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

Clinical Phenotype of Bernard Soulier Syndrome Case Resulting from Compound Heterozygous Inheritance

Background: Bernard Soulier Syndrome (BSS) is a rare, autosomal recessive inheritance disorder of platelet function. Estimated to affect one per one million, there are currently only 200 cases reported worldwide presenting more commonly in families with parental consanguinity. This syndrome occurs when there is a genetic defect in the subunits (GPIb-alpha, GPIB-beta, and GP9) that form the GPIb-IX-V complex. The result is inadequate binding to von Willebrand factor. The clotting cascade is, therefore, unable to begin, causing symptoms of excessive and prolonged bleeding. Objectives: We report a case with multiple episodes of exaggerated bleeding and easy bruising. Methods: We analyzed complete blood count, coagulation studies, platelet aggregation assays, platelet glycoprotein expression by flow cytometry, as well as screened both patient and parents for relevant genes responsible for BSS. Results: 14-month-old Caucasian male born at 38w3d gestational age, non-consanguineous parents with multiple episodes of exaggerated bleeding and easy bruising from minor injuries. His symptoms started early in life with excessive bleeding after circumcision. No history of intramuscular, joint, or intracranial bleeding. Complete blood counts showed macrothrombocytopenia (98 X109 /L MPV 12.3 fl) no leukocyte inclusion bodies on peripheral smear. Coagulation tests (prothrombin time, activated partial thromboplastin time, vWF antigen, and vW-Ristocetin cofactor activity, platelet function assay) were normal. Platelet glycoprotein expression by flow cytometry revealed significantly reduced binding of monoclonal antibodies to platelet GPIb and normal GPIIb/IIIa. Comprehensive platelet disorder panel revealed two clinically significant variants missense mutations in the GP9 gene (P.Cys135 Tyr and P.Asn61Ser) These variants were on opposite alleles and results were consistent with the diagnosis of Bernard Soulier syndrome (BSS). The mother reported heavy menstrual cycles, the father had no significant bleeding symptoms, and both parents had normal platelet counts. Target genetic testing identified these two distinct missense mutations from both Mother and Father of the child. Conclusion: The two rare variants occurring on the gene for GPIX (GP9) increase the number of known genetic defects associated with the manifestation of Bernard Soulier Syndrome

Current Trends in High-Grade Gliomas

This is an overview of the current trends in the management of high-grade gliomas based on the current evidence available at the time of compiling this chapter in the first quarter of 2016, by a dedicated, high-volume Neurosurgical Oncology team of clinical and surgical Neuro-Oncologists based in central Pennsylvania

Annual prediction of shoreline erosion and subsequent recovery

publisher: Elsevier articletitle: Annual prediction of shoreline erosion and subsequent recovery journaltitle: Coastal Engineering articlelink: http://dx.doi.org/10.1016/j.coastaleng.2017.09.008 content_type: article copyright: Crown Copyright © 2017 Published by Elsevier B.V. All rights reserved

The physiological roles of carnosine and β-alanine in exercising human skeletal muscle

Carnosine (β-alanyl-L-histidine) plays an important role in exercise performance and skeletal muscle homeostasis. Dietary supplementation with the rate-limiting precursor β-alanine leads to an increase in skeletal muscle carnosine content, which further potentiates its effects. There is significant interest in carnosine and β-alanine across athletic and clinical populations. Traditionally, attention has been given to performance outcomes with less focus on the underlying mechanism(s). Putative physiological roles in human skeletal muscle include acting as an intracellular pH buffer, modulating energy metabolism, regulating Ca2+ handling and myofilament sensitivity, and scavenging of reactive species. Emerging evidence shows that carnosine could also act as a cytoplasmic Ca2+–H+ exchanger and form stable conjugates with exercise-induced reactive aldehydes. The enigmatic nature of carnosine means there is still much to learn regarding its actions and applications in exercise, health and disease. In this review, we examine the research relating to each physiological role attributed to carnosine, and its precursor β-alanine, in exercising human skeletal muscle

Awareness of the 20-20-20 Rule Amongst Students, Faculty, and Staff

In the past several years, medical schools have increased utilization of recorded lectures and electronic devices: computers, smartphones, and tablets. Increased screen exposure hours where students, faculty, and staff may acquire eye strain. Many are not aware of the 20-20-20 rule: for every 20 minutes of screen time, it is recommended to look at something 20 feet away for 20 seconds; a reminder to take frequent breaks to help prevent eye strain. We want to share reports from our institution regarding student, faculty and staff digital device usage and awareness of the 20-20-20 rule

Assessing the Prevalence of Computer Vision Syndrome at an Osteopathic Medical School with an Electronic Content Delivery Model

To determine the overall prevalence of computer vision syndrome (CVS) among students, faculty, and staff while promoting awareness. CVS is caused by extended screen exposure that can lead to eye discomfort and vision changes which can affect quality of life and educational performance. Our institution is a new Osteopathic medical school that aims to create an innovative approach to medical education delivery via employment of modern technology that is already prevalent. Implementation of pre-recorded lecture materials in the curriculum requires 4-6 additional electronic screen exposure hours. Members of our institution are potentially at increased risk for CVS stemming from the curriculum delivery style and the accelerated use of technology

Reinvestigating the Photoprotection Properties of a Mycosporine Amino Acid Motif

With the growing concern regarding commercially available ultraviolet (UV) filters damaging the environment, there is an urgent need to discover new UV filters. A family of molecules called mycosporines and mycosporine-like amino acids (referred to as MAAs collectively) are synthesized by cyanobacteria, fungi and algae and act as the natural UV filters for these organisms. Mycosporines are formed of a cyclohexenone core structure while mycosporine-like amino acids are formed of a cyclohexenimine core structure. To better understand the photoprotection properties of MAAs, we implement a bottom-up approach by first studying a simple analog of an MAA, 3-aminocyclohex-2-en-1-one (ACyO). Previous experimental studies on ACyO using transient electronic absorption spectroscopy (TEAS) suggest that upon photoexcitation, ACyO becomes trapped in the minimum of an S1 state, which persists for extended time delays (>2.5 ns). However, these studies were unable to establish the extent of electronic ground state recovery of ACyO within 2.5 ns due to experimental constraints. In the present studies, we have implemented transient vibrational absorption spectroscopy (as well as complementary TEAS) with Fourier transform infrared spectroscopy and density functional theory to establish the extent of electronic ground state recovery of ACyO within this time window. We show that by 1.8 ns, there is >75% electronic ground state recovery of ACyO, with the remaining percentage likely persisting in the electronic excited state. Long-term irradiation studies on ACyO have shown that a small percentage degrades after 2 h of irradiation, plausibly due to some of the aforementioned trapped ACyO going on to form a photoproduct. Collectively, these studies imply that a base building block of MAAs already displays characteristics of an effective UV filter

Current practice in the diagnosis and management of sarcopenia and frailty – results from a UK-wide survey

Objectives: Despite a rising clinical and research profile, there is limited information about how frailty and sarcopenia are diagnosed and managed in clinical practice. Our objective was to build a picture of current practice by conducting a survey of UK healthcare professionals. Methods: We surveyed healthcare professionals in NHS organisations, using a series of four questionnaires. These focussed on the diagnosis and management of sarcopenia, and the diagnosis and management of frailty in acute medical units, community settings and surgical units. Results: Response rates ranged from 49/177 (28%) organisations for the sarcopenia questionnaire to 104/177 (59%) for the surgical unit questionnaire. Less than half of responding organisations identified sarcopenia; few made the diagnosis using a recognised algorithm or offered resistance training. The commonest tools used to identify frailty were the Rockwood Clinical Frailty Scale or presence of a frailty syndrome. Comprehensive Geriatric Assessment was offered by the majority of organisations, but this included exercise therapy in less than half of cases, and medication review in only one-third to two-thirds of cases. Conclusions: Opportunities exist to improve consistency of diagnosis and delivery of evidence-based interventions for both sarcopenia and frailty