of faculty clinical practice as an opportunity to enhance their learning. Narrative accounts of time spent in the clinical areas being expressed as invaluable as it allowed the authors to become part of the health professional team, refine clinical skills, gain clinical confidence, and share knowledge. This, in turn, impacted upon the academic's teaching style as well as redefined it by introducing incidents and stories from their experience. It has been concluded by the authors that faculty clinical practice allows academics to increase confidence, encourage leadership skills, and improve their teaching abilities in their clinical area of expertise.