The Handoff Culture: Can we change how an ICU to floor transfer works?

Handoffs between providers have increased following the implementation of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions. Properly structured and timed handoffs are essential to patient safety.1 Despite this, studies have shown that errors in code status, medication allergies, and important updates to the problem list are common, all of which can lead to adverse outcomes to patients.2 At Thomas Jefferson University Hospital (TJUH) the 2016 Safety Culture Survey revealed that across all specialties, 37% of residents felt that things “fall through the cracks” when transferring patients from one unit to another. Our interdepartmental Housestaff Quality and Safety Leadership Council (HQSLC) sought to evaluate and modify the TJUH ICU to floor handoff process. Through engaging our diverse membership, we realized that the ICU to floor handoff process at TJUH lacks standardization. The following areas demonstrated a high degree of variation, and were seen as targets for improvement: ● Timing of handoff: Some departments give the handoff at the time of transfer order, and others at bed assignment. ● Incorporation of best practices: Both verbal and written handoffs should be performed with time for follow up questions by the receiving team ● Closed loop communication: Both sending and receiving teams should clearly communicate the plan of care, and the receiving team should clearly indicate when they have taken over primary responsibility. Poster presented at: House Staff Quality and Safety Leadership Council conference at Thomas Jefferson University.https://jdc.jefferson.edu/patientsafetyposters/1073/thumbnail.jp

Seizure detection from Electroencephalogram signals via Wavelets and Graph Theory metrics

Epilepsy is one of the most prevalent neurological conditions, where an epileptic seizure is a transient occurrence due to abnormal, excessive and synchronous activity in the brain. Electroencephalogram signals emanating from the brain may be captured, analysed and then play a significant role in detection and prediction of epileptic seizures. In this work we enhance upon a previous approach that relied on the differing properties of the wavelet transform. Here we apply the Maximum Overlap Discrete Wavelet Transform to both reduce signal \textit{noise} and use signal variance exhibited at differing inherent frequency levels to develop various metrics of connection between the electrodes placed upon the scalp. %The properties of both the noise reduced signal and the interconnected electrodes differ significantly during the different brain states. Using short duration epochs, to approximate close to real time monitoring, together with simple statistical parameters derived from the reconstructed noise reduced signals we initiate seizure detection. To further improve performance we utilise graph theoretic indicators from derived electrode connectivity. From there we build the attribute space. We utilise open-source software and publicly available data to highlight the superior Recall/Sensitivity performance of our approach, when compared to existing published methods

A comparison of imaging modalities for the diagnosis of osteomyelitis

Osteomyelitis is an increasingly common pathology that often poses a diagnostic challenge to clinicians. Accurate and timely diagnosis is critical to preventing complications that can result in the loss of life or limb. In addition to history, physical exam, and laboratory studies, diagnostic imaging plays an essential role in the diagnostic process. This narrative review article discusses various imaging modalities employed to diagnose osteomyelitis: plain films, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, bone scintigraphy, and positron emission tomography (PET). Articles were obtained from Pubmed and screened for relevance to the topic of diagnostic imaging for osteomyelitis. The authors conclude that plain films are an appropriate first step, as they may reveal osteolytic changes and can help rule out alternative pathology. MRI is often the most appropriate second study, as it is highly sensitive and can detect bone marrow changes within days of an infection. Other studies such as CT, ultrasound, and bone scintigraphy may be useful in patients who cannot undergo MRI. CT is useful for identifying necrotic bone in chronic infections. Ultrasound may be useful in children or those with sickle-cell disease. Bone scintigraphy is particularly useful for vertebral osteomyelitis. Finally, PET scan has demonstrated high sensitivity and specificity; however, its clinical application is limited by its high cost and poor availability. When used appropriately, diagnostic imaging can provide high sensitivity and specificity for detecting osteomyelitis, making radiographic evaluation a crucial step in the diagnostic process of this debilitating condition

Surgery Poster - 2019

Surgery Poster - 2019https://scholarlycommons.libraryinfo.bhs.org/research_education/1016/thumbnail.jp

How To Manage Knee Arthritis: Best Practices for Treatment Prior to Orthopaedic Referral

Osteoarthritis (OA) of the knee is a debilitating disease in which degeneration of the joint space cartilage can lead to life-altering pain and stiffness. The prevalence of OA has a strong correlation with age, with evidence of radiographic knee OA found in 37.4% of persons older than 60 years of age. According to the Agency for Healthcare Research and Quality’s (AHRQ) 2013 report, osteoarthritis was ranked the second most expensive condition for Medicare and private insurers, with over 90% of the hospitalizations for OA involving a knee or hip replacement. It is projected that by 2030 the number of primary total knee arthroplasties will increase by 525% and the number of primary hip arthroplasties by 101%. Proper diagnosis and treatment of all stages of osteoarthritis, is essential to increase value and reduce costs for all stakeholders including patients, physicians and payers. In this article, only the non-operative management of knee OA is discussed. We present a simple algorithm that combines expert opinion, the American Academy of Orthopaedic Surgeon’s(AAOS) Clinical Practice Guidelines, and Medicare requirements

Vitamin D Deficiency: At Risk Patient Populations and Potential Drug Interactions

Vitamin D is known to play an essential role in calcium homeostasis; however, excessive amounts can have harmful effects. Calcium and vitamin D levels are known to be influenced by drug interactions and pathology ranging from of cancer to cardiovascular disease. Vitamin D supplementation has become widespread, and it is important for clinicians to understand the way that certain conditions and medications interact with vitamin D and calcium homeostasis. The purpose of this review is to outline the benefits and adverse effects of vitamin D and how its levels are affected by certain pathologic and pharmacologic interactions

Vitamin K2 (menaquinone) Supplementation and its Benefits in Cardiovascular Disease, Osteoporosis, and Cancer

Vitamin K is known to play an essential role in the coagulation cascade; however, a growing body of research has found that a subtype of this vitamin, vitamin K2 (menaquinone) may have a beneficial effect in osteoporosis, cardiovascular disease, and cancer. This purpose of this article is to provide a comprehensive review of recent literature regarding menaquinone and its role in human health. This review discusses the physiology of menaquinone, its clinical benefits in cardiovascular disease, osteoporosis, and cancer, and how it may interact with certain medications. The authors conclude that menaquinone supplementation has been shown to improve carboxylation of osteocalcin and matrix-Gla protein to their active forms, two proteins that possess important roles in calcium distribution. In the setting of cardiovascular disease, menaquinone intake has been shown to lower the risk of coronary calcification and coronary heart disease, and a randomized controlled trial has demonstrated that it can reduce arterial stiffness. In osteoporosis, menaquinone has been shown by numerous randomized controlled trials to decrease the rate of bone loss at the lumbar spine and forearm and reduce the risk of fracture. In cancer, menaquinone intake has been shown to reduce overall incidence and mortality; clinical trials have suggested that it may have a role in reducing recurrence and death from hepatocellular carcinoma. However, in all clinical settings, more large randomized controlled trials are needed to definitively determine the clinical benefits of menaquinone supplementation, as many studies have failed to show any significant benefit. Lastly, more research is needed to determine how menaquinone supplementation interacts with medications such as warfarin, bile-acid sequestrants, orlistat, mineral oil and CYP3A4 substrates

Relationship of Paroxysmal Atrial Tachyarrhythmias to Volume Overload

BACKGROUND: Clinical experience suggests that atrial tachyarrhythmias (ATs) are a frequent comorbidity in heart failure patients with left ventricular systolic dysfunction and that volume overload may increase AT susceptibility. However, substantiating this apparent relationship in free-living patients is difficult. Recently, certain implantable cardioverter-defibrillators provide, by measuring transpulmonary electric bioimpedance, an index of intrathoracic fluid status (OptiVol index [OI]). The goal of this study was to determine whether periods of greater intrathoracic fluid congestion (as detected by OI) correspond with increased AT event frequency. METHODS AND RESULTS: This analysis retrospectively assessed the relation between AT events and OI estimate of volume overload in patients with left ventricular systolic dysfunction and OI-capable implantable cardioverter-defibrillators. OI values were stratified into 3 levels: group 1, \u3c40; group 2, 40 to 60; and group 3, \u3e60. An OI threshold-crossing event was defined as OI \u3e or = 60, a value previously associated with clinically significant volume overload. Findings in 59 patients (mean left ventricular ejection fraction, 24%) with 225 follow-up visits (mean, 3.8 visits per patient) were evaluated. AT prevalence was 73%. AT frequency (percent of patients visits with at least 1 episode of AT since previous device interrogation) was greater in group 3 versus group 1 (P=0.0342). Finally, in terms of temporal sequence, AT episodes preceded OI threshold-crossing event in 43% of incidences, followed threshold-crossing event in 29%, and was simultaneous or indeterminate in the remainder. CONCLUSIONS: These findings not only support the view that worsening pulmonary congestion is associated with increased AT frequency in patients with left ventricular dysfunction but also suggest that AT events may be responsible for triggering episodic pulmonary congestion more often than previously suspected

Quantum Oscillations in EuFe2As2 single crystals

Quantum oscillation measurements can provide important information about the Fermi surface (FS) properties of strongly correlated metals. Here, we report a Shubnikov-de Haas (SdH) effect study on the pnictide parent compounds EuFe$_{2}$As$_{2}$ (Eu122) and BaFe$_{2}$As$_{2}$ (Ba122) grown by In-flux. Although both members are isovalent compounds with approximately the same density of states at the Fermi level, our results reveal subtle changes in their fermiology. Eu122 displays a complex pattern in the Fourier spectrum, with band splitting, magnetic breakdown orbits, and effective masses sistematically larger when compared to Ba122, indicating that the former is a more correlated metal. Moreover, the observed pockets in Eu122 are more isotropic and 3D-like, suggesting an equal contribution from the Fe $3d$ orbitals to the FS. We speculate that these FS changes may be responsible for the higher spin-density wave ordering temperature in Eu122.Comment: 5 pages, 4 figure