Collaboration, supervision and patient safety in the era of COVID-19: an analysis of medical wards and ICU.

AIMS: COVID-19 resulted in significant changes across medical wards and ICU in St James's Hospital Dublin. This included the implementation of ward-based medical teams (WBMT). The purpose of this study was to identify how these structural changes affected inter-professional collaboration, supervision and patient safety. METHODS: Questionnaires were distributed to doctors working on medical wards and ICU at the height of the first wave of COVID-19. The sense of collaboration, patient safety and supervision were assessed. RESULTS: Fifty-three doctors took part in the study. Thirty-three (62%) felt that collaboration was better than normal. Forty-six (87%) of participants described supervision as "good" or "excellent". Thirty-one out of 40 participants (77%) felt that patient safety was better than normal. DISCUSSION: Implementation of WBMT may result in improved sense of collaboration, supervision and patient safety during COVID-19; however, the increased sense of solidarity and comradery felt during the initial surge make drawing these conclusions challenging.

Supervision and Care Quality as Perceived by Redeployed Attendings, Fellows, and Residents During a COVID-19 Surge: Lessons for the Future.

PURPOSE: To better prepare for potential future large-scale redeployments, this study examines quality of supervision and care as perceived by redeployed residents, fellows, and attendings during a COVID-19 surge. METHOD: During April and May 2020, attendings, fellows, and residents redeployed at 2 teaching hospitals were invited to participate in a survey, which included questions on respondents' prior experience; redeployed role; amount of supervision needed and received; and perceptions of quality of supervision, patient care, and interprofessional collaboration. Frequencies, means, and P values were calculated to compare perceptions by experience and trainee status. Narrative responses to 2 open-ended questions were independently coded; themes were constructed. RESULTS: Overall, 152 of 297 (51.2%) individuals responded, including 64 of 142 attendings (45.1%), 40 of 79 fellows (50.6%), and 48 of 76 residents (63.2%). Fellows and attendings, regardless of prior experience, perceived supervision as adequate. In contrast, experienced residents reported receiving more supervision than needed, while inexperienced residents reported receiving less supervision than needed and rated overall supervision as poor. Attendings, fellows, and experienced residents rated the overall quality of care as acceptable to good, whereas inexperienced residents perceived overall quality of care as worse to much worse, particularly when compared with baseline. CONCLUSIONS: Narrative themes indicated that the quality of supervision and care was buffered by strong camaraderie, a culture of informal consultation, team composition (mixing experienced with inexperienced), and clinical decision aids. The markedly negative view of inexperienced residents suggests a higher risk for disillusionment, perhaps even moral injury, during future redeployments. Implications for planning are explored.

Supervision, Interprofessional Collaboration, and Patient Safety in Intensive Care Units during the COVID-19 Pandemic.

Background: To meet coronavirus disease (COVID-19) demands in the spring of 2020, many intensive care (IC) units (ICUs) required help of redeployed personnel working outside their regular scope of practice, causing an expansion and change of staffing ratios. Objective: How did this composite alternative ICU workforce experience supervision, interprofessional collaboration, and quality and safety of care under the unprecedented clinical circumstances at the height of the first pandemic wave as lived experiences uniquely captured during the first peak of the pandemic? Methods: An international, cross-sectional survey was conducted among physicians, nurses, and allied personnel deployed or redeployed to ICUs in Utrecht, New York, and Dublin from April to May of 2020. Data were analyzed separately for the three sites. Quantitative data were treated for descriptive statistics; qualitative data were analyzed thematically and combined for general interpretations. Results: On the basis of 234, 83, and 34 responses (response rates of 68%, 48%, and 41% in Utrecht, New York, and Dublin, respectively), we found that the amount of supervision and the quality and safety of care were perceived as being lower than usual but still acceptable. The working atmosphere was overwhelmingly felt to be collaborative and supportive. Where IC-certified nurse-to-patient ratios had decreased most (Utrecht), nurses voiced criticism about supervision and quality of care. Continuity within the work environment, team composition, and informal ("curbside") consultations were critical mediators of success. Conclusion: In the exceptional circumstances encountered during the COVID-19 pandemic, many ICUs were managed by a composite workforce of IC-certified and redeployed personnel. Although supervision is critical for safe care, supervisory roles were not clearly related to the amount of prior ICU experience. Vital for satisfaction with the quality of care was the span of control for those who assumed supervisory roles (i.e., the ratio of certified to noncertified personnel). Stable teams that matched less experienced personnel with more experienced personnel; a strong, interprofessional, collaborative atmosphere; a robust culture of informal consultation; and judicious, more flexible use of rules and regulations proved to be essential.

Fostering the development of professional identity within healthcare education-interdisciplinary innovation.

INTRODUCTION: Historical theories on development of professionalism are no longer sufficient in modern radiation therapy or radiography curricula with the focus moving from 'virtues-based professionalism' to 'professional identity formation'. Professional identity formation is a new concept that is described as a transformative journey from being a layperson to 'becoming' a professional. Knowledge, values, and behaviours are transformative and unique to each individual. The overall aim is to produce a consensus statement outlining evidence based programme initiatives to support healthcare students' professional identity formation. METHODS: 'Think tank' methodology was used for individual and final combined group reflective tasks to enable the creation of an evidenced based consensus statement. Participants discussed their personal views and beliefs regarding the process of Professional Identity Formation for teaching, learning, assessment, and evaluation. Discussions were recorded, transcribed, and analysed using thematic analysis from an interpretivist perspective. 'Think Tank' participants were asked to attend masterclasses to gain a greater understanding of professional identity formation from leading experts before the final combined 'Think Tanks'. RESULTS: Faculty and students across all Disciplines (N22) within the school of medicine attended the 'Think Tank' sessions. DISCUSSION: During each student's transformative process of professional identity formation, healthcare educators need to create evidence based pedagogic opportunities to support them. It is no longer sufficient to leave to chance within a 'hidden' or 'informal' curriculum. Professional identity is more than a set of learned behaviours that are assessed within the clinical environment. CONCLUSION: The development of this consensus statement is an innovative educational strategy that will ultimately enhance the education of professionalism in the clinical environment for radiographers and radiation therapists. Through seeking an understanding of the educational needs of students and faculty, the multidisciplinary team were able to create a tailored approach to professional identity formation within the institution. This student-faculty partnership is unique and beneficial to all parties involved and is an effective method of seeking a shared understanding.

Developing a national undergraduate standardized curriculum for future healthcare professionals on "Making Every Contact Count" for chronic disease prevention in the Republic of Ireland.

This report describes the development of the first national undergraduate interprofessional standardized curriculum in chronic disease prevention for healthcare professionals in the Republic of Ireland. This project brought together for the first time all higher education institutions nationwide in a novel collaboration with the national health service i.e. the Health Service Executive (HSE), to develop a standardized national curriculum for undergraduate health care professions. The curriculum sits within the framework of Making Every Contact Count, the goal of which is to re-orientate health services to embed the ethos of prevention through lifestyle behavior change as part of the routine care of health professionals. The core focus of Making Every Contact Count is chronic disease prevention, targeting four main lifestyle risk factors for chronic disease; tobacco use, alcohol consumption, physical inactivity and unhealthy eating. Making Every Contact Count is a key component of Healthy Ireland, the Irish national framework for health and wellbeing. The aim of the curriculum is to prepare newly qualified health professionals with the skills needed to support patients to achieve lifestyle behavior change delivered as part of routine clinical care.

A Robust PCR Protocol for HIV Drug Resistance Testing on Low-Level Viremia Samples.

The prevalence of drug resistance (DR) mutations in people with HIV-1 infection, particularly those with low-level viremia (LLV), supports the need to improve the sensitivity of amplification methods for HIV DR genotyping in order to optimize antiretroviral regimen and facilitate HIV-1 DR surveillance and relevant research. Here we report on a fully validated PCR-based protocol that achieves consistent amplification of the protease (PR) and reverse transcriptase (RT) regions of HIV-1 pol gene across many HIV-1 subtypes from LLV plasma samples. HIV-spiked plasma samples from the External Quality Assurance Program Oversight Laboratory (EQAPOL), covering various HIV-1 subtypes, as well as clinical specimens were used to optimize and validate the protocol. Our results demonstrate that this protocol has a broad HIV-1 subtype coverage and viral load span with high sensitivity and reproducibility. Moreover, the protocol is robust even when plasma sample volumes are limited, the HIV viral load is unknown, and/or the HIV subtype is undetermined. Thus, the protocol is applicable for the initial amplification of the HIV-1 PR and RT genes required for subsequent genotypic DR assays.

The emerging use of in vivo optical imaging in the study of neurodegenerative diseases.

The detection and subsequent quantification of photons emitted from living tissues, using highly sensitive charged-couple device (CCD) cameras, have enabled investigators to noninvasively examine the intricate dynamics of molecular reactions in wide assortment of experimental animals under basal and pathophysiological conditions. Nevertheless, extrapolation of this in vivo optical imaging technology to the study of the mammalian brain and related neurodegenerative conditions is still in its infancy. In this review, we introduce the reader to the emerging use of in vivo optical imaging in the study of neurodegenerative diseases. We highlight the current instrumentation that is available and reporter molecules (fluorescent and bioluminescent) that are commonly used. Moreover, we examine how in vivo optical imaging using transgenic reporter mice has provided new insights into Alzheimer's disease, amyotrophic lateral sclerosis (ALS), Prion disease, and neuronal damage arising from excitotoxicity and inflammation. Furthermore, we also touch upon studies that have utilized these technologies for the development of therapeutic strategies for neurodegenerative conditions that afflict humans.

Using multiple structural proteomics approaches for the characterization of prion proteins.

Structural proteomics approaches are valuable tools, particularly in cases where the exact mechanisms of protein conformational changes or the structures of proteins and protein complexes cannot be elucidated by traditional structural biology techniques like X-ray crystallography or NMR methods. Each structural proteomics method can provide a different set of data, all of which can be used as structural constraints for modeling the protein. We have applied a combination of limited proteolysis, surface modification, chemical crosslinking, and hydrogen/deuterium exchange for the characterization of structural differences in prion proteins in native monomeric and in the aggregated ß-oligomeric states. Data from these multiple proteomics approaches are in remarkable agreement in pointing to the rearrangement of the beta sheet 1-helix1-beta sheet 2-helix 2 (ß1-H1-ß2-H2) region as a major conformational change between the native and oligomeric prion protein forms. This data is also consistent with the ß1-H1-ß2 loop moving away from the H2-H3 core during the prion protein conversion. This is an example of how complementary data from multiple structural proteomics approaches can provide novel insights into the three-dimensional structures of proteins and protein complexes. This article is part of a Special Issue entitled: From protein structures to clinical applications.

Prolonged response of relapsed high grade serous ovarian carcinoma to the oral angiokinase inhibitor nintedanib in a patient with a germline BRCA1 mutation.

► Nintedanib is an anti-angiogenic agent that has demonstrated activity in relapsed ovarian cancer. ► Our patient had prolonged response to nintedanib, allowing her to have potentially curative surgery 6 years after her diagnosis. ► The relationship between angiogenesis and BRCA mutation is worth exploring in ovarian cancer.

Death and dignity through fresh eyes.

BACKGROUND: Trinity College Dublin remains one of the Medical Schools that uses traditional dissection to teach anatomy, exposing students from the first week of entry to cadavers. This early exposure makes it imperative that issues surrounding death and donor remains are explored early on within the main structure of the curriculum. CONTEXT: The School of Medicine began a programme of Medical Humanities student-selected modules (SSMs) in 2010, and the opportunity to offer a module on medical ethics regarding death and dignity was taken. INNOVATION: A course was devised that touched only lightly on subjects such as palliative care and the concept of a good death. The course focused much more strongly on the reality of death as part of cultural and societal identity and placement. This was facilitated by field trips to settings where discussions regarding death, dying and dignity were commonplace and authentic experiences, rather than classroom discussions based on theoretical circumstances that may not yet have been experienced by the student. IMPLICATIONS: The module ran very well, with students feeling that they had had a chance to think critically about the role of death as an event with significance within society and culture, rather than purely in a medico-legal framework. Options to extend the module to the compulsory element of the course, to be built upon in later years looking at more technical aspects surrounding death, are being explored.

Histologic and colposcopic correlation of cervical cytology showing "? glandular neoplasia".

OBJECTIVE: To evaluate the role of cervical cytology and colposcopy in the management of patients with cervical smear reported "? glandular neoplasia". STUDY DESIGN: A retrospective study of 116 patients referred to the colposcopy clinic with cytology samples showing "? glandular neoplasia". RESULTS: Histological results were available for 114 patients; of those, 103 had cervical biopsy, 52 had endometrial biopsy and 41 patients had both. 17 (15.5%) had invasive disease, 12 cervical carcinoma (11 adenocarcinoma and one squamous cell carcinoma) and 5 endometrial adenocarcinoma. 12 (10.5%) had high-grade cervical glandular intra-epithelial neoplasia (HG CGIN). 23 (20.2%) had high-grade cervical intra-epithelial neoplasia (HG CIN). None of the patients in whom colposcopy was normal were found to have invasive cervical disease. All the patients with endometrial carcinoma were above the age of 50 years, and none of the patients with cervical carcinoma was above this age. CONCLUSIONS: Cytology samples with "? glandular neoplasia" are associated with significant pathology. Colposcopy is important in the assessment of this group of patients. Endometrial assessment should be offered to all patients above the age of 50 years or postmenopausal presenting with such cytology.

Improved screening for anal neoplasia by immunocytochemical detection of minichromosome maintenance proteins.

PURPOSE: Early detection of anal intraepithelial neoplasia (AIN) and anal squamous cell carcinoma (SCC) by screening will improve clinical outcome. Assessment of anal cytology samples using routine Papanicolaou testing suffers from shortcomings in sensitivity and/or specificity, suggesting that screening tests based on biomarkers may be of value. We tested the suitability in this context of minichromosome maintenance (MCM) proteins, accurate markers of the deregulated cell cycle entry that characterizes malignancy and premalignancy. EXPERIMENTAL DESIGN: We undertook an initial immunohistochemical study of 54 anal tissue samples and validated our findings using an independent prospective cohort study of 235 anal cytology samples from 144 subjects. RESULTS: In the progression from normal anal epithelium through AIN to SCC, there was increasing expression of MCM2 and MCM5, including in the superficial epithelial third, the source of the majority of cells collected by anal swab. The median labeling indices (LI) for MCM2 and MCM5 in the superficial third of AIN2/3 and SCCs combined were 90.2% and 84.0%, respectively. MCM LIs in the superficial layers were significantly greater than LIs for Ki67, an alternative marker of cell cycle entry (P<0.0001). By immunocytochemistry using a mixture of anti-MCM2 and anti-MCM5 antibodies, immunopositive cells were readily identified in anal cytology samples, even at low magnification. MCM testing showed sensitivity for AIN2/3 of 84% (95% confidence interval, 75,93) and for AIN1/viral changes of 76% (68, 84), with overall specificity (for any lesion) of 77% (64, 90). CONCLUSIONS: MCMs are promising biomarkers for improving detection of AIN and SCC in anal cytology samples.

Sub-Tc electron transfer at the HTSC/polymer interface.

The first kinetic measurements for electron transfer (ferrocene/ferricinium reaction) at the interface between an HTSC (Tl,Pb1223) and a redox polymer (ferrocene-tagged poly-pyrrole) show that superconductivity affects electron transfer rate, which thus offers a novel probe of the superconducting state.