Virtual Procedural Supervision During the COVID-19 Pandemic: A Novel Pilot for Supervising Invasive Bedside Procedures in the ICU.

The ability to perform invasive bedside procedures (IBPs) safely and efficiently is a core skill set within critical care medicine. Fellowship training provides a pivotal time for learners to attain baseline proficiency in such procedures to decrease patient complications. The coronavirus disease 2019 pandemic has posed distinct challenges to the traditional model of teaching and supervising IBPs in the intensive care unit, including stewardship of personal protective equipment and limiting health care worker exposure to persons with coronavirus disease 2019. To address these challenges, we piloted a novel method of IBP supervision and teaching using a virtual monitoring system. In this virtual procedural supervision model, the supervising teacher is located outside the patient room, limiting personal protective equipment use and health care worker exposure. An audiovisual monitoring system allowed communication between the teacher and the learner as well as supervisor visualization of the procedural encounter. Virtual supervision was used for central line placement and bronchoscopy in the medical intensive care unit with no complications or instances of the supervisor needing to enter the patient room. Success was felt to depend on camera positioning and preprocedure planning and to be best for advanced learners who would not require tactile feedback. Upper level learners appreciated autonomy granted by this process. Virtual IBP supervision is felt to be a useful tool in specific situations. As with any tool, there are notable strengths and limitations. Success is felt to be optimized when attention is paid to procedural teaching best practices, learner selection, and technological logistics.

Cryptococcal Meningitis in an Apparent Immunocompetent Patient.

Cryptococcal meningitis is an uncommon and severe infection that tends to affect immunocompromised hosts worldwide and in the United States. Annually it is estimated that there are 200 000 cases of cryptococcal meningitis, with the most recent estimate of 3400 cases per year in the United States alone. However, despite the low incidence, 1-year mortality is estimated at 20% to 30% even with long-term consolidation antifungal therapy. A 37-year-old man presented to the emergency department with headaches, dysarthria, hallucinations, and acute worsening of altered mental status, and he was found to have increased intracranial pressure, cerebrospinal fluid leukocytosis, and few encapsulated yeasts consistent with Cryptococcus neoformans meningitis in addition to radiologic evidence consistent with a cryptococcoma of the lungs. This report highlights the occurrence of Cryptococcus neoformans meningitis in a presumed immunocompetent host. The clinician should be aware of sources of minor immunosuppression, as they may contribute to development of Cryptococcus neoformans meningitis. Mortality in this condition remains high due to subacute presentations and delayed diagnosis in non-immunocompromised patients.

Usability Evaluation of a Blood Glucose Monitoring System With a Spill-Resistant Vial, Easier Strip Handling, and Connectivity to a Mobile App: Improvement of Patient Convenience and Satisfaction.

BACKGROUND: Proper management of diabetes mellitus requires regular self-monitoring of blood glucose (SMBG). This research evaluated the usability of the Accu-Chek® Guide Meter that includes a spill-resistant vial, easier strip handling, and wireless connectivity to a mobile app. METHODS: A total of 197 participants were allowed to experience typical blood glucose testing tasks on the Accu-Chek Guide Meter, review data such as last result, patterns, and target percentage on the meter and on the mobile app, and then evaluate their experience through a human factors usability survey. Participants used a 6-point agree/disagree scale to rate 34 market statement questions. RESULTS: The results of a Pearson chi-square proportions test for each of the 34 market statement questions showed a significant difference (P < .0001) between the disagree responses (1-3) and agree responses (4-6). An overwhelming majority of participants found all aspects of the system, including the test strips, strip vial, and data analysis on the meter and the mobile app, to be a good fit for their lifestyle and to provide a better testing experience. CONCLUSIONS: This study found superior usability of the new meter system over the participants' current meters in both the United States and France.

TGFß1 overexpression by keratinocytes alters skin dendritic cell homeostasis and enhances contact hypersensitivity.

Overexpression of transforming growth factor beta-1 (TGFß1) in mouse epidermis causes cutaneous inflammation and keratinocyte hyperproliferation. Here we examined acute effects of TGFß1 overproduction by keratinocytes on skin dendritic cells (DCs). TGFß1 induction for 2 and 4 days increased the numbers and CD86 expression of B220(+) plasmacytoid DCs (pDCs) and CD207(+)CD103(+), CD207(-)CD103(-)CD11b(+), and CD207(-)CD103(-)CD11b(-) dermal DCs (dDCs) in skin-draining lymph nodes (SDLNs). The dermis of TGFß1-overexpressing mice had significantly more pDCs, CD207(+)CD103(+) dDCs, and CD207(-)CD11b(+) dDCs in the absence of increased dermal proliferation. Application of dye, tetramethyl rhodamine iso-thiocyanate (TRITC), in dibutylpthalate (DBP) solution after TGFß1 induction increased the numbers of TRITC(+)CD207(-) dDCs in SDLNs, and augmented TRITC/DBP-induced Langerhans cell (LC) migration 72 hours post TRITC treatment. Consistent with this, LC migration was increased in vitro by TGFß1 overexpression in skin explants and by exogenous TGFß1 in culture media. Transient TGFß1 induction during DNFB sensitization increased contact hypersensitivity responses by 1.5-fold. Thus, elevated epidermal TGFß1 alone is sufficient to alter homeostasis of multiple cutaneous DC subsets, and enhance DC migration and immune responses to contact sensitizers. These results highlight a role for keratinocyte-derived TGFß1 in DC trafficking and in the initiation of skin inflammation.

Comparison of lancing devices for self-monitoring of blood glucose regarding lancing pain.

BACKGROUND: Self-monitoring of blood glucose empowers diabetes patients to effectively control their blood glucose (BG) levels. A potential barrier to frequent BG controls is lancing pain, intrinsically linked to pricking the finger several times a day. In this study, we compared different state-of-the-art lancing devices from leading manufacturers regarding lancing pain, and we intended to identify lancing devices that are less painful. METHODS: First, 165 subjects compared 6 different BG monitoring systems-consisting of a lancing device and a BG meter-at home for 36 days and at least 3 BG tests per day. Second, the subjects directly compared 6 different lancing devices-independent from a BG meter-in a laboratory setting. The test results were collected in questionnaires, and lancing pain was rated on a numerical rating scale. RESULTS: One hundred fifty-seven subjects were included in the analysis. Accu-Chek BG monitoring systems were significantly (p < or = .006) preferred to competitor BG monitoring systems and were rated by >50% of the subjects as "less painful" than competitor BG monitoring systems. Accu-Chek lancing devices were significantly (p < .001) preferred to competitor lancing devices and were rated by >60% of the subjects as "less painful" than competitor lancing devices. CONCLUSIONS: We found significant differences in lancing pain between lancing devices. Diabetes patients clearly preferred lancing devices that cause less lancing pain. In order to improve patient compliance with respect to an adequate glycemic control, the medical staff should preferentially prescribe lancing devices that cause less lancing pain.

The development of a theoretical framework and design tool for process usability assessment.

The purpose of usability engineering is to facilitate the deployment of new products by decreasing development costs and improving the quality of systems. This paper will discuss the development and delivery of a unique, theoretically based software tool that provides engineers and designers with easy access to the most recent advances in human-machine interface design. This research combines several theoretical views of the interaction process into a hybrid model. Based on this model, a software tool was produced that allows engineers to model the human interaction process within their design. The system then provides feedback on the interaction process through items such as: the amount of mental effort required by a user, the degree to which the system conforms to human capabilities, the expected time to complete the interaction, where potential human error may occur, as well as potential misunderstandings or points of confusion to the users. The designer may then use this information to improve the design of the system. Validation of this technique indicates that the hybrid model produces accurate predictions of usability attributes and that the technique transfers from the laboratory to the real world.

The implementation and evaluation of a theory for high level cognitive skill acquisition through expert systems modelling techniques.

From previous studies by Koubek and Salvendy (1988), it has been established that differences exist in the high level controlled processes between expert (E) and super-expert (SE) subjects on computer program modification tasks. This study examines the implications of this finding by applying modelling techniques via expert systems technology. To examine the hypothesis that the knowledge representation is critical to SE performance, and to indicate how these results might have practical application, two small prototype expert systems were developed using the E and SE knowledge representations respectively. A qualitative analysis reveals significant performance differences between systems attributable to the knowledge representation and suggests a combination of E and SE knowledge be used for construction of a hybrid expert system. The SE knowledge base is a hierarchical structure and is organized under abstract categories, suggesting a breadth first approach. This structure allows for interactions within the program itself and between the program and user environment. The E knowledge base is narrow and task specific, indicating a depth first approach. In conclusion, theoretical and practical implications of this research into SE performance and modelling techniques are discussed.