General Surgery Resuscitation Preference Documentation: A Quality Improvement Initiative.

BACKGROUND/PURPOSE: Documentation of resuscitation preferences is crucial for patients undergoing surgery. Unfortunately, this remains an area for improvement at many institutions. We conducted a quality improvement initiative to enhance documentation percentages by integrating perioperative resuscitation checks into the surgical workflow. Specifically, we aimed to increase the percentage of general surgery patients with documented resuscitation statuses from 82% to 90% within a 1-year period. METHODS: Three key change ideas were developed. First, surgical consent forms were modified to include the patient's resuscitation status. Second, the resuscitation status was added to the routinely used perioperative surgical checklist. Finally, patient resources on resuscitation processes and options were updated with support from patient partners. An audit survey was distributed mid-way through the interventions to evaluate process measures. RESULTS: The initiatives were successful in reaching our study aim of 90% documentation rate for all general surgery patients. The audit revealed a high uptake of the new consent forms, moderate use of the surgical checklist, and only a few patients for whom additional resuscitation details were added to their clinical note. CONCLUSIONS: We successfully increased the documentation percentage of resuscitation statuses within our large tertiary care center by incorporating checks into routine forms to prompt the conversation with patients early.

The Need for Health Policy Training for Surgeons.

BACKGROUND: Improvements in surgery at a systems level can be mediated by effective health policy. METHODS: We reviewed three contemporary challenges in surgical care to understand the potential role of health policy. RESULTS: The pandemic-related backlog, and international economic and logistical challenges to surgical care may be improved through policy change and advocacy by surgeons. CONCLUSIONS: A surgeon-policy expert training pathway and professional role will ensure surgeons contribute meaningfully to health policy development.

Assessment of finger dexterity through the DIGITS joint tracking web application-An evaluation study with comparison to the nine-hole pegboard test.

BACKGROUND: Hand dexterity is an important clinical marker after hand surgery as it can greatly impact one's ability to perform their day-to-day activities. With the increased focus on remote patient monitoring after hand surgery, new technologies are required to remotely monitor hand dexterity. PURPOSE: The purpose of this study is to identify dexterity outcomes using the web application "DIGITS" and compare these outcomes to the nine-hole-pegboard test (NHPT). STUDY DESIGN: Cross-sectional observational study. METHODS: This was a two-part study with a pilot of our remote dexterity design using DIGITS followed by a validation study comparing DIGITS to a gold-standard metric of dexterity, NHPT. The pilot study recruited 42 healthy subjects between the ages of 18-65 to perform a remote finger tapping exercise using DIGITS. The second part of the study included 50 subjects between the ages of 18-65. Participants completed a demographic questionnaire and then completed three finger tapping sequences for 20 seconds using DIGITS and three trials of the NHPT with each hand. Correlational analyses were done to compare the DIGITS dexterity test with the NHPT. RESULTS: Four outcome measures to assess dexterity were identified, which included (1) total sequences completed in 20 seconds, (2) time to complete 10 sequences, (3) average frequency per sequence, and (3) sequence accuracy. Significant negative correlations were found with the NHPT and total sequences completed in 20 seconds in both dominant and non-dominant hand trials. Additionally, significant negative correlations were found between the NHPT and the time to complete 10 sequences and average frequency in the non-dominant hand trials. CONCLUSIONS: This study shows promising results for the use of DIGITS as a remote measure of hand dexterity. The total number of sequences completed significantly correlates with the NHPT and should be further explored in representative patient populations.

Next-Generation Remote Hand Assessments: Cross-Platform DIGITS Web Application.

Purpose: We have previously developed DIGITS, a platform for remote evaluation of range of motion, dexterity, and swelling of fingers for reducing barriers to accessing clinical resources. The current study was aimed at evaluating DIGITS across different devices with varied operating systems and camera resolutions using a single person's hands. Methods: Our team has now developed a web application version of the DIGITS platform, which makes it accessible on any device that is equipped with a camera, including computers, tablets, and smartphones. In the present study, we aimed to validate this web application by comparing flexion and extension measurements on the same person's hands using three different devices with cameras of different resolutions. The absolute difference, SD, standard mean error, and intraclass correlation coefficient were calculated. Additionally, equivalency testing was performed using the confidence interval approach. Results: Our findings indicated that the differences in degree measured between the devices ranged from 2° to 3° when digit extension was assessed (all hand landmarks are visible in the camera's direct view) and from 3° to 8° when digit flexion was assessed (some of the hand landmarks are hidden from view). The intraclass correlation coefficient of individual trials ranged from 0.82 to 0.96 for extension and 0.77 to 0.87 for flexion across all devices. Additionally, within a 90% confidence interval, our data showed equivalency with measurements using three different devices. Conclusions: The absolute differences were within an acceptable 9° tolerance for measurements taken between devices for flexion and extension. Equivalency was observed for measurements of finger range of motion taken using DIGITS, regardless of devices, platforms, or camera resolutions. Clinical relevance: In summary, the DIGITS web application has good test-retest reliability to generate data on finger range of motion for hand telerehabilitation. DIGITS can reduce costs to patients, providers, and health care facilities for conducting postoperative follow-up assessments.

Airway registries in primarily adult, emergent endotracheal intubation: a scoping review.

BACKGROUND: Emergency Department (ED) airway registries are formalized methods to collect and document airway practices and outcomes. Airway registries have become increasingly common in EDs globally; yet there is no consensus of airway registry methodology or intended utility. This review builds on previous literature and aims to provide a thorough description of international ED airway registries and discuss how airway registry data is utilized. METHODS: A search of Medline, Embase, Scopus, Cochrane Libraries, Web of Science, and Google Scholar was performed with no date limitations applied. English language full-text publications and grey literature from centres implementing an ongoing airway registry to monitor intubations performed in mainly adult patients in an ED setting were included. Non-English publications and publications describing airway registries to monitor intubation practices in predominantly paediatric patients or settings outside of the ED were excluded. Study screening for eligibility was performed by two team members individually, with any disagreements resolved by a third team member. Data was charted using a standardized data charting tool created for this review. RESULTS: Our review identified 124 eligible studies from 22 airway registries with a global distribution. We found that airway registry data is used for quality assurance, quality improvement, and clinical research regarding intubation practices and contextual factors. This review also demonstrates that there is a great deal of heterogeneity in definitions of first-pass success and adverse events in the peri-intubation period. CONCLUSIONS: Airway registries are used as a crucial tool to monitor and improve intubation performance and patient care. ED airway registries inform and document the efficacy of quality improvement initiatives to improve intubation performance in EDs globally. Standardized definitions of first-pass success and peri-intubation adverse events, such as hypotension and hypoxia, may allow for airway management performance to be compared on a more equivalent basis and allow for the development of more reliable international benchmarks for first-pass success and rates of adverse events in the future.

Modeling the Role of Wnt Signaling in Human and Drosophila Stem Cells.

The discovery of induced pluripotent stem (iPS) cells, barely more than a decade ago, dramatically transformed the study of stem cells and introduced a completely new way to approach many human health concerns. Although advances have pushed the field forward, human application remains some years away, in part due to the need for an in-depth mechanistic understanding. The role of Wnts in stem cells predates the discovery of iPS cells with Wnts established as major pluripotency promoting factors. Most work to date has been done using mouse and tissue culture models and few attempts have been made in other model organisms, but the recent combination of clustered regularly interspaced short palindromic repeats (CRISPR) gene editing with iPS cell technology provides a perfect avenue for exploring iPS cells in model organisms. Drosophila is an ideal organism for such studies, but fly iPS cells have not yet been made. In this opinion article, we draw parallels between Wnt signaling in human and Drosophila stem cell systems, propose ways to obtain Drosophila iPS cells, and suggest ways to exploit the versatility of the Drosophila system for future stem cell studies.

An embryonic system to assess direct and indirect Wnt transcriptional targets.

During animal development, complex signals determine and organize a vast number of tissues using a very small number of signal transduction pathways. These developmental signaling pathways determine cell fates through a coordinated transcriptional response that remains poorly understood. The Wnt pathway is involved in a variety of these cellular functions, and its signals are transmitted in part through a ß-catenin/TCF transcriptional complex. Here we report an in vivo Drosophila assay that can be used to distinguish between activation, de-repression and repression of transcriptional responses, separating upstream and downstream pathway activation and canonical/non-canonical Wnt signals in embryos. We find specific sets of genes downstream of both ß-catenin and TCF with an additional group of genes regulated by Wnt, while the non-canonical Wnt4 regulates a separate cohort of genes. We correlate transcriptional changes with phenotypic outcomes of cell differentiation and embryo size, showing our model can be used to characterize developmental signaling compartmentalization in vivo.

Imprinted NanoVelcro Microchips for Isolation and Characterization of Circulating Fetal Trophoblasts: Toward Noninvasive Prenatal Diagnostics.

Circulating fetal nucleated cells (CFNCs) in maternal blood offer an ideal source of fetal genomic DNA for noninvasive prenatal diagnostics (NIPD). We developed a class of nanoVelcro microchips to effectively enrich a subcategory of CFNCs, i.e., circulating trophoblasts (cTBs) from maternal blood, which can then be isolated with single-cell resolution by a laser capture microdissection (LCM) technique for downstream genetic testing. We first established a nanoimprinting fabrication process to prepare the LCM-compatible nanoVelcro substrates. Using an optimized cTB-capture condition and an immunocytochemistry protocol, we were able to identify and isolate single cTBs (Hoechst+/CK7+/HLA-G+/CD45-, 20 µm > sizes > 12 µm) on the imprinted nanoVelcro microchips. Three cTBs were polled to ensure reproducible whole genome amplification on the cTB-derived DNA, paving the way for cTB-based array comparative genomic hybridization (aCGH) and short tandem repeats analysis. Using maternal blood samples collected from expectant mothers carrying a single fetus, the cTB-derived aCGH data were able to detect fetal genders and chromosomal aberrations, which had been confirmed by standard clinical practice. Our results support the use of nanoVelcro microchips for cTB-based noninvasive prenatal genetic testing, which holds potential for further development toward future NIPD solution.

Genetics in LGB Assisted Reproduction: Two Flipped Classroom, Progressive Disclosure Cases.

INTRODUCTION: There have been several educational reforms calling for increasing lesbian, gay, bisexual, and transgender (LGBT) education materials, application of basic sciences to clinical medicine, and active engagement of students. While the amount of educational materials for LGBT clinical cases is increasing, this session for preclinical medical students uniquely combines basic science population genetics, cisgender lesbian, gay, and bisexual (LGB) cultural issues and reproductive endocrinology in a 1.5-hour flipped classroom session. METHODS: Students were assigned a prediscussion video and reading. Facilitators attended a 1.5-hour training session prior to discussion. Each classroom of 30 students with small groups of six was led by a third- or fourth-year medical student facilitator who taught from a PowerPoint that included discussion questions. An audience response system was used to show aggregated, real-time anonymous responses to case questions, a pre- and postsurvey was used to analyze changes in student attitudes and knowledge of assisted reproduction services for same-sex couples, and course evaluations captured overarching student impressions. RESULTS: All first-year students (N = 180) attended this mandatory session. Audience response questions showed a high level of knowledge of population genetics concepts. Voluntary surveys showed a higher number of assisted reproduction recommendations for LGB patients compared to heterosexual patients before discussion, with this difference disappearing after the discussion. This may indicate a shift in student attitudes and knowledge of LGB patient barriers and assisted reproduction. Course evaluations showed appreciation of LGB material integration within the course. DISCUSSION: Educators will be able to successfully integrate the application of population genetics, assisted reproduction cases, and an examination of cultural barriers in health care for LGB patients with this session.

Proof of concept: preimplantation genetic screening without embryo biopsy through analysis of cell-free DNA in spent embryo culture media.

OBJECTIVE: To assess whether preimplantation genetic screening (PGS) is possible by testing for free embryonic DNA in spent IVF media from embryos undergoing trophectoderm biopsy. DESIGN: Prospective cohort analysis. SETTING: Academic fertility center. PATIENT(S): Seven patients undergoing IVF and 57 embryos undergoing trophectoderm biopsy for PGS. INTERVENTION(S): On day 3 of development, each embryo was placed in a separate media droplet. All biopsied embryos received a PGS result by array comparative genomic hybridization. Preimplantation genetic screening was performed on amplified DNA extracted from media and results were compared with PGS results for the corresponding biopsy. MAIN OUTCOME MEASURE(S): [1] Presence of DNA in spent IVF culture media. [2] Correlation between genetic screening result from spent media and corresponding biopsy. RESULT(S): Fifty-five samples had detectable DNA ranging from 2-642 ng/µL after a 2-hour amplification. Six samples with the highest DNA levels underwent PGS, rendering one result with a derivative log ratio SD (DLRSD) of <0.85 (a quality control metric of oligonucleotide array comparative genomic hybridization). The fluid sample and trophectoderm results were identical demonstrating (45XY, -13). Three samples were reamplified 1 hour later and tested showing improving DLRSD. One of the three samples with a DLRSD of 0.85 demonstrated (46XY), consistent with the biopsy. Overnight DNA amplification showed DNA in all samples. CONCLUSION(S): We demonstrate two novel findings: the presence of free embryonic DNA in spent media and a result that is consistent with trophectoderm biopsy. Improvements in DNA collection, amplification, and testing may allow for PGS without biopsy in the future.

Disparities between online assisted reproduction patient education for same-sex and heterosexual couples.

STUDY QUESTION: Does the prevalence of online education in fertility center websites differ for lesbian, gay, bisexual, transgender (LGBT) couples compared to online education for heterosexual couples? SUMMARY ANSWER: This review of fertility center websites showed that the majority of websites with patient education for heterosexual couples do not have similar materials for LGBT couples. WHAT IS KNOWN ALREADY: In order to have biologically related children, LGBT individuals or couples utilize assisted reproductive technologies (ART). Fertility clinic websites provide online education to familiarize patients with the different ART procedures; however, no studies have examined the prevalence of educational information for LGBT couples compared to information for heterosexual couples utilizing ART. STUDY DESIGN, SIZE AND DURATION: This website review evaluated Centers for Disease Control and Prevention (CDC)-reported fertility center websites. Websites were reviewed in 2014 using the latest 2011 CDC report, and reviewed again in 2015 with the latest 2013 CDC report. PARTICIPANTS/MATERIALS, SETTING, METHOD: Patient education information was coded using categories determined after a sample review, and differences were analyzed with χ(2) tests, with P-values calculated with Fisher's exact test. MAIN RESULTS AND THE ROLE OF CHANCE: In 2014, 31.1% (121) of 389 websites with information for heterosexual couples also contained information for LGBT couples. In 2015, the number of fertility centers with information for LGBT couples increased by 52.9% to 185 (P < 0.001) of 407 (45.5%) fertility center websites. However, the majority of fertility clinic websites (54.5%) with information for heterosexual couples still do not include information specific to LGBT couples. LIMITATIONS, REASONS FOR CAUTION: The lack of online information on fertility center websites may not directly reflect the quality of care LGBT individuals or couples receive in the clinic, and the effect of this absence of online information on the clinical experiences of LGBT patients is unknown. WIDER IMPLICATIONS OF THE FINDINGS: These findings add to the growing body of work showing disparities in the treatment of LGBT persons compared to the overall population. To overcome these discrepancies, healthcare providers should adapt their practice to include this growing and underserved patient population. STUDY FUNDING/COMPETING INTERESTS: Funding was provided by the Medical Student Summer Research Scholarship, Barbur Khalique Foundation. There are no competing interests.