Nontechnical Skills for Intraoperative Team Members

Nontechnical skills, defined as the set of cognitive and social skills used by individuals and teams to reduce error and improve performance in complex systems, have become increasingly recognized as a key contributor to patient safety. Efforts to characterize, quantify, and teach nontechnical skills in the context of perioperative care continue to evolve. This review article summarizes the essential behaviors for safety, described in taxonomies for nontechnical skills assessments developed for intraoperative clinical team members (eg, surgeons, anesthesiologists, scrub practitioners, perfusionists). Furthermore, the authors describe emerging methods to advance understanding of the impact of nontechnical skills on perioperative outcomes.

Surgical outcomes of patients at prohibitive risk who are reconsidered for surgery

Objectives

Transcatheter treatment of advanced mitral and tricuspid valve disease is largely limited to patients at prohibitive surgical risk, although many are not candidates for transcatheter treatment. Here, we describe surgical outcomes of patients at prohibitive risk who were ineligible for transcatheter therapies to guide surgeons in management of this unique population.

Methods

Patients at prohibitive risk, defined per surgeon or cardiologist discretion, who were initially referred for a transcatheter mitral or tricuspid intervention in a multidisciplinary atrioventricular valve clinic, were identified from 2019 to 2022. Preoperative risk, operative outcomes, and long-term mortality were evaluated.

Results

A total of 337 patients at prohibitive risk were referred for evaluation in a multidisciplinary atrioventricular valve clinic. Of those, 161 underwent transcatheter therapy, 130 patients underwent continued medical management, and 45 were reevaluated and had high-risk surgery. Among surgical patients, 51% were women with a median age of 76 years (quartile 1-quartile 3, 65-81 years). Most patients presented in heart failure (83%; n = 37 out of 45), and 73% were in New York Heart Association functional class III or IV. Most patients (94%; n = 43) had a mitral valve intervention, of whom 56% (24 out of 43) had a mitral valve replacement. The 30-day mortality rate was 4% (2 out of 45) and major morbidity occurred in 33% (15 out of 45). By Kaplan-Meier analysis, 1-year survival was 86% ± 9%.

Conclusions

Select patients at prohibitive risk who were ineligible for transcatheter mitral or tricuspid valve intervention underwent surgery with overall low operative mortality and excellent 1-year survival. Patients a prohibitive risk whose anatomy is not amenable to transcatheter devices should be reconsidered for surgery.

Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers' sedation practices

Background

Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric procedural sedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation.

Methods

This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes.

Results

Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers.

Conclusions

The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings.

More Than Just a Passport: Resources and Implementation Strategies to Optimize Preparation for Global Health Work

During the past decade, many resources have been developed to support trainees and clinicians seeking to prepare for global health work. For time-constrained health care providers, figuring out how to prepare can be overwhelming. Given the wide variation in types of travelers and work plans, there is not a "one size fits all" preparation resource. This article offers a summary of preparation topics that all travelers should consider; compiles curated, high-yield resources designed to prepare health care providers for global health experiences; and provides implementation strategies to best meet the unique needs of each traveler, taking into consideration factors such as provider expertise (trainee vs practicing clinician), solo versus group travel, and time available before departure. These curated resources include a variety of training modalities (self-directed, group-based, train-the-trainer, and in-person courses), all summarized here to empower health care providers to create individualized, comprehensive preparation plans before engaging globally. [Pediatr Ann. 2023;52(9):e330-e334.].

Interactions With Police in the Emergency Care of Children: Ethical and Legal Considerations

OBJECTIVES

Emergency medicine providers may interface with law enforcement personnel (LEP) on behalf of their pediatric patients for a variety of reasons, from reporting child abuse to caring for children who are in police custody. Given the unique nature of caring for minors who may not have legal or medical autonomy, interactions with LEP can raise ethical concerns for emergency providers, specifically with regard to legal representation, developmental immaturity, and the civil rights of children and their parents/guardians.

METHODS

We review 4 patient scenarios, based on real cases experienced by the authors, to demonstrate the legal and ethical issues that may arise when LEP are involved in the emergency care of a child. These scenarios discuss parental/guardian visitation for children in police custody in the emergency department (ED), the practice of making arrests on hospital grounds, and police interviews of children in the ED.

RESULTS

Using the ethical principles of autonomy, beneficence, and justice, we offer recommendations for emergency providers on how to advocate for their pediatric patients in LEP custody within the constraints and protections of the law. We also suggest best practices for hospital systems to develop policies surrounding LEP activity in the ED.

CONCLUSIONS

These nuanced situations require careful advocacy for the child and a collaborative approach between medical providers and LEP to balance the child's well-being with public safety. We offer recommendations here, and we maintain that clear, widely adopted best practices for the care of minors in LEP custody are long overdue.

Paediatric trauma education in low- and middle-income countries: A systematic literature review

Background

Trauma-specific training improves clinician comfort and reduces patient morbidity and mortality; however, curricular content, especially with regard to paediatric trauma, varies greatly by region and income status. We sought to understand how much paediatric education is included in trauma curricula taught in low- and middle-income countries (LMICs).

Methods

We conducted a systematic literature review in October 2020 and in July 2022 based on PRISMA guidelines, utilizing seven databases: MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Reviews, Cochrane Trials, and Global Index Medicus. Reports were limited to those from World Bank-designated LMICs. Key information reviewed included use of a trauma curriculum, patient-related outcomes, and provider/participant outcomes.

Results

The search yielded 2008 reports, with 987 included for initial screening. Thirty-nine of these were selected for review based on inclusion criteria. Sixteen unique trauma curricula used in LMICs were identified, with only two being specific to paediatric trauma. Seven of the adult-focused trauma programmes included sections on paediatric trauma. Curricular content varied significantly in educational topics and skills assessed. Among the 39 included curricula, 33 were evaluated based on provider-based outcomes and six on patient-based outcomes. All provider-based outcome reports showed increased knowledge acquisition and comfort. Four of the five patient-based outcome reports showed reduction in trauma-related morbidity and mortality.

Conclusion

Trauma curricula in LMICs positively impact provider knowledge and may decrease trauma-related morbidity and mortality; however, there is significant variability in existing trauma curricula regarding to paediatric-specific content. Trauma education in LMICs should expand paediatric-specific education, as this population appears to be underserved by most existing curricula.

Five days of fever and myocardial inflammation

Multisystem inflammatory syndrome in children is an emerging pediatric illness associated with severe acute respiratory syndrome coronavirus 2 infection. The syndrome is rare, and evidence-based guidelines are lacking. This report reviews a patient who presented for medical care multiple times early in the course of his illness, thus offering near-daily documentation of symptoms and laboratory abnormalities. The patient did not have thrombocytopenia, anemia, or myocardial inflammation until the fifth day of fever. These laboratory abnormalities coincided with the onset of rash, conjunctival injection, vomiting, and diarrhea: clinical signs that could serve as indicators for when to obtain blood tests. The timing of this patient’s onset of multisystem involvement suggests that testing for multisystem inflammatory syndrome in children after only 24 h of fever, as the Centers for Disease Control and Prevention recommends, may yield false-negative results. Testing for multisystem inflammatory syndrome in children after 4 days of fever may be more reliable.

The effects of mobile health on emergency care in low- and middle-income countries: A systematic review and narrative synthesis

BACKGROUND

In resource-constrained settings, mobile health (mHealth) has varied applications. While there is strong evidence for its use in chronic disease management, the applications of mHealth for management of acute illness in low- and middle-income countries (LMICs) are not as well described. This review systematically explores current available evidence on the effectiveness of mHealth interventions at improving health outcomes in emergency care settings in LMICs.

METHODS

A systematic search of the literature was performed in accordance with PRISMA guidelines, utilizing seven electronic databases and manual searches to identify peer-reviewed literature containing each of three search elements: mHealth, emergency care (EC), and LMICs. Articles quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

After removing duplicates, 6498 studies met initial search criteria; 108 were eligible for full text review and 46 met criteria for inclusion. Thirty-six pertained to routine emergency care, and 10 involved complex humanitarian emergencies. Based on the GRADE criteria, 15 studies were rated as "Very Low" quality, 24 as "Low" quality, 6 as "Moderate" quality, and 1 as "High" quality. Eight studied data collection, 9 studied decision support, 15 studied direct patient care, and 14 studied health training. All 46 studies reported positive impacts of mHealth on EC in LMICs.

CONCLUSIONS

Mobile health interventions can be effective in improving provider-focused and patient-centered outcomes in both routine and complex EC settings. Future investigations focusing on patient-centered outcomes are needed to further validate these findings.

Global Emergency Medicine: A Review of the Literature from 2018

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts a systematic annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most rigorously conducted and widely relevant research in global EM.

METHODS

An electronic search of PubMed, a comprehensive retrieval of articles from specific journals, and search of the gray literature were conducted. Title and abstracts retrieved by these searches were screened by a total of 22 reviewers based on their relevance to the field of global EM, across the domains of disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). All articles that were deemed relevant by at least one reviewer, their editor, and the managing editor underwent formal scoring of overall methodologic quality and importance to global EM. Two independent reviewers scored all articles; editors provided a third score in cases of widely discrepant scores.

RESULTS

A total of 19,102 articles were identified by the searches and, after screening and removal of duplicates, a total of 517 articles underwent full review. Twenty-five percent were categorized as DHR, 61% as ECRLS, and 15% as EMD. Inter-rater reliability testing between the reviewers revealed a Cohen's kappa score of 0.213 when considering the complete score or 0.426 when excluding the more subjective half of the score. A total of 25 articles scored higher than 17.5 of 20; these were selected for a full summary and critique.

CONCLUSIONS

In 2018, the total number of articles relevant to global EM that were identified by our search continued to increase. Studies and reviews focusing on pediatric infections, several new and traditionally underrepresented topics, and landscape reviews that may help guide clinical care in new settings represented the majority of top-scoring articles. A shortage of articles related to the development of EM as a specialty was identified.

Aortic recoarctation and pseudoaneurysm five decades after repair

BACKGROUND

Coarctation of the aorta is a congenital cardiac defect characterized by a narrowing of the proximal thoracic aorta. Despite excellent long-term results, surgical repair is rarely complicated by recoarctation.

METHODS/RESULTS

We describe a case with the longest time to reintervention to date, featuring surgical repair of delayed aortic recoarctation and pseudoaneurysm 53 years after the initial operation.

DISCUSSION

This case emphasizes the need for lifelong surveillance in this patient population and exemplifies a multidisciplinary approach in evaluating treatment options of complex aortic pathology, including open and endovascular considerations.

A Highly Active Isoform of Lentivirus Restriction Factor SAMHD1 in Mouse

The triphosphohydrolase SAMHD1 (sterile α motif and histidine-aspartate domain-containing protein 1) restricts HIV-1 replication in nondividing myeloid cells by depleting the dNTP pool, preventing reverse transcription. SAMHD1 is also reported to have ribonuclease activity that degrades the virus genomic RNA. Human SAMHD1 is regulated by phosphorylation of its carboxyl terminus at Thr-592, which abrogates its antiviral function yet has only a small effect on its phosphohydrolase activity. In the mouse, SAMHD1 is expressed as two isoforms (ISF1 and ISF2) that differ at the carboxyl terminus due to alternative splicing of the last coding exon. In this study we characterized the biochemical and antiviral properties of the two mouse isoforms of SAMHD1. Both are antiviral in nondividing cells. Mass spectrometry analysis showed that SAMHD1 is phosphorylated at several amino acid residues, one of which (Thr-634) is homologous to Thr-592. Phosphomimetic mutation at Thr-634 of ISF1 ablates its antiviral activity yet has little effect on phosphohydrolase activity in vitro dGTP caused ISF1 to tetramerize, activating its catalytic activity. In contrast, ISF2, which lacks the phosphorylation site, was significantly more active, tetramerized, and was active without added dGTP. Neither isoform nor human SAMHD1 had detectable RNase activity in vitro or affected HIV-1 genomic RNA stability in newly infected cells. These data support a model in which SAMHD1 catalytic activity is regulated through tetramer stabilization by the carboxyl-terminal tail, phosphorylation destabilizing the complexes and inactivating the enzyme. ISF2 may serve to reduce the dNTP pool to very low levels as a means of restricting virus replication.

SAMHD1 has differential impact on the efficacies of HIV nucleoside reverse transcriptase inhibitors

Sterile alpha motif- and histidine/aspartic acid domain-containing protein 1 (SAMHD1) limits HIV-1 replication by hydrolyzing deoxynucleoside triphosphates (dNTPs) necessary for reverse transcription. Nucleoside reverse transcriptase inhibitors (NRTIs) are components of anti-HIV therapies. We report here that SAMHD1 cleaves NRTI triphosphates (TPs) at significantly lower rates than dNTPs and that SAMHD1 depletion from monocytic cells affects the susceptibility of HIV-1 infections to NRTIs in complex ways that depend not only on the relative changes in dNTP and NRTI-TP concentrations but also on the NRTI activation pathways.

High resolution shading correction

Quantitative cytology requires accurate representation of a specimen's optical densities. As the requirements for measurement precision increase, instrument-induced errors become increasingly more difficult to reduce to the point at which their effect on experimental data is insignificant compared to the measured parameters. Shading induces a significant amount of amplitude ambiguity to data obtained from a scanning system. A method of shading correction on single pixels is introduced as a new way to reduce some errors that currently plague scanning systems.