The COMET framework: A novel approach to design an escape room workshop for interprofessional objectives.

While recreational escape rooms have gained momentum across education and team training in multiple professions, few published escape room designs have been truly interprofessional. A major obstacle faced by educators and team leaders alike is the lack of any practical design framework for escape room development that is specific to meeting learning objectives. The COMET Framework (Context, Objectives, Materials, Execution, and Team Dynamics) was developed as a step-by-step approach to escape room design using general terminology and piloted in a one-hour workshop at a regional interprofessional conference. Surveys completed by participants suggest that application of the COMET framework increased understanding and confidence regarding escape room design regardless of prior experience with the format. The generality of the COMET framework may allow it to be utilized for team exercise design more broadly in the contexts of interprofessional training and faculty development.

Complete Atrioventricular Septal Defect with Truncus Arteriosus and Interrupted Aortic Arch in the Fetus.

Complete atrioventricular septal defect is generally diagnosed on the four-chamber view of the fetal heart. This defect can be accompanied by additional outflow tract lesions, including truncus arteriosus. Although truncus arteriosus in isolation can be associated with interrupted aortic arch, we describe a fetal case with the rare association of all three diagnoses: complete atrioventricular septal defect with truncus arteriosus and interrupted aortic arch. This case points to the importance of evaluating the complete fetal heart even after one congenital cardiac abnormality is noted. The complexity of heart disease has implications for prenatal counseling and postnatal management.

25-Hydroxyvitamin D2 /D3 levels and factors associated with systemic inflammation and melanoma survival in the Leeds Melanoma Cohort.

Lower 25-hydroxyvitamin D2 /D3 levels at melanoma diagnosis are associated with thicker primaries and poorer survival. We postulated that this might relate to the deleterious effect of systemic inflammation as 25-hydroxyvitamin D2 /D3 levels are inversely associated with levels of C-reactive protein. 2,182 participants in the Leeds Melanoma Cohort (median follow-up 7.98 years) provided data on drug exposure, comorbidities and a serum 25-hydroxyvitamin D2 /D3 level at recruitment. Factors reported to modify systemic inflammation (low vitamin D levels, high body mass index, use of aspirin or nonsteroidal anti-inflammatory drugs or smoking were tested as predictors of microscopic ulceration (in which primary tumors are inflamed) and melanoma-specific survival (MSS). Ulceration was independently associated with lower 25-hydroxyvitamin D2 /D3 levels (odds ratio (OR) = 0.94 per 10 nmol/L, 95% CI 0.88-1.00, p = 0.05) and smoking at diagnosis (OR = 1.47, 95% CI 1.00-2.15, p = 0.04). In analyses adjusted for age and sex, a protective effect was seen of 25-hydroxyvitamin D2 /D3 levels at diagnosis on melanoma death (OR = 0.89 per 10 nmol/L, 95% CI 0.83-0.95, p < 0.001) and smoking increased the risk of death (OR = 1.13 per 10 years, 95% CI 1.05-1.22, p = 0.001). In multivariable analyses (adjusted for tumor thickness) the associations with death from melanoma were low 25-hydroxyvitamin D2 /D3 level at recruitment (<20 nmol/L vs. 20-60 nmol/L, hazard ratio (HR) = 1.52, 95% CI 0.97-2.40, p = 0.07) and smoking duration at diagnosis (HR = 1.11, 95% CI 1.03-1.20, p = 0.009). The study shows evidence that lower vitamin D levels and smoking are associated with ulceration of primary melanomas and poorer MSS. Further analyses are necessary to understand any biological mechanisms that underlie these findings.

Post-transplant lymphoproliferative disease and other malignancies after pediatric cardiac transplantation: an evolving landscape.

PURPOSE OF REVIEW: Post-transplant lymphoproliferative disorders (PTLDs) remain a significant cause of morbidity and mortality after pediatric solid organ transplantation (SOT). PTLD treatment outcomes have improved steadily over the past decade, in large part due to an enhanced understanding of the disease process, newer immunosuppression regimens, and implementation of evolving chemotherapeutic treatment protocols. RECENT FINDINGS: New therapies continue to be employed to treat PTLDs while maintaining normal allograft function in SOT recipients. These include use of immunosuppressant medications with antitumor activity (mammalian target of rapamycin inhibitors), monoclonal antibody therapies, and the advent of cytotoxic T-cell therapy. Treatment methods to render latent Epstein-Barr virus (EBV)-infected tumor cells more susceptible to antiviral agents continue to be investigated. SUMMARY: PTLD remains a significant potential complication after SOT, particularly in pediatric patients who are more likely to be EBV-negative at the time of transplant and subsequently undergo EBV seroconversion. Risk for PTLD may be reduced by employing strategies such as EBV prophylaxis in seronegative patients, minimizing overall intensity of immunosuppression, and utilizing newer agents that have both immunosuppressive and antiproliferative properties. Treatment outcomes for PTLD have steadily improved over the past decade, related in part to the availability of monoclonal antibody therapies and refined chemotherapeutic regimens.

Pulmonary perfused blood volume with dual-energy CT as surrogate for pulmonary perfusion assessed with dynamic multidetector CT.

PURPOSE: To compare measurements of regional pulmonary perfused blood volume (PBV) and pulmonary blood flow (PBF) obtained with computed tomography (CT) in two pig models. MATERIALS AND METHODS: The institutional animal care and use committee approved all animal studies. CT-derived PBF and PBV were determined in four anesthetized, mechanically ventilated, supine swine by using two methods for creating pulmonary parenchymal perfusion heterogeneity. Two animals were examined after sequentially moving a pulmonary arterial balloon catheter from a distal to a central location, and two others were examined over a range of static airway pressures, which varied the extents of regional PBF. Lung sections were divided into blocks and Pearson correlation coefficients calculated to compare matching regions between the two methods. RESULTS: CT-derived PBF, CT-derived PBV, and their associated coefficients of variation (CV) were closely correlated on a region-by-region basis in both the balloon occlusion (Pearson R = 0.91 and 0.73 for animals 1 and 2, respectively; Pearson R = 0.98 and 0.87 for comparison of normalized mean and CV for animals 1 and 2, respectively) and lung inflation studies (Pearson R = 0.94 and 0.74 for animals 3 and 4, respectively; Pearson R = 0.94 and 0.69 for normalized mean and CV for animals 3 and 4, respectively). When accounting for region-based effects, correlations remained highly significant at the P < .001 level. CONCLUSION: CT-derived PBV heterogeneity is a suitable surrogate for CT-derived PBF heterogeneity.

Telehealth Training for Surgeons to Empathetically Deliver Bad News Via Video-Mediated Communication.

BACKGROUND: The COVID-19 pandemic resulted in a sudden increase in the need to effectively use telehealth in all realms of health care communication, including the delivery of bad news. METHODS: A single arm, unblinded, feasibility study was performed at a tertiary care center located in Central Virginia to explore the value and utility of providing a telehealth training program based on SPIKES to teach surgical residents and faculty best practice for disclosing difficult news via video-mediated communication (VMC). Surgical interns (categorical and preliminary), surgical residents, and surgical faculty from General, Neuro, Pediatric, Plastics, Oncology, Urology, and Vascular surgical specialties were recruited via email to voluntarily participate in a telehealth simulation-based workshop, with 33 surgical learners participating in the training and 28 completing evaluation surveys. RESULTS: Only six respondents (22%) indicated they had prior formal training on telehealth communication with patients or families, while 13 (46%) said they had prior experience giving bad news via telehealth. Comments about improving the training focused on providing more scenarios to practice and more time for feedback. Overall, 25 learners (86%) agreed the activity was a valuable learning experience and the majority (61%) of responses were positive for future use of telehealth for breaking bad news. DISCUSSION: Practicing communication skills with VMC was found to be valuable by surgical interns, residents, and faculty. Formal training should be provided for surgeons at every stage of training and practice to improve skill in the delivery of bad news to patients and their families.

Adapting Compassionate Conversations for Virtual Mediated Communication.

OBJECTIVE: The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions. DESIGN: The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed. SETTING: Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated. PARTICIPANTS: Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators. RESULTS: A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall. CONCLUSIONS: This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

Multiphase preclinical assessment of a novel device to locate unintentionally retained surgical sharps: a proof-of-concept study.

BACKGROUND: Retained surgical sharps (RSS) is a "never event" that is preventable but may still occur despite of correct count and negative X-ray. This study assesses the feasibility of a novel device ("Melzi Sharps Finder®" or MSF) in effective detection of RSS. METHODS: The first study consisted of determination of the presence of RSS or identification of RSS in an ex-vivo model (a container with hay in a laparoscopic trainer box). The second study consisted of determining presence of RSS in an in-vivo model (laparoscopy in live adult Yorkshire pigs) with 3 groups: C-arm, C-arm with MSF and MSF. The third study used similar apparatus though with laparotomy and included 2 groups: manual search and MSF. RESULTS: In the first study, the MSF group had a higher rate of identification of a needle and decreased time to locate a needle versus control (98.1% vs. 22.0%, p < 0.001; 1.64 min ± 1.12vs. 3.34 min ± 1.28, p < 0.001). It also had increased accuracy of determining the presence of a needle and decreased time to reach this decision (100% vs. 58.8%, p < 0.001; 1.69 min ± 1.43 vs. 4.89 min ± 0.63, p < 0.001). In-the second study, the accuracy of determining the presence of a needle and time to reach this decision were comparable in each group (88.9% vs. 100% vs. 84.5%, p < 0.49; 2.2 min ± 2.2 vs. 2.7 min ± 2.1vs. 2.8 min ± 1.7, p = 0.68). In the third study, MSF group had higher accuracy in determining the presence of a needle and decreased time to reach this decision than the control (97.0% vs. 46.7%, p < 0.001; 2.0 min ± 1.5 vs. 3.9 min ± 1.4; p < 0.001). Multivariable analysis showed that MSF use was independently associated with an accurate determination of the presence of a needle (OR 12.1, p < 0.001). CONCLUSIONS: The use of MSF in this study's RSS models facilitated the determination of presence and localization of RSS as shown by the increased rate of identification of a needle, decreased time to identification and higher accuracy in determining the presence of a needle. This device may be used in conjunction with radiography as it gives live visual and auditory feedback for users during the search for RSS.

Chipscale, single-shot gated ultrafast optical recorder.

We introduce a novel, chipscale device capable of single-shot ultrafast recording with picosecond-scale resolution over hundreds of picoseconds of record length. The device consists of two vertically-stacked III-V planar waveguides forming a Mach-Zehnder interferometer, and makes use of a transient, optically-induced phase difference to sample a temporal waveform injected into the waveguides. The pump beam is incident on the chip from above in the form of a diagonally-oriented stripe focused by a cylindrical lens. Due to time-of-flight, this diagonal orientation enables the sampling window to be shifted linearly in time as a function of position across the lateral axis of the waveguides. This time-to-space mapping allows an ordinary camera to record the ultrafast waveform with high fidelity. We investigate the theoretical limits of this technique, present a simulation of device operation, and report a proof-of-concept experiment in GaAs, demonstrating picosecond-scale resolution over 140 ps of record length.

From chaos to creativity: Designing collaborative communication training for the delivery of bad news.

BACKGROUND: Before the COVID-19 pandemic, teaching communication skills in health care focused primarily on developing skills during face-to-face conversation. Even experienced clinicians were unprepared for the transition in communication modalities necessitated due to physical distancing requirements and visitation restrictions during the COVID-19 pandemic. We aimed to develop and pilot a comprehensive video-mediated communication training program and test its feasibility in multiple institutional settings and medical disciplines. METHODS: The education team, consisting of clinician-educators in general surgery and emergency medicine (EM) and faculty specialists in simulation and coaching, created the intervention. Surgery and EM interns in addition to senior medical students applying in these specialties were recruited to participate. Three 90-minute sessions were offered focusing on 3 communication topics that became increasingly complex and challenging: breaking bad news, goals of care discussions, and disclosure of medical error. This was a mixed-methods study using survey and narrative analysis of open comment fields. RESULTS: Learner recruitment varied by institution but was successful, and most (75%) learners found the experience to be valuable. All of the participants reported feeling able to lead difficult discussions, either independently or with minimal assistance. Only about half (52%) of the participants reported feeling confident to independently disclose medical error subsequent to the session. CONCLUSION: We found the program to be feasible based on acceptability, demand, the ability to implement, and practicality. Of the 3 communication topics studied, confidence with disclosure of medical error proved to be the most difficult. The optimal length and structure for these programs warrants further investigation.

Cytochrome P450 (CYP2D6) genotype is associated with elevated systolic blood pressure in preterm infants after discharge from the neonatal intensive care unit.

OBJECTIVE: To determine genetic and clinical risk factors associated with elevated systolic blood pressure (ESBP) in preterm infants after discharge from the neonatal intensive care unit (NICU). STUDY DESIGN: A convenience cohort of infants born at <32 weeks gestational age was followed after NICU discharge. We retrospectively identified a subgroup of subjects with ESBP (systolic blood pressure [SBP] >90th percentile for term infants). Genetic testing identified alleles associated with ESBP. Multivariate logistic regression analysis was performed for the outcome ESBP, with clinical characteristics and genotype as independent variables. RESULTS: Predictors of ESBP were cytochrome P450, family 2, subfamily D, polypeptide 6 (CYP2D6) (rs28360521) CC genotype (OR, 2.92; 95% CI, 1.48-5.79), adjusted for outpatient oxygen therapy (OR, 4.53; 95% CI, 2.23-8.81) and history of urinary tract infection (OR, 4.68; 95% CI, 1.47-14.86). Maximum SBP was modeled by multivariate linear regression analysis: maximum SBP=84.8 mm Hg + 6.8 mm Hg if cytochrome P450, family 2, subfamily D, polypeptide 6 (CYP2D6) CC genotype + 6.8 mm Hg if discharged on supplemental oxygen + 4.4 mm Hg if received inpatient glucocorticoids (P=.0002). CONCLUSIONS: ESBP is common in preterm infants with residual lung disease after discharge from the NICU. This study defines clinical factors associated with ESBP, identifies a candidate gene for further testing, and supports the recommendation to monitor blood pressure before age 3 years, as is suggested for term infants.

Video-mediated breaking bad news simulation.

BACKGROUND: Communication between clinicians, patients, and families is a core component of medical care that requires deliberate practice and feedback to improve. In March 2020, the COVID-19 pandemic caused a sudden transformation in communication practices because of new physical distancing requirements, necessitating physicians to communicate bad news via telephone and video-mediated communication (VMC). This study investigated students' experience with a simulation-based communications training for having difficult conversations using VMC. METHODS: Thirty-eight fourth-year medical students preparing for their surgical residency participated in a simulated scenario where students discussed a new COVID-19 diagnosis with a standardised family member (SFM) of a sick patient via VMC. Learners were introduced to an established communications model (SPIKES) by an educational video. After the simulation, SFM and course facilitators guided a debrief and provided feedback. Learners completed surveys evaluating reactions to the training, preparedness to deliver bad news, and attitudes about telehealth. RESULTS: Twenty-three students completed evaluation surveys (response rate=61%). Few students had prior formal training (17%) or experience communicating bad news using telehealth (13%). Most respondents rated the session beneficial (96%) and felt they could express empathy using the VMC format (83%). However, only 57% felt ready to deliver bad news independently after the training and 52% reported it was more difficult to communicate without physical presence. Comments highlighted the need for additional practice. CONCLUSION: This pilot study demonstrated the value and feasibility of teaching medical students to break bad news using VMC as well as demonstrating the need for additional training.

Left heart decompression by atrial stenting during extracorporeal membrane oxygenation.

Persistent severe left ventricular dysfunction during extracorporeal membrane oxygenation (EcmO) requires left heart decompression. We describe stenting of the atrial septum as an alternative emergency approach for left heart decompression during EcmO in addition to the already published surgical and transcatheter approaches.

MDCT-based quantification of porcine pulmonary arterial morphometry and self-similarity of arterial branching geometry.

The pig is frequently used as an experimental model for studies of the pulmonary circulation, yet the branching and dimensional geometry of the porcine pulmonary vasculature remains poorly defined. The purposes of this study are to improve the geometric definition of the porcine pulmonary arteries and to determine whether the arterial tree exhibits self-similarity in its branching geometry. Five animals were imaged using thin slice spiral computed tomography in the prone posture during airway inflation pressure at 25 cmH2O. The luminal diameter and distance from the inlet of the left and right pulmonary arteries were measured along the left and right main arterial pathway in each lung of each animal. A further six minor pathways were measured in a single animal. The similarity in the rate of reduction of diameter with distance of all minor pathways and the two main pathways, along with similarity in the number of branches arising along the pathways, supports self-similarity in the arterial tree. The rate of reduction in diameter with distance from the inlet was not significantly different among the five animals (P > 0.48) when normalized for main pulmonary artery diameter and total main artery pathlength, which supports intersubject similarity. Other metrics to quantify the tree geometry are strikingly similar to those from airways of other quadrupeds, with the exception of a significantly larger length to diameter ratio, which is more appropriate for the vascular tree. A simplifying self-similar model for the porcine pulmonary arteries is proposed to capture the important geometric features of the arterial tree.

Rasputin functions as a positive regulator of orb in Drosophila oogenesis.

The determination of cell fate and the establishment of polarity axes during Drosophila oogenesis depend upon pathways that localize mRNAs within the egg chamber and control their on-site translation. One factor that plays a central role in regulating on-site translation of mRNAs is Orb. Orb is a founding member of the conserved CPEB family of RNA-binding proteins. These proteins bind to target sequences in 3' UTRs and regulate mRNA translation by modulating poly(A) tail length. In addition to controlling the translation of axis-determining mRNAs like grk, fs(1)K10, and osk, Orb protein autoregulates its own synthesis by binding to orb mRNA and activating its translation. We have previously shown that Rasputin (Rin), the Drosophila homologue of Ras-GAP SH3 Binding Protein (G3BP), associates with Orb in a messenger ribonucleoprotein (mRNP) complex. Rin is an evolutionarily conserved RNA-binding protein believed to function as a link between Ras signaling and RNA metabolism. Here we show that Orb and Rin form a complex in the female germline. Characterization of a new rin allele shows that rin is essential for oogenesis. Co-localization studies suggest that Orb and Rin form a complex in the oocyte at different stages of oogenesis. This is supported by genetic and biochemical analyses showing that rin functions as a positive regulator in the orb autoregulatory pathway by increasing Orb protein expression. Tandem Mass Spectrometry analysis shows that several canonical stress granule proteins are associated with the Orb-Rin complex suggesting that a conserved mRNP complex regulates localized translation during oogenesis in Drosophila.

An in-vivo computed tomography approach for quantifying porcine pulmonary arterial morphometry.

The objective of this study was to develop an in vivo CT imaging-based approach for pulmonary arterial morphometry measurement, and to improve the geometrical basis for studies of the porcine vasculature. The luminal diameter and distance from the inlet of left and right pulmonary arteries, and pulmonary arteries within the lungs of two porcine subjects were measured at inflation pressure of 25 cmH(2)O. The results suggest that the porcine pulmonary arteries have geometric self-similarity, and that this approach will have utility for systematically quantifying pulmonary arterial vessel dimensions in vivo in a larger group of animals.

Over-the-wire intravascular ultrasound in an animal model of pulmonary hypertension.

BACKGROUND: Intravascular ultrasound (IVUS) measures prognostically important pulsatile flow indexes in patients with pulmonary hypertension (PH). IVUS catheters traditionally require a guiding catheter for placement which can impact hemodynamics in small infants because the guiding catheter renders the atrioventricular valve incompetent. METHODS: Domestic swine (1.4-2.2 kg) were raised in isobaric normoxia (n = 4) or hypoxia (n = 3, FiO(2) 10-12%) for 72 hr for induction of PH. Cardiac catheterization and intravascular imaging was performed using a 3.5-Fr 20-MHz Eagle Eye Gold catheter (Volcano Corp., CA, USA) over a 0.014'' guide wire. Intima-media thickness (IMT) was measured and relative area change and vascular pulsatility were calculated. RESULTS: The IVUS probe was easily manipulated over a 0.014'' wire without hemodynamic compromise in all animals. The IMT was thicker in the hypoxic group than the normoxic group (0.19 ± 0.03 mm vs. 0.31 ± 0.04 mm, p = .067). Hypoxic animals had systolic PH (39.66 ± 2.51 vs. 21.75 ± 2.87 mmHg, p = .02). Systemic arterial pressures between the groups were the same (hypoxic 68 ± 10.44 vs. normoxic 79.75 ± 14.84 mmHg, p = .26). Vascular pulsatility was similar (hypoxic 24 ± 2.64 vs. 20.25 ± 0.57%, p = .18). However, the arterial wall distensibility was significantly different (0.98 ± 0.2 vs. 2.01 ± 1.38 %/mmHg, p = .04). CONCLUSIONS: Monorail IVUS imaging without a guide catheter overcomes a major limitation for use in infants and small animal experimental models by avoiding hemodynamic compromise. This would be a valuable tool for assessment of PH in the research and clinical setting.

Occupational therapy consultation for case managers in community mental health: exploring strategies to improve job satisfaction and self-efficacy.

UNLABELLED: The purpose of this study was 2-fold: (1) to examine to what extent case managers' job satisfaction and self-efficacy were impacted by the addition of an occupational therapy consultation model and (2) to identify factors that both positively and negatively impacted the occupational therapy consultation services. PRIMARY PRACTICE SETTING: The study was conducted at a mental health community support program in a local homeless center. METHODOLOGY AND SAMPLE: In a 2-year study, a mixed-methods design was used to study changes over time in job satisfaction and perceived self-efficacy among 14 case managers who received ongoing occupational therapy consultation. Job satisfaction and self-efficacy data were obtained using standardized questionnaires. Qualitative data related to factors impacting the consultation program were obtained using open-ended written questions, focus groups, and individual interviews. RESULTS: Statistically significant differences in job satisfaction and perceptions of self-efficacy were found 18 months into the study, when case managers were more actively seeking occupational therapy consultation services and were reporting improved client outcomes from occupational therapy intervention. In addition, themes related to both positive and negative factors impacting the occupational therapy consultation program were identified and provided useful data for development of future consultation services. IMPLICATION FOR CASE MANAGEMENT PRACTICE: Results suggest that ongoing training and professional support for case managers who are paraprofessionals and/or new to mental health practice may improve job satisfaction and efficacy. Occupational therapy consultation may be helpful in developing services for health promotion, including self-care management, cognitive assessments, activity-based programming, and home safety evaluation and modification. In addition, new graduates and paraprofessional case managers working with clients who are high utilizers of services may benefit from smaller caseloads and support from clinical professionals.