Presentation design and delivery to improve knowledge translation in a remote world.

The practical dissemination of new knowledge is not given adequate attention despite large investment in undertaking high-quality research and the desire for evidence-based practice. It is important that those involved in knowledge translation and continuing medical education understand the fundamental principles of effective presentations, whether at scientific conferences, workshops or group teaching sessions. The switch to remote presentations has made this a more challenging endeavour. We describe established presentation techniques that improve knowledge translation and how to use them in both face-to-face and remote settings.

The Baby Shark (Songs Heard Affecting Resuscitation Kinetics) study.

Previous research has examined the utilisation of musical cues to improve the performance of cardiopulmonary resuscitation (CPR) delivered in training environments. We postulated a musical cue that is both contemporary and transcends cultures may improve CPR performance. Our aim was to establish whether chest compressions are performed with improved rate and depth if a song of a fixed beat (PinkFong's 'Baby Shark' with a tempo of 115 beats per minute (bpm) and 15 beats in each verse) is played to a healthcare professional immediately before undertaking CPR compared to whale noises (a non-metronomic rhythm). 58 Participants of a paediatric conference (majority doctors) were randomly assigned to listen to a minute of Baby Shark (28) or whale song (30) and then undertake a minute of CPR. There was no significant difference in the mean compression rate between the Baby Shark and control groups, with the groups achieving 121 and 125 bpm, respectively (p=0.18). In relation to compression depth within the target zone, the Baby Shark group had more compressions completed within the target zone (55%) than the control group (39%) although this difference was not significant (p=0.08). Listening to Baby Shark prior to undertaking simulated CPR does not improve overall performance, but there is a potential tendency to improve adequate compression depth which may be beneficial in training exercises.

Presentations beyond the matrix: The Fred MacLeod JPS lecture, CAPS 2019.

Current research calculates the time between development of new evidence-based knowledge into established clinical practice as 17 years. This is the knowledge translation gap. The factors influencing this delay are multiple, but it is clear across the history of medicine that knowledge from new, well-constructed studies does not lead directly to change. A significant factor within the knowledge translation gap is the nature of the presentations as they are currently delivered. In the 1999 film The Matrix, there is a discussion between two characters regarding the concept that the world we perceive is, in fact, a virtual reality. As we inhabit this construct, we have a fleeting awareness that the world may not be as we perceive it, but the truth of what that entails is overwhelming. The implicit beliefs underpinning a presentation are that reading out a presentation is teaching, and the corollary, that listening to that presentation is learning. The evidence in the psychological and educational literature is clear that this is false. The implications of this are significant. This is The Matrix of knowledge translation.

The ventriculo-cholecystic shunt: does CSF volume matter?

INTRODUCTION: The management of hydrocephalus in paediatric patients where the peritoneum has failed can be challenging. One option is to perform a ventriculo-cholecystic shunt. However, little is known about the capacity of the gall bladder to accommodate cerebrospinal fluid (CSF). METHODS: A retrospective case series was performed to include all paediatric patients who received a ventriculo-cholecystic shunt at a single centre, Sheffield Children's Hospital. RESULTS: We identified three patients who had a ventriculo-cholecystic shunt inserted. The shunt survived past 1 year in two patients, who had pre-operative external ventricular drain (EVD) outputs of 8 and 10 ml/h respectively. One patient shunt failed at day four post-op due to distal dysfunction, his pre-operative EVD was over 30 ml/h. CONCLUSIONS: When considering a patient for a ventriculo-cholecystic shunt, caution should be taken if a high CSF output is known, for example, as per an EVD measurement.

Social-media-enabled learning in emergency medicine: a case study of the growth, engagement and impact of a free open access medical education blog.

BACKGROUND: Clinicians are increasingly using social media for professional development and education. In 2012, we developed the St.Emlyn's blog, an open access resource dedicated to providing free education in the field of emergency medicine. OBJECTIVE: To describe the development and growth of this international emergency medicine blog. METHOD: We present a narrative description of the development of St.Emlyn's blog. Data on scope, impact and engagement were extracted from WordPress, Twitter and Google Analytics. RESULTS: The St.Emlyn's blog demonstrates a sustained growth in size and user engagement. Since inception in 2012, the site has been viewed over 1.25 million times with a linear year-on-year growth. We have published over 500 blog posts, each of which attracts a mean of 2466 views (range 382-69 671). The site has been viewed in nearly every country in the world, although the majority (>75%) of visitors come from the USA, UK and Australia. SUMMARY: This case study of an emergency medicine blog quantifies the reach and engagement of social-media-enabled learning in emergency medicine.

Major trauma from suspected child abuse: a profile of the patient pathway.

BACKGROUND: Networked organised systems of care for patients with major trauma now exist in many countries, designed around the needs of the majority of patients (90% adults). Non-accidental injury is a significant cause of paediatric major trauma and has a different injury and age profile from accidental injury (AI). This paper compares the prehospital and inhospital phases of the patient pathway for children with suspected abuse, with those accidentally injured. METHODS: The paediatric database of the national trauma registry of England and Wales, Trauma Audit and Research Network, was interrogated from April 2012 (the launch of the major trauma networks) to June 2015, comparing the patient pathway for cases of suspected child abuse (SCA) with AI. RESULTS: In the study population of 7825 children, 7344 (94%) were classified as AI and 481 (6%) as SCA. SCA cases were younger (median 0.4 years vs 7 years for AI), had a higher Injury Severity Score (median 16vs9 for AI), and had nearly three times higher mortality (5.7%vs2.2% for AI). Other differences included presentation to hospital evenly throughout the day and year, arrival by non-ambulance means to hospital (74%) and delayed presentation to hospital from the time of injury (median 8 hours vs 1.8 hours for AI). Despite more severe injuries, these infants were less likely to receive key interventions in a timely manner. Only 20% arrived to a designated paediatric-capable major trauma centre. Secondary transfer to specialist care, if needed, took a median of 21.6 hours from injury(vs 13.8 hours for AI). CONCLUSION: These data show that children with major trauma that is inflicted rather than accidental follow a different pathway through the trauma system. The current model of major trauma care is not a good fit for the way in which child victims of suspected abuse present to healthcare. To achieve better care, awareness of this patient profile needs to increase, and trauma networks should adjust their conventional responses.

A novel xenograft model to study the role of TSLP-induced CRLF2 signals in normal and malignant human B lymphopoiesis.

Thymic stromal lymphopoietin (TSLP) stimulates in-vitro proliferation of human fetal B-cell precursors. However, its in-vivo role during normal human B lymphopoiesis is unknown. Genetic alterations that cause overexpression of its receptor component, cytokine receptor-like factor 2 (CRLF2), lead to high-risk B-cell acute lymphoblastic leukemia implicating this signaling pathway in leukemogenesis. We show that mouse thymic stromal lymphopoietin does not stimulate the downstream pathways (JAK/STAT5 and PI3K/AKT/mTOR) activated by the human cytokine in primary high-risk leukemia with overexpression of the receptor component. Thus, the utility of classic patient-derived xenografts for in-vivo studies of this pathway is limited. We engineered xenograft mice to produce human thymic stromal lymphopoietin (+T mice) by injection with stromal cells transduced to express the cytokine. Control (-T) mice were produced using stroma transduced with control vector. Normal levels of human thymic stromal lymphopoietin were achieved in sera of +T mice, but were undetectable in -T mice. Patient-derived xenografts generated from +T as compared to -T mice showed a 3-6-fold increase in normal human B-cell precursors that was maintained through later stages of B-cell development. Gene expression profiles in high-risk B-cell acute lymphoblastic leukemia expanded in +T mice indicate increased mTOR pathway activation and are more similar to the original patient sample than those from -T mice. +T/-T xenografts provide a novel pre-clinical model for understanding this pathway in B lymphopoiesis and identifying treatments for high-risk B-cell acute lymphoblastic leukemia with overexpression of cytokine-like factor receptor 2.

A profile of suspected child abuse as a subgroup of major trauma patients.

INTRODUCTION: Non-accidental injury (NAI) in children is an important cause of major injury. The Trauma Audit Research Network (TARN) recently analysed data on the demographics of paediatric trauma and highlighted NAI as a major cause of death and severe injury in children. This paper examined TARN data to characterise accidental versus abusive cases of major injury. METHODS: The national trauma registry of England and Wales (TARN) database was interrogated for the classification of mechanism of injury in children by intent, from January 2004 to December 2013. Contributing hospitals' submissions were classified into accidental injury (AI), suspected child abuse (SCA) or alleged assault (AA) to enable demographic and injury comparisons. RESULTS: In the study population of 14 845 children, 13 708 (92.3%, CI 91.9% to 92.8%) were classified as accidental injury, 368 as alleged assault (2.5%, CI 2.2% to 2.7%) and 769 as SCA (5.2%, CI 4.8% to 5.5%). Nearly all cases of severely injured children suffering trauma because of SCA occurred in the age group of 0-5 years (751 of 769, 97.7%), with 76.3% occurring in infants under the age of 1 year. Compared with accidental injury, suspected victims of abuse have higher overall injury severity scores, have a higher proportion of head injury and a threefold higher mortality rate of 7.6% (CI 5.51% to 9.68%) vs 2.6% (CI 2.3% to 2.9%). CONCLUSIONS: This study highlights that major injury occurring as a result of SCA has a typical demographic pattern. These children tend to be under 12 months of age, with more severe injury. Understanding these demographics could help receiving hospitals identify children with major injuries resulting from abuse and ensure swift transfer to specialist care.

Exploiting pre-rRNA processing in Diamond Blackfan anemia gene discovery and diagnosis.

Diamond Blackfan anemia (DBA), a syndrome primarily characterized by anemia and physical abnormalities, is one among a group of related inherited bone marrow failure syndromes (IBMFS) which share overlapping clinical features. Heterozygous mutations or single-copy deletions have been identified in 12 ribosomal protein genes in approximately 60% of DBA cases, with the genetic etiology unexplained in most remaining patients. Unlike many IBMFS, for which functional screening assays complement clinical and genetic findings, suspected DBA in the absence of typical alterations of the known genes must frequently be diagnosed after exclusion of other IBMFS. We report here a novel deletion in a child that presented such a diagnostic challenge and prompted development of a novel functional assay that can assist in the diagnosis of a significant fraction of patients with DBA. The ribosomal proteins affected in DBA are required for pre-rRNA processing, a process which can be interrogated to monitor steps in the maturation of 40S and 60S ribosomal subunits. In contrast to prior methods used to assess pre-rRNA processing, the assay reported here, based on capillary electrophoresis measurement of the maturation of rRNA in pre-60S ribosomal subunits, would be readily amenable to use in diagnostic laboratories. In addition to utility as a diagnostic tool, we applied this technique to gene discovery in DBA, resulting in the identification of RPL31 as a novel DBA gene.

Omental infarct in a hernia: an unusual cause of paediatric acute scrotum.

We report a case of paediatric acute scrotum due to segmental haemorrhagic infarct of the omentum secondary to strangulation in the left inguinal hernia in a toddler as initial presentation after hernia being noticed by mother once earlier. A 4-year-old boy with non-traumatic acute left scrotum who had a history of left inguinal swelling once earlier presented with massively swollen, painful and discoloured left hemiscrotum extending into the groin simulating acute testicular torsion. Interestingly, there was a segmental omental infarct which precipitated the emergency and had ipsilateral testicular ascent and atrophy as long-term sequelae. Strangulated segmental omental infarct is a rare cause of acute abdomen/scrotum in children. Omentum is a very rare content of inguinal hernia in a toddler and infarct is exceptional. The diagnosis is usually not established before surgery in children. It should be included in the differential diagnoses of acute scrotum, especially in patients with untreated inguinal hernia.

A case report of B-cell lymphoma masquerading as superior mesenteric artery syndrome.

Superior mesenteric artery (SMA) syndrome is a rare cause of intestinal obstruction, especially in children, whereas intussusception is far more common. We report the case of a child, who after an episode of acute weight loss presented with features suggestive of SMA syndrome. This child subsequently was shown at operation to have disseminated lymphoma causing a secondary high jejunal intussusception and tumor involvement of retroperitoneal lymph nodes causing compression of the third part of the duodenum. This case emphasizes that the SMA syndrome should be considered a sign rather than a diagnosis in itself. As such, an active search should be made to determine the cause of the condition. Routine preoperative imaging is recommended.

The exceptionally rare (sic) Common Scoter.

A 1-month-old infant with congenital heart disease underwent initial cardiac surgery (Mee Shunt) at day 20 but was later readmitted because of poor shunt flow and hypoxemia. Despite therapy, the infant deteriorated and suffered a cardiopulmonary arrest. After 40 minutes of resuscitation, spontaneous cardiac output was reestablished, and subsequently, the child was placed on extracorporeal circulation membrane oxygen (ECMO) support. The infant deteriorated further over the next 3 days with persistent acidosis, marked abdominal distension associated with significant nasogastric aspirates, and the passage of small amounts of bloodstained stool. The presumed diagnosis was necrotizing enterocolitis, and despite the grave prognostic indicators, the decision was taken to undertake laparotomy. At surgery, there was 350 mL of unclotted venous blood in the peritoneal cavity. The bowel was grossly normal. A ruptured, infarcted, hemorrhagic spleen was discovered to be the cause of the bleeding. A splenectomy was performed, and the child made rapid recovery, sufficiently well to undergo redo Mee shunt 2 days later. A splenic infarct was confirmed at pathological examination. The cause of the splenic infarct and rupture is uncertain in this baby but may have been related to either cardiopulmonary resuscitation and/or ECMO. The importance of this case is the similarity in presentation in a baby with congenital heart disease between necrotizing enterocolitis (which is relatively common) and hemoperitoneum secondary to splenic rupture (which is very rare). Medical practice contains many useful maxims such as, "What walks like a duck, talks like a duck, is often a duck." This case demonstrates that not all ducks are the common Mallard (Anas platyrhynchos) but occasionally the exceptionally rare (sic) Common Scoter (Melanitta nigra). The management of neonatal cardiac patients on ECMO therapy continues to be a challenge, and particular diagnostic rigor should be applied in their care.

Splenoptosis complicated by a large splenic cyst: case report and discussion of combined management.

Splenoptosis is a rare condition in children. Its association with a cyst is rare. A case of splenoptosis complicated by a large cyst is reported. The child presented with features of intermittent abdominal pain, constipation and clinical examination revealed a mass apparently rising out of the pelvis. Ultrasound confirmed the mass as spleen with a 15 cm cyst in the lower pole. At surgery the cyst was marsupialised and splenopexy undertaken placing the cyst in a retro-peritoneal pouch. This is only the second report of such a case in the English literature.