From Innovation to Intrapreneurship: Fostering academic success via the GridlockED project and innovation fund.

Background: Funding for educational innovations is increasingly scarce in academic medicine. While there is some funding for medical education research, this is often for discovery or application work, and there are few avenues for those with a heavy innovation focus to fund early work. Objective of the Innovation: The objective was to develop an intrapreneurial unit focused on medical education projects and scholarship. Development Process and Implementation: The GridlockED and TriagED games are educational or serious games that seek to teach health care learners about emergency medicine processes. Both games were cocreated with learners and brought to market in the past 3 years. All of the proceeds from the sales of these games have been accrued over time to create a new innovation fund. This fund seeks to support trainees and early career educators in their medical education projects. Outcomes: Sales for GridlockED began in March 2018 and the TriagED began in November 2019. In the first year, sales for GridlockED yielded a total of $9,534. After 18 months of sales, the fund has accrued a total of $14,530. The fund has helped finance the development of new games. Additionally, the fund awarded two internal $500 Kickstarter grants to assist with evaluating and improving two local education projects. The GridlockED and TriagED games have also spurred multiple academic opportunities for junior educators interested in this domain: five workshops, eight conference abstracts, two peer-reviewed papers, and two research protocols are being developed. Conclusions: The GridlockED and TriagED games represent a new academically oriented, intrapreneurial approach to medical education work.

Feeling the flow with a serious game workshop: GridlockED as Medical Education 2 study (GAME2 study).

OBJECTIVE: GridlockED gameplay workshops were delivered in Canada. This project investigated workshop attendees' experiences, seeking to identify learning points to inform improvement of the workshop. METHODS: GridlockED sessions were held through 2018 and 2019. Workshops targeted medical trainees. After a standardized video, learners played for approximately 90 minutes. Learners completed a postgameplay survey with 7-point Likert scale questions about their experience. RESULTS: Seventy-two participants responded to our survey (41 medical students, 13 physician assistant students, 12 emergency medicine residents, and six faculty members). Trainees rated GridlockED as both enjoyable and a meaningful educational experience, with a mean (±SD) rating of 6.53 (±0.96) of 7 for enjoyment and 6.17 (±1.13) for education. Attendees identified teamwork and communication (49%) as the most helpful learning domain, with patient flow (43%) being second and basics of how the ED worked (31%) being third. The respondents self-identified top areas of learning as resource management (38.9%), improved understanding of various provider roles in the ED (33%), and improved communication skills (33%). CONCLUSION: Medical learners identified GridlockED to be an educational and enjoyable learning experience. Attendees reported that playing this serious game assisted with learning about health systems and communication.

Using Observation to Determine Teachable Moments Within a Serious Game: A GridlockED as Medical Education (GAME) Study.

BACKGROUND: The use of serious games as an educational tool may be an effective strategy to improve knowledge and skill among health care trainees. GridlockED is a serious board game designed to simulate a shift in the emergency department (ED) that incorporates concepts such as prioritization in a multipatient environment and stewardship of finite resources. Serious games can present concepts to learners that are not easily accessible through other teaching methods. GridlockED was designed to demonstrate the principles behind ED flow and how to prioritize in a complex multipatient environment. The objective of this study was to identify teaching points to which learners are exposed while playing the GridlockED game. METHODS: We conducted a prospective, observational study from May to August 2017. Practicing emergency physicians, residents, and nurses were recruited as participants to play GridlockED. Participants were instructed on how to play the game and then engaged in playing GridlockED, during which their gameplay was video recorded. The videos of the play sessions were qualitatively analyzed using an interpretive description technique. All teaching points explicitly stated by players or implicitly observed by researchers were recorded. RESULTS: Teaching points were identified in the GridlockED play sessions centered around the concepts of patient prioritization and staff placement. Major themes present in gameplay, as well as deviations from reality and frequent misconceptions about emergency care, were also identified. CONCLUSION: Observations of experienced ED practitioners reveal that the GridlockED board game creates opportunities for engaging medical learners in systems-level teaching. Our findings will help create the basis for future education modules, but further study is required to ensure that junior trainees actually learn when playing the game.

Identification of Bioactive SNM1A Inhibitors.

SNM1A is a nuclease required to repair DNA interstrand cross-links (ICLs) caused by some anticancer compounds, including cisplatin. Unlike other nucleases involved in ICL repair, SNM1A is not needed to restore other forms of DNA damage. As such, SNM1A is an attractive target for selectively increasing the efficacy of ICL-based chemotherapy. Using a fluorescence-based exonuclease assay, we screened a bioactive library of compounds for inhibition of SNM1A. Of the 52 compounds initially identified as hits, 22 compounds showed dose-response inhibition of SNM1A. An orthogonal gel-based assay further confirmed nine small molecules as SNM1A nuclease activity inhibitors with IC50 values in the mid-nanomolar to low micromolar range. Finally, three compounds showed no toxicity at concentrations able to significantly potentiate the cytotoxicity of cisplatin. These compounds represent potential leads for further optimization to sensitize cells toward chemotherapeutic agents inducing ICL damage.

Building impactful systems-focused simulations: integrating change and project management frameworks into the pre-work phase.

Healthcare organizations strive to deliver safe, high-quality, efficient care. These complex systems frequently harbor gaps, which if unmitigated, could result in harm. Systems-focused simulation (SFS) projects, which include systems-focused debriefing (SFD), if well designed and executed, can proactively and comprehensively identify gaps and test and improve systems, enabling institutions to improve safety and quality before patients and staff are placed at risk.The previously published systems-focused debriefing framework, Promoting Excellence and Reflective Learning in Simulation (PEARLS) for Systems Integration (PSI), describes a systematic approach to SFD. It includes an essential "pre-work" phase, encompassing evidence-informed steps that lead up to a SFD. Despite inclusion in the PSI framework, a detailed description of the pre-work phase, and how each component facilitates change management, was limited.The goal of this paper is to elucidate the PSI "Pre-work" phase, everything leading up to the systems-focused simulation and debriefing. It describes how the integration of project and change management principles ensures that a comprehensive collection of safety and quality issues are reliably identified and captured.

Just the facts: Organ donation in the emergency department: When you can't save one, save eight.

A 16-year-old female presents to a community emergency room following a suicide attempt by hanging. Prehospital, on arrival of paramedics, the patient was in a pulseless electrical activity rhythm. Paramedics provided advanced cardiac life support for 20 minutes before they obtained return of spontaneous circulation. In the emergency department, she had another 25-minute cardiac arrest with ultimate return of spontaneous circulation. She is now hemodynamically stable on Levophed 0.2 µg/kg/min. Her neurological exam shows pupils to be 3 mm and fixed bilaterally, absent cough and gag, and no response to central or peripheral pain. She occasionally triggers 2-3 spontaneous breaths per minute above the set rate on the ventilator. Her CT head scan shows severe anoxic changes and cerebral edema.

Case Report: Human Subcutaneous Sparganosis in a Thai Migrant.

Human sparganosis is a cestode infection which is neglected as a differential diagnosis outside endemic countries. Diagnosis and therapy may be challenging depending on the clinical presentation and anatomic localization. The disease manifests predominantly as subcutaneous nodule(s) or intracranial mass lesion(s). Infection is primarily acquired by ingesting raw or undercooked amphibian or reptile flesh or by drinking water containing copepods. We report an unusual case of subcutaneous Spirometra erinaceieuropaei sparganosis presenting with two nonmigratory nodules in close proximity to each other on the right thigh of a Thai woman living in Switzerland.

Creating GridlockED: A Serious Game for Teaching About Multipatient Environments.

PROBLEM: As patient volumes increase, it is becoming increasingly important to find novel ways to teach junior medical learners about the intricacies of managing multiple patients simultaneously and about working in a resource-limited environment. APPROACH: Serious games (i.e., games not intended purely for fun) are a teaching modality that have been gaining momentum as teaching tools in medical education. From May 2016 to August 2017, the authors designed and tested a serious game, called GridlockED, to provide a focused educational experience for medical trainees to learn about multipatient care and patient flow. The game allows as many as six people to play it at once. Gameplay relies on the players working collaboratively (as simulated members of a medical team) to triage, treat, and disposition "patients" in a manner that simulates true emergency department operations. After researching serious games, the authors developed the game through an iterative design process. Next, the game underwent preliminary peer review by experienced gamers and practicing clinicians, whose feedback the authors used to adjust the game. Attending physicians, nurses, and residents have tested GridlockED for usability, fidelity, acceptability, and applicability. OUTCOMES: On the basis of initial testing, clinicians suggest that this game will be useful and has fidelity for teaching patient-flow concepts. NEXT STEPS: Further play testing will be needed to fully examine learning opportunities for various populations of trainees and for various media. GridlockED may also serve as a model for developing other games to teach about processes in other environments or specialties.

Impact of Wide-Awake Local Anesthesia No Tourniquet on Departmental Settings, Cost, Patient and Surgeon Satisfaction, and Beyond.

This article reviews the impact of wide-awake hand surgery without tourniquet on departmental settings and savings on patients' medical cost, and efficiency of fellowship training and practice of junior hand surgeons in 3 units in 3 countries. The medical cost of the commonly performed procedures is decreased remarkably with this approach in the 3 units. Hand surgery fellowship training and practice of junior surgeons are benefited from this approach in 2 units in Turkey and Switzerland. Overall, this approach improves the surgeons' and patients' quality of life and its application is expanding to almost all procedures of hand surgery.

The effect of an infographic promotion on research dissemination and readership: A randomized controlled trial.

OBJECTIVE: Journals use social media to increase the awareness of their publications. Infographics show research findings in a concise and visually appealing manner, well suited for dissemination on social media platforms. We hypothesized that infographic abstracts promoted on social media would increase the dissemination and online readership of the parent research articles. METHODS: Twenty-four articles were chosen from the six issues of CJEM published between July 2016 and June 2017 and randomized to infographic or control groups. All articles were disseminated through the journal's social media accounts (Twitter and Facebook). Control articles were promoted using a screen capture image of each article's abstract on the journal's social media accounts. Infographic articles were promoted similarly using a visual infographic. Infographics were also published and promoted on the CanadiEM.org's website and social media channels. Abstract views, full-text views, and the change in Altmetric score were compared between groups using unpaired two-tailed t-tests. RESULTS: There were no significant differences in the groups at baseline. Abstract views (mean, 95% CI) were higher in the infographics (379, 287-471) than the control group (176, 136-215, p<0.001). Mean change in Altmetric scores was higher in the infographics (26, 18-34) than in the control group (3, 2-4, p<0.0001). There was no difference in full-text views between the infographics (50, 0-101) and control groups (25, 18-32). CONCLUSION: The promotion of CJEM articles using infographics on social media and the CanadiEM.org website increased Altmetric scores and abstract views. Infographics may have a role in increasing awareness of medical literature.

Structure-specific endonuclease activity of SNM1A enables processing of a DNA interstrand crosslink.

DNA interstrand crosslinks (ICLs) covalently join opposing strands, blocking both replication and transcription, therefore making ICL-inducing compounds highly toxic and ideal anti-cancer agents. While incisions surrounding the ICL are required to remove damaged DNA, it is currently unclear which endonucleases are needed for this key event. SNM1A has been shown to play an important function in human ICL repair, however its suggested role has been limited to exonuclease activity and not strand incision. Here we show that SNM1A has endonuclease activity, having the ability to cleave DNA structures that arise during the initiation of ICL repair. In particular, this endonuclease activity cleaves single-stranded DNA. Given that unpaired DNA regions occur 5' to an ICL, these findings suggest SNM1A may act as either an endonuclease and/or exonuclease during ICL repair. This finding is significant as it expands the potential role of SNM1A in ICL repair.

The impact of social media promotion with infographics and podcasts on research dissemination and readership.

OBJECTIVE: In 2015 and 2016, the Canadian Journal of Emergency Medicine (CJEM) Social Media (SoMe) Team collaborated with established medical websites to promote CJEM articles using podcasts and infographics while tracking dissemination and readership. METHODS: CJEM publications in the "Original Research" and "State of the Art" sections were selected by the SoMe Team for podcast and infographic promotion based on their perceived interest to emergency physicians. A control group was composed retrospectively of articles from the 2015 and 2016 issues with the highest Altmetric score that received standard Facebook and Twitter promotions. Studies on SoMe topics were excluded. Dissemination was quantified by January 1, 2017 Altmetric scores. Readership was measured by abstract and full-text views over a 3-month period. The number needed to view (NNV) was calculated by dividing abstract views by full-text views. RESULTS: Twenty-nine of 88 articles that met inclusion were included in the podcast (6), infographic (11), and control (12) groups. Descriptive statistics (mean, 95% confidence interval) were calculated for podcast (Altmetric: 61, 42-80; Abstract: 1795, 1135-2455; Full-text: 431, 0-1031), infographic (Altmetric: 31.5, 19-43; Abstract: 590, 361-819; Full-text: 65, 33-98), and control (Altmetric: 12, 8-15; Abstract: 257, 159-354; Full-Text: 73, 38-109) articles. The NNV was 4.2 for podcast, 9.0 for infographic, and 3.5 for control articles. Discussion Limitations included selection bias, the influence of SoMe promotion on the Altmetric scores, and a lack of generalizability to other journals. CONCLUSION: Collaboration with established SoMe websites using podcasts and infographics was associated with increased Altmetric scores and abstract views but not full-text article views.

An ectopic approach for engineering a vascularized tracheal substitute.

Tissue engineering can provide alternatives to current methods for tracheal reconstruction. Here we describe an approach for ectopic engineering of vascularized trachea based on the implantation of co-cultured scaffolds surrounded by a muscle flap. Poly(L-lactic-co-glycolic acid) (PLGA) or poly(ε-caprolactone) (PCL) scaffolds were seeded with chondrocytes, bone marrow stem cells and co-cultured both cells respectively (8 groups), wrapped in a pedicled muscle flap, placed as an ectopic culture on the abdominal wall of rabbits (n = 24), and harvested after two and four weeks. Analysis of the biochemical and mechanical properties demonstrated that the PCL scaffold with co-culture cells seeding displayed the optimal chondrogenesis with adequate rigidity to maintain the cylindrical shape and luminal patency. Histological analysis confirmed that cartilage formed in the co-culture groups contained a more homogeneous and higher extracellular matrix content. The luminal surfaces appeared to support adequate epithelialization due to the formation of vascularized capsular tissue. A prefabricated neo-trachea was transferred to the defect as a tracheal replacement and yielded satisfactory results. These encouraging results indicate that our co-culture approach may enable the development of a clinically applicable neo-trachea.

Trapping and rotating microparticles and bacteria with moiré-based optical propelling beams.

We propose and demonstrate trapping and rotation of microparticles and biological samples with a moiré-based rotating optical tweezers. We show that polystyrene beads, as well as Escherichia coli cells, can be rotated with ease, while the speed and direction of rotation are fully controllable by a computer, obviating mechanical movement or phase-sensitive interference. Furthermore, we demonstrate experimentally the generation of white-light propelling beams and arrays, and discuss the possibility of optical tweezing and particle micro-manipulation based on incoherent white-light rotating patterns.

Trapping and transporting aerosols with a single optical bottle beam generated by moiré techniques.

We demonstrate optical trapping and manipulation of aerosols with an optical bottle beam generated by the moiré techniques. We observe stable trapping and back-and-forth transportation of a variety of absorbing carbon particles suspended in air, ranging from clusters of nanosized buckminsterfullerene C60 to micrometer-sized carbon powders.

Cardiac tamponade and large pericardial effusions in systemic sclerosis: a report of four cases and a review of the literature.

Cardiac tamponade in systemic sclerosis is rare. We report four cases of SSc with hemodynamically significant pericardial effusions associated with pulmonary arterial hypertension, three of whom died, two following pericardiocentesis. Of 26 SSc cases reported in the literature with large pericardial effusions, seven were associated with PAH. Including our series, the mortality rate is 55%.The potential contributory role of PAH in the development of pericardial effusion and the management implications are explored. In SSc patients with hemodynamically significant pericardial effusions and severe pulmonary hypertension, initial stabilization of pulmonary artery pressure and right heart function with vasoactive therapy and then cautious pericardial drainage should be considered.

Persistence and breakdown of Airy beams driven by an initial nonlinearity.

We study the behavior of Airy beams propagating from a nonlinear medium to a linear medium. We show that an Airy beam initially driven by a self-defocusing nonlinearity experiences anomalous diffraction and can maintain its shape in subsequent propagation, but its intensity pattern and acceleration cannot persist when driven by a self-focusing nonlinearity. The unusual behavior of Airy beams is examined from their energy flow as well as the Brillouin zone spectrum of self-induced chirped photonic lattices.