Improving weekend handover in a teaching hospital elective general surgery department

BackgroundEffective documentation and transfer of clinical information are vital for the continuity of care, patient safety, and maintaining medico-legal records, as outlined by the Royal College of Surgeons “Safe Handover: Guidance from the Working Time Directive working party”. Our elective surgery weekend team cross-covers both Colorectal and Upper Gastrointestinal surgical specialties across multiple wards, which poses a significant challenge. The aim of this study was to improve the documentation of patients' weekend plans through the introduction of a weekend handover proforma.MethodWe reviewed the weekend plans of 199 patients overall. 41 records were initially reviewed over a 2-week period. The surgical multidisciplinary team was then surveyed to establish the need for an improved weekend handover. Following this, a weekend handover proforma was introduced as part of the Friday ward round and education on the expectations were provided at a local Surgery Clinical Governance meeting. The documentation of the weekend plan was reviewed for 158 patients over a 6-week period and a post-intervention survey was disseminated.ResultsThe preliminary survey highlighted concerns for delayed discharges and patient safety over the weekend, with 88.2% of respondents agreeing a weekend handover proforma would be beneficial. The initial data confirmed inadequate documentation of diagnosis (19.5%), operation/procedure (28.1%), and weekend plans for blood tests (19.5%), discharge planning (2.4%), diet (46.3%), antibiotics (19.5%), intravenous (IV) fluids (22.0%), mobility (19.5%) and drain/wound care (37.5%). After education and implementing a weekend handover proforma, these results increased for documentation of diagnosis (61.2%), operation/procedure (83.2%), blood tests (59.7%), and discharge planning (85.8%). However, there was little improvement in diet (53.0%) and no improvement in the weekend plans for antibiotics (14.2%), IV fluids (17.2%), mobility (14.9%) and drain/wound care (20.2%). The post-intervention survey showed an improvement across all areas, notably continuity of care and patient safety, with 95.5% of individuals finding the weekend handover proforma aided in patient care over the weekend.ConclusionEducation of the ward team and implementation of a weekend handover proforma resulted in a marked improvement in the documentation of patients' weekend plans, which is essential to ensure the continuation of safe and effective patient care

Molecular Diversity of Terpene Synthases in the Liverwort Marchantia polymorpha

Marchantia polymorpha is a basal terrestrial land plant, which like most liverworts accumulates structurally diverse terpenes believed to serve in deterring disease and herbivory. Previous studies have suggested that the mevalonate and methylerythritol phosphate pathways, present in evolutionarily diverged plants, are also operative in liverworts. However, the genes and enzymes responsible for the chemical diversity of terpenes have yet to be described. In this study, we resorted to a HMMER search tool to identify 17 putative terpene synthase genes from M. polymorpha transcriptomes. Functional characterization identified four diterpene synthase genes phylogenetically related to those found in diverged plants and nine rather unusual monoterpene and sesquiterpene synthase-like genes. The presence of separate monofunctional diterpene synthases for ent-copalyl diphosphate and ent-kaurene biosynthesis is similar to orthologs found in vascular plants, pushing the date of the underlying gene duplication and neofunctionalization of the ancestral diterpene synthase gene family to \u3e400 million years ago. By contrast, the mono- and sesquiterpene synthases represent a distinct class of enzymes, not related to previously described plant terpene synthases and only distantly so to microbial-type terpene synthases. The absence of a Mg2+ binding, aspartate-rich, DDXXD motif places these enzymes in a noncanonical family of terpene synthases

DECTIN-1: A modifier protein in CTLA-4 haploinsufficiency.

Autosomal dominant loss-of-function (LoF) variants in cytotoxic T-lymphocyte associated protein 4 (CTLA4) cause immune dysregulation with autoimmunity, immunodeficiency and lymphoproliferation (IDAIL). Incomplete penetrance and variable expressivity are characteristic of IDAIL caused by CTLA-4 haploinsufficiency (CTLA-4h), pointing to a role for genetic modifiers. Here, we describe an IDAIL proband carrying a maternally inherited pathogenic CTLA4 variant and a paternally inherited rare LoF missense variant in CLEC7A, which encodes for the β-glucan pattern recognition receptor DECTIN-1. The CLEC7A variant led to a loss of DECTIN-1 dimerization and surface expression. Notably, DECTIN-1 stimulation promoted human and mouse regulatory T cell (Treg) differentiation from naïve αβ and γδ T cells, even in the absence of transforming growth factor-β. Consistent with DECTIN-1's Treg-boosting ability, partial DECTIN-1 deficiency exacerbated the Treg defect conferred by CTL4-4h. DECTIN-1/CLEC7A emerges as a modifier gene in CTLA-4h, increasing expressivity of CTLA4 variants and acting in functional epistasis with CTLA-4 to maintain immune homeostasis and tolerance.S

Neural responses in parietal and occipital areas in response to visual events are modulated by prior multisensory stimuli

The effect of multi-modal vs uni-modal prior stimuli on the subsequent processing of a simple flash stimulus was studied in the context of the audio-visual 'flash-beep' illusion, in which the number of flashes a person sees is influenced by accompanying beep stimuli. EEG recordings were made while combinations of simple visual and audio-visual stimuli were presented. The experiments found that the electric field strength related to a flash stimulus was stronger when it was preceded by a multi-modal flash/beep stimulus, compared to when it was preceded by another uni-modal flash stimulus. This difference was found to be significant in two distinct timeframes--an early timeframe, from 130-160 ms, and a late timeframe, from 300-320 ms. Source localisation analysis found that the increased activity in the early interval was localised to an area centred on the inferior and superior parietal lobes, whereas the later increase was associated with stronger activity in an area centred on primary and secondary visual cortex, in the occipital lobe. The results suggest that processing of a visual stimulus can be affected by the presence of an immediately prior multisensory event. Relatively long-lasting interactions generated by the initial auditory and visual stimuli altered the processing of a subsequent visual stimulus.status: publishe

Grand averages for UNI (red) and MULTI (green) difference waves.

<p>Grey boxes show time points at which a permutation test indicated a significant difference between the waveforms. The x-axis represents time relative to the first flash. The time of the second flash (67 ms) is marked on the x-axis.</p

Mean accuracy for counting flashes (± SEM) for each stimulus type.

<p>In fission illusion trials (1F2B), participants often reported more flashes than were present; in fusion illusion trials (2F1B), participants sometimes reported less flashes than were presented.</p

Timing Diagram.

<p>Diagram showing various responses to a simultaneous flash/beep stimulus at time zero. A1 – Primary Auditory Cortex, V1 – Primary Visual Cortex, PL – Parietal Lobes. See text for explanation of numbered points.</p

Flash beep stimulus timing.

<p>Shown is an example of a 2-flash, 2-beep (2F2B) trial.</p

The development of multisensory integration as indexed by an auditory-visual illusion

Abstract not available

Grand average ERPs for UNI (top panel) and MULTI (bottom panel) stimuli.

<p>Significant differences between the waveforms are marked with grey boxes (permutation test, p <.05). The x-axis represents time relative to the first flash. The time of the second flash (67 ms) is marked on the x-axis.</p