Improving compliance with personal protective equipment among anaesthetists through behaviour-changing interventions during the coronavirus disease 2019(COVID-19) pandemic.

Since 2020, the coronavirus disease 2019 (COVID-19) pandemic has seen many changes in our daily infection prevention behaviours so as to reduce healthcare-associated transmission of COVID-19 in patients and healthcare workers. In the early phases of the COVID-19 pandemic of 2020, there was much emphasis on compliant personal protective equipment utilization in the operating theatres (OTs) for COVID-19-positive patients. However, during this period, there was a lack of international validated protocols on the appropriate handling and subsequent storage of personal protective equipment in the context of aerosol-generating procedures in OTs for asymptomatic antigen rapid test (ART)-negative patients. Given the potential for transmission even with a negative ART due to the incubation period, our team developed a checklist of eye protection (e.g. goggles/face shield) and N95 mask handling and storage in non-isolation OTs for these patients. We sought to improve the compliance of best practices from 20% to 80% amongst junior anaesthetists in Singapore General Hospital so as to prevent infection transmission and cross-contamination in the OT through education and behaviour-changing interventions. This quality improvement project took place over 19 weeks from June to October 2020 by our team of anaesthetists and nurse clinicians in the non-isolation OT setting. To analyse the problem, we performed a root cause analysis to understand attitudes and beliefs driving their behaviour. The top 80% of cited root causes for non-compliance then guided prioritization of resources for subsequent behaviour-changing interventions. Using the comprehensive infection control checklist, we conducted several plan-do-study-act cycles while implementing this new checklist amongst junior anaesthetists. A total of 227 assessments of junior anaesthetists were made in the care of asymptomatic ART-negative patients. Compliance with correctly handling goggles post-intubation started out as 33.3% in Week 1, which improved to 78.5% by Week 19. Compliance with goggle storage and face shield disposal started out at 13.6% in Week 1 and increased to 78.6% by Week 19. We attributed this improvement to education and behaviour-changing interventions. This quality improvement project focusing on improving compliance with personal protective equipment utilization during the COVID-19 pandemic in the management of asymptomatic ART-negative patients in non-isolation OTs demonstrated the importance of interventions of education, persuasion, modelling, and training in effecting and sustaining organizational behaviour change in physicians and other healthcare personnel.

Monochorionic twin pregnancy in a patient with type III osteogenesis imperfecta: a multidisciplinary challenge.

A woman with severe type III osteogenesis imperfecta spontaneously conceived a monochorionic, diamniotic twin pregnancy. Due to the severity of her condition, her pregnancy required close follow-up involving a multidisciplinary team, including high-risk obstetricians, anaesthetists, pulmonologists and respiratory therapists. Eventually, the twins were delivered via caesarean section at 26 weeks' gestation.We discuss the challenges and considerations in managing her high-risk pregnancy, highlighting the importance of multidisciplinary care in achieving a safe outcome for mother and babies.

Grit protects medical students from burnout: a longitudinal study.

BACKGROUND: Burnout is a serious issue plaguing the medical profession with potential negative consequences on patient care. Burnout symptoms are observed as early as medical school. Based on a Job Demands-Resources model, this study aims to assess associations between specific job resources measured at the beginning of the first year of medical school with burnout symptoms occurring later in the first year. METHODS: The specific job resources of grit, tolerance for ambiguity, social support and gender were measured in Duke-NUS Medical School students at the start of Year 1. Students were then surveyed for burnout symptoms at approximately quarterly intervals throughout the year. Using high ratings of cynicism and exhaustion as the definition of burnout, we investigated the associations of the occurrence of burnout with student job resources using multivariable logistic regression analysis. RESULTS: Out of 59 students, 19 (32.2%) indicated evidence of burnout at some point across the first year of medical school. Stepwise multivariable logistic regression analysis identified grit as having a significant protective effect against experiencing burnout (Odds Ratio, 0.84; 95%CI 0.74 to 0.96). Using grit as a single predictor of burnout, area under the ROC curve was 0.76 (95%CI: 0.62 to 0.89). CONCLUSIONS: Grit was identified as a protective factor against later burnout, suggesting that less gritty students are more susceptible to burnout. The results indicate that grit is a robust character trait which can prognosticate burnout in medical students. These students would potentially benefit from enhanced efforts to develop grit as a personal job resource.

Survey of neuromuscular monitoring and assessment of postoperative residual neuromuscular block in a postoperative anaesthetic care unit.

INTRODUCTION: The use of neuromuscular blocking agents (NMBAs) is common during general anaesthesia. Neuromuscular monitoring with a peripheral nerve stimulator (PNS) is essential to prevent postoperative residual neuromuscular block (PRNB), defined as a train-of-four (TOF) ratio < 0.9. PRNB remains a common complication and may contribute to morbidity in the postoperative anaesthetic care unit (PACU). METHODS: An online survey was sent to anaesthesiologists in our department to assess their knowledge and clinical practices related to neuromuscular blockade. Next, a study was conducted on adult patients scheduled for elective surgery under general anaesthesia requiring NMBAs. Upon admission to the PACU, TOF monitoring was performed. RESULTS: A large proportion of anaesthesiologists showed a lack of knowledge of neuromuscular blockade or non-adherence to the best clinical practices associated with it. The majority (98.7%) stated that they did not routinely use PNS monitoring. In the clinical study, TOF monitoring was only used in 17.9% of the 335 patients who were assessed. The prevalence of PRNB was 33.4% and was associated with the elderly (age ≥ 65 years), a higher dose of NMBA used, a shorter duration of surgery, and a shorter duration between the last dose of NMBA and measurement of PRNB in the PACU. The incidence of adverse symptoms in the PACU was observed to be higher in patients with PRNB. CONCLUSION: PRNB remains a clinically significant problem, but routine PNS monitoring is rare in our institution. This is compounded by inadequate knowledge and poor adherence to best clinical guidelines related to neuromuscular blockade.

Anesthetic Implications for Cesarean Section in a Parturient with Complex Congenital Cyanotic Heart Disease.

The discordance between increased physiological demand during pregnancy and congenital cardiac pathology of a parturient is a perilous threat to the maternal-fetal well-being. Early involvement of a multidisciplinary team is essential in improving peripartum morbidity and mortality. Designing the most appropriate anesthetic care will require a concerted effort, with inputs from the obstetricians, obstetric and cardiac anesthesiologists, cardiologists, neonatologists, and cardiothoracic surgeons. We report the multidisciplinary peripartum care and anesthetic management for cesarean section (CS) of a 28-year-old primigravida who has partially corrected transposition of the great arteries, atrial and ventricular septal defect, dextrocardia, right ventricle hypoplasia, and tricuspid atresia.

How do Singapore patients view post-anaesthesia adverse outcomes? A single-centre willingness-to-pay study.

INTRODUCTION: Knowing how patients value the quality of anaesthesia helps anaesthesiologists to customise their service. However, generalising findings from Western population-based willingness-to-pay studies across different cultures and societies might result in the oversight of some contextualised perspectives of the anaesthesia experience. This study aimed to capture the Singapore perspective of undesired post-anaesthesia outcomes. METHODS: 132 patients recruited in a pre-anaesthetic evaluation clinic were given questionnaires describing ten possible post-anaesthetic outcomes. Outcomes were ranked for undesirability and assigned relative value through the hypothetical proportioning of SGD 100 to avoid their occurrence. Data was analysed with reference to patients' background and anaesthetic history. RESULTS: A response rate of 69.1% (n = 132/191) was achieved. Outcomes from the most to least undesirable were pain; vomiting; nausea; shivering; orodental trauma; sore throat; abrasions; somnolence; and thirst. Relative values allocated, in descending order, were pain; vomiting; nausea; orodental trauma; abrasions; sore throat; shivering; somnolence; and thirst. CONCLUSION: Similar to previous studies in Western populations, pain, vomiting and nausea were the top three adverse outcomes that Singapore patients wished to avoid. However, discrepancies with Western patients were seen in spending attitudes, possibly accounted for by differences in healthcare socioeconomics. This study provided a better understanding of Singapore patients' perspectives on post-anaesthesia adverse outcomes and could help to improve treatment strategy and resource management.

Anaesthetic management of acute airway obstruction.

The acutely obstructed airway is a medical emergency that can potentially result in serious morbidity and mortality. Apart from the latest advancements in anaesthetic techniques, equipment and drugs, publications relevant to our topic, including the United Kingdom's 4th National Audit Project on major airway complications in 2011 and the updated American Society of Anesthesiologists' difficult airway algorithm of 2013, have recently been published. The former contained many reports of adverse events associated with the management of acute airway obstruction. By analysing the data and concepts from these two publications, this review article provides an update on management techniques for the acutely obstructed airway. We discuss the principles and factors relevant to the decision-making process in formulating a logical management plan.

Developing clinical skills bundles.

BACKGROUND: This article describes an innovative method of learning clinical skills. A care bundle is defined as a small set of evidence-based interventions that, when implemented together, results in significantly better patient outcomes than when implemented individually. Care bundles improve the consistency of standards of care delivered, and hence reduce harm. CONTEXT: In 2007 The Scottish Clinical Skills Strategy identified the use of simulation-based education to ensure all health care staff can deliver a consistently high standard of clinical skills practice throughout the National Health Service in Scotland (NHS Scotland). INNOVATION: Clinical skills bundles were developed to underpin a number of evidence-based care bundles. Grouping the clinical skills together and learning them as a clinical skills bundle may improve the reliability of skills delivery for each care bundle. Three groups were recruited and asked to identify a consensus of the essential technical and non-technical skills for clinical skills bundle for a central venous catheter (CVC) maintenance care bundle. As a pilot, six clinical skills bundle workshops were held for junior doctors, nursing and medical students, and clinical skills educators. The aims of the workshops were to introduce the concepts of clinical skills bundles and to give participants a chance to practice the underpinning clinical skills bundle for a care bundle using simulation. The majority of participants rated the workshop as excellent or good. Self-reported learning included refreshing their clinical skills in a different context. Care bundles improve the consistency of standards of care delivered IMPLICATION: Learning skills together as a bundle may enhance the reliability of clinical skills performance for care bundles, and may also reinforce the use of care bundles.

Antiproliferative activities and SAR studies of substituted anthraquinones and 1,4-naphthoquinones.

STAT3 is constitutively active in a large variety of cancers. The search for STAT3 inhibitors led to the discoveries of LLLs 3 and 12, which are substituted anthraquinones. LLL12 is an extremely potent compound that exhibits high levels of antiproliferative activity. Herein the synthesis and evaluation of compounds containing either an anthraquinone or 1,4-naphthoquinone moiety are reported. Analogs were evaluated in several cancer cell lines. Interestingly, it was found that the anthraquinones did not follow the same trends as the 1,4-naphthoquinones in regards to potency. LLL12, which contains a sulfonamide at position 1, was found to be the most potent of the anthraquinones. In contrast, the methyl ketone and methyl ester derivatives (LLLs 3.1 and 5.1) were found to be the most potent of the 1,4-naphthoquinones. Selected 1,4-naphthoquinones were also evaluated in the STAT3 fluorescence polarization assay in order to evaluate their abilities to bind to the STAT3 SH2 domain. They were found to have similar affinities, and their activities suggest that STAT3 is one of their molecular targets.

Anticancer activity and SAR studies of substituted 1,4-naphthoquinones.

In this paper, we report the structure-activity relationship studies of substituted 1,4-naphthoquinones for its anticancer properties. 1,4-Naphthoquinone, Juglone, Menadione, Plumbagin and LLL12.1 were used as lead molecules to design PD compounds. Most of the PD compounds showed improved antiproliferative activity in comparison to the lead molecule in prostate (DU-145), breast (MDA-MB-231) and colon (HT-29) cancer cell lines. PD9, PD10, PD11, PD13, PD14 and PD15 were found to be the most potent compound with an IC0 value of 1-3 µM in all cancer cell lines. Fluorescent polarization assay was employed to study the inhibition of STAT3 dimerization by PD compounds. PD9 and PD18 were found to be potent STAT3 dimerization inhibitors.