Teleconsultation in primary ophthalmic emergencies during the COVID-19 lockdown in Paris: Experience with 500 patients in March and April 2020

This prospective observational cohort study is based on the first 500 patients who requested emergency teleconsultation during the initial days of the COVID-19 lockdown in Paris, France between 20 March and 10 April 2020. It is the first study to assess the utility of emergency teleophthalmology with a simple smartphone application or web browser and a webcam to manage emergency eye care in a population with sudden restricted access to ophthalmologists. In this study, every patient who asked for an ophthalmic emergency consultation in a single specialized center in Paris (‘SOS Œil’) first had to undergo a teleconsultation appointment to evaluate the indication for a physical consultation to preserve lockdown. Under medical advice only, a physical appointment was given within a day (if necessary). The aim of the study was to describe the population and diagnoses and evaluate the main judgment criteria, defined as the ‘ability of teleconsultation to properly indicate a physical consultation for fair diagnosis and treatment in eye emergencies’. This organization has permitted physicians and patients to preserve social distancing while avoiding 3 or 4 physical consultations per person. Notably, 27% of teleconsultations were followed by a physical appointment. There was a mean 4.12-day delay between symptom apparition and consultation, and less than 1 day for traumas, superficial corneal foreign body and neuro-ophthalmological emergencies. There was a 96% sensitivity and 95% specificity to properly evaluate the indication of a physical consultation and only 1.0% misdiagnoses that lead to delayed care. Hence, teleconsultation maintained satisfactory healthcare access to patients with severe ophthalmological disorders while preserving social distancing and sanitary precautions. Therefore, teleconsultation may be seriously considered as a way to efficiently regulate ophthalmic emergencies, especially for patients with limited access to a specialist.

Association of a Surgical Task During Training With Team Skill Acquisition Among Surgical Residents: The Missing Piece in Multidisciplinary Team Training

Importance

The human patient simulators that are currently used in multidisciplinary operating room team training scenarios cannot simulate surgical tasks because they lack a realistic surgical anatomy. Thus, they eliminate the surgeon's primary task in the operating room. The surgical trainee is presented with a significant barrier when he or she attempts to suspend disbelief and engage in the scenario.

Objective

To develop and test a simulation-based operating room team training strategy that challenges the communication abilities and teamwork competencies of surgeons while they are engaged in realistic operative maneuvers.

Design, Setting, and Participants

This pre-post educational intervention pilot study compared the gains in teamwork skills for midlevel surgical residents at Wake Forest Baptist Medical Center after they participated in a standardized multidisciplinary team training scenario with 3 possible levels of surgical realism: (1) SimMan (Laerdal) (control group, no surgical anatomy); (2) "synthetic anatomy for surgical tasks" mannequin (medium-fidelity anatomy), and (3) a patient simulated by a deceased donor (high-fidelity anatomy).

Interventions

Participation in the simulation scenario and the subsequent debriefing.

Main Outcomes and Measures

Teamwork competency was assessed using several instruments with extensive validity evidence, including the Nontechnical Skills assessment, the Trauma Management Skills scoring system, the Crisis Resource Management checklist, and a self-efficacy survey instrument. Participant satisfaction was assessed with a Likert-scale questionnaire.

Results

Scenario participants included midlevel surgical residents, anesthesia providers, scrub nurses, and circulating nurses. Statistical models showed that surgical residents exposed to medium-fidelity simulation (synthetic anatomy for surgical tasks) team training scenarios demonstrated greater gains in teamwork skills compared with control groups (SimMan) (Nontechnical Skills video score: 95% CI, 1.06-16.41; Trauma Management Skills video score: 95% CI, 0.61-2.90) and equivalent gains in teamwork skills compared with high-fidelity simulations (deceased donor) (Nontechnical Skills video score: 95% CI, -8.51 to 6.71; Trauma Management Skills video score: 95% CI, -1.70 to 0.49).

Conclusions and Relevance

Including a surgical task in operating room team training significantly enhanced the acquisition of teamwork skills among midlevel surgical residents. Incorporating relatively inexpensive, medium-fidelity synthetic anatomy in human patient simulators was as effective as using high-fidelity anatomies from deceased donors for promoting teamwork skills in this learning group.

Troubles du sommeil dans l’alcoolo-dépendance : intérêt de l’auto-évaluation ?

Les troubles du sommeil et l’alcoolo-dépendance (AD) sont deux comorbidités fréquemment associées dans les pathologies psychiatriques, telles que l’anxiété, la dépression, les troubles bipolaires ou la schizophrénie [1]. Depuis plusieurs années, les études conduites dans l’AD ont permis de mieux préciser les atteintes cognitives et cérébrales de ces patients [2]. Par ailleurs, certains résultats ont également souligné chez les AD la présence d’altérations du sommeil (36 à 72 % selon les études) qui seraient un facteur de risque de rechute [3]. En pratique clinique, l’évaluation du sommeil est principalement réalisée à l’aide de questionnaires, du fait de leur rapidité de passation et leur facilité d’analyse. L’objectif de cette étude est d’explorer les liens entre la plainte du sommeil évaluée à l’aide d’un autoquestionnaire nommé le « Pittsburg Sleep Quality Index » (PSQI) [4], les troubles cognitifs et les altérations cérébrales structurales des patients AD. Trente-neuf patients AD et 16 sujets sains recrutés au sein du protocole ALCOBRAIN ont été inclus dans la présente étude. Nos données indiquent que plus de 76 % des patients AD abstinents évoquent une plainte de sommeil. Les patients qui ne rapportent pas de plainte de sommeil présentent les troubles exécutifs les plus sévères. Par ailleurs, ces patients présenteraient également des altérations cérébrales plus importantes que ceux présentant une plainte de sommeil, notamment au sein de régions impliquées dans les capacités de métacognition. Ces résultats suggèrent qu’une forme infraclinique d’anosognosie pourrait être présente chez certains patients AD, entraînant une conscience partielle de leurs troubles du sommeil. En pratique clinique, il semble donc nécessaire de rester vigilant vis-à-vis de l’évaluation subjective du sommeil par le biais de questionnaires. Des études complémentaires sont nécessaires afin de préciser les liens entre sommeil, cognition et cerveau, notamment à l’aide de mesures objectives de la qualité du sommeil.

[Validation of a self assessment for speech disorders (Phonation Handicap Index)]

OBJECTIVE

The aim of this work is the psychometric validation of a self assessment questionnaire about speech in dysarthria.

MATERIALS AND METHODS

A prospective study was performed on 91 persons to analyze reliability and validity of this new questionnaire. It is composed of 25 items subdivided in 3 domains: Physical, functional and emotional. We first compared 17 normal speakers to 21 dysarthric patients. Then we analysed the intra-individual variability with 53 patients who completed the questionnaire twice with two weeks interval between the completion. The statistical analysis verified internal consistency of each item, intra-subject reliability was analyzed through Pearson test and clinical validity was calculated through the non parametric Mann Whitney test.

RESULTS

The internal consistency reliability was correct (Cronbach's alpha > 0.9). It appeared a statically significant difference between normal speakers and dysarthric patients (p < 0.05). The correlations to the handicap and severity felt were fair ensured us of the content's validity. However the absence of difference for 5 items drove us to eliminate them. Also, analysis the test / retest by the correlation matrix allowed to delete 5 other questions. The obtained total score was 0,861. As for the validity of contents, the correlations in the handicap and in the degree of severity felt by the dysarthric patients were satisfactory.

CONCLUSION

The results of this study allows to resume the validation of this questionnaire, its short form of 15 items is particularly adapted to dysarthric patients. It now remains to test its reliability with the medical evolution of the patients. We propose to name it "Phonation Handicap Index".

[The Voice Handicap Index: impact of the translation in French on the validation]

The aim of this prospective investigation was to validate a French version of the Voice Handicap Index (VHI). A population of 52 normal subjects and 63 patients with voice disorders replied to the questionnaire at the day of their first consultation and ten to thirty days after the consultation (before any treatment). Reproducing the methodology of the American authors, the test-retest reliability and the internal consistency reliability were measured. The validity and the sensibility related to a non dysphonic population were also analysed. Regarding the normal subjects, the maximum scores for total score and subscale scores were 20 (total), 12 (physical), 7 (functional), 6 (Emotional). These scores are statistically different when compared with pathological subjects (p < 0.00001). Test-Retest stability of the pathological subjects was found to be satisfactory for both total score and subscale scores (r > 0.87). From this data set, the critical difference scores were derived for the VHI total score (15 points), for the physical subscale (9 points) and for the functional and emotional.subscales (6 points each). As for as the internal consistency reliability, Cronbach's alpha is correct (r > 7) for the pathological subjects. Yet, the analysis of the validity reply by reply, reveals some abnormalities. In conclusion, the validity of the French translation of the VHI is confirmed but the results prompt us to improve the quality of the translation.

Production of phosphatidylinositol 3,4,5-trisphosphate and phosphatidic acid in platelet rafts: evidence for a critical role of cholesterol-enriched domains in human platelet activation

Glycosphingolipid- and cholesterol-enriched membrane microdomains, called rafts, can be isolated from several mammalian cells, including platelets. These microdomains appear to play a critical role in signal transduction in several hematopoietic cells, but their function in blood platelets remains unknown. Herein, we first characterized the lipid composition, including the fatty acid composition of phospholipids, of human platelet rafts. Then their role in platelet activation process was investigated. Interestingly, thrombin stimulation led to morphological changes of rafts correlating with the production of lipid second messengers in these microdomains. Indeed, we could demonstrate for the first time that a large part of the stimulation-dependent production of phosphatidic acid and phosphoinositide 3-kinase products was concentrated in rafts. Moreover, cholesterol depletion with methyl-beta-cyclodextrin disrupted platelet rafts, dramatically decreased the agonist-dependent production of these lipid signaling molecules, and impaired platelet secretion and aggregation. Cholesterol repletion restored the physiological platelet responses. Altogether our data indicate that rafts are highly dynamic platelet membrane structures involved in critical signaling mechanisms linked to the production of lipid second messengers. The demonstration of phosphatidylinositol 3,4,5-trisphosphate production in rafts may have general implications for the understanding of the role of this key second messenger found ubiquitously in higher eucaryotic cells.

Phosphoinositides: key players in cell signalling, in time and space

Over the last few years, many reports have extended our knowledge of the inositol lipid metabolism and brought out some exciting information about the location, the variety and the role of phosphoinositides (PIs). Besides the so-called "canonical PI pathway" leading to the production of phosphatidylinositol 4,5-bisphosphate (PtdIns(4,5)P2), the precursor of the intracellular second messengers inositol 1,4,5-trisphosphate and diacylglycerol (DAG), many other metabolic pathways have been identified to produce seven different polyphosphoinositides. Several of these quantitatively minor lipid molecules appear to be specifically involved in the control of cellular events, such as the spatial and temporal organisation of key signalling pathways, the rearrangement of the actin cytoskeleton or the intracellular vesicle trafficking. This is consistent with the fact that many of the enzymes, such as kinases and phosphatases, involved in the tight control of the intracellular level of polyphosphoinositides, are regulated and/or relocated through cell surface receptors for extracellular ligands. The remarkable feature of PIs, which can be rapidly synthesised and degraded in discrete membrane domains or even subnuclear structures, places them as ideal regulators and integrators of very dynamic mechanisms of cell regulation. In this review, we will summarise recent studies on the potential location, the metabolic pathways and the role of the different PIs. Some aspects of the temporal synthesis of D3 PIs will also be discussed.

The integrin alpha IIb/beta 3 in human platelet signal transduction

Platelets are critical for the maintenance of the integrity of the vascular system and are the first line of defence against haemorrhage. When they encounter a subendothelial matrix exposed by injury to a vessel, platelets adhere, are activated, and become adhesive for other platelets so that they aggregate. alpha IIb/beta 3, a platelet-specific integrin, is largely prominent amongst the adhesion receptors and is essential for platelet aggregation. The ligands for alpha IIb/beta 3 are the multivalent adhesive proteins fibrinogen and von Willebrand factor. In resting platelets, alpha IIb/beta 3 is normally in a low activation state, unable to interact with soluble fibrinogen. Stimulation of platelets with various agonists will induce a conformational change in alpha IIb/beta 3 (inside-out signalling), which is then able to bind soluble fibrinogen resulting in the onset of platelet aggregation. However, fibrinogen binding to its membrane receptor is not simply a passive event allowing the formation of intercellular bridges between platelets. Indeed, a complex signalling pathway triggered by integrin ligation and clustering (outside-in signalling) will regulate the extent of irreversible platelet aggregation and clot retraction. Amongst the signalling enzymes activated downstream of alpha IIb/beta 3 engagement, phosphoinositide 3-kinase plays an important role in the control of the irreversible phase of aggregation.

Myotubularin, a phosphatase deficient in myotubular myopathy, acts on phosphatidylinositol 3-kinase and phosphatidylinositol 3-phosphate pathway

Myotubular myopathy (MTM1) is an X-linked disease, characterized by severe neonatal hypotonia and generalized muscle weakness, with pathological features suggesting an impairment in maturation of muscle fibres. The MTM1 gene encodes a protein (myotubularin) with a phosphotyrosine phosphatase consensus. It defines a family of at least nine genes in man, including the antiphosphatase hMTMR5/Sbf1 and hMTMR2, recently found mutated in a recessive form of Charcot-Marie-Tooth disease. Myotubularin shows a dual specificity protein phosphatase activity in vitro. We have performed an in vivo test of tyrosine phosphatase activity in Schizosaccharomyces pombe, indicating that myotubularin does not have a broad specificity tyrosine phosphatase activity. Expression of active human myotubularin inhibited growth of S.pombe and induced a vacuolar phenotype similar to that of mutants of the vacuolar protein sorting (VPS) pathway and notably of mutants of VPS34, a phosphatidylinositol 3-kinase (PI3K). In S.pombe cells deleted for the endogenous MTM homologous gene, expression of human myotubularin decreased the level of phosphatidylinositol 3-phosphate (PI3P). We have created a substrate trap mutant which shows relocalization to plasma membrane projections (spikes) in HeLa cells and was inactive in the S.pombe assay. This mutant, but not the wild-type or a phosphatase site mutant, was able to immunoprecipitate a VPS34 kinase activity. Wild-type myotubularin was also able to directly dephosphorylate PI3P and PI4P in vitro. Myotubularin may thus decrease PI3P levels by down-regulating PI3K activity and by directly degrading PI3P.

pp60c-src associates with the SH2-containing inositol-5-phosphatase SHIP1 and is involved in its tyrosine phosphorylation downstream of alphaIIbbeta3 integrin in human platelets

SH2-containing inositol-5-phosphatase 1 (SHIP1) was originally identified as a 145 kDa protein that became tyrosine-phosphorylated in response to multiple cytokines. It is now well established that SHIP1 is specifically expressed in haemopoietic cells and is important as a negative regulator of signalling. We found recently that SHIP1 was present in human blood platelets as an Ins(1,3,4, 5)P(4)-phosphatase and a PtdIns(3,4,5)P(3)-5-phosphatase that became tyrosine-phosphorylated and was relocated to the cytoskeleton in an integrin-dependent manner. Here we report biochemical and pharmacological evidence that the tyrosine kinase pp60(c-src) is constitutively associated with SHIP1 and is involved in its tyrosine phosphorylation downstream of integrin engagement in thrombin-activated human platelets. The use of cytochalasin D allowed us to demonstrate that the actin cytoskeleton reorganization induced on thrombin stimulation was not required for its integrin-mediated phosphorylation. Moreover, the integrin-dependent relocation of SHIP1 to the cytoskeleton did not require its tyrosine phosphorylation. These results suggest that SHIP1 is first recruited to the integrin-linked signalling complexes and then becomes tyrosine-phosphorylated through a Src-kinase-dependent mechanism but independently of the actin cytoskeleton reorganization.

Amino acid sequence and embryonic expression of msr/apj, the mouse homolog of Xenopus X-msr and human APJ

We have recently identified a new G protein-coupled receptor, X-msr, whose expression is associated with the endothelial lineage in Xenopus laevis (Devic, E., Paquereau, L., Vernier, P., Knibiehler, B., Audigier, Y., 1996. Expression of a new G protein-coupled receptor X-msr is associated with an endothelial lineage in Xenopus laevis. Mech. Dev. 59, 129-140). Based on its structural analogy to the human orphan receptor APJ, we cloned the murine msr/apj receptor and analyzed its expression in developing tissues. As observed for X-msr, msr/apj transcripts are detected in the endothelium of the primary blood vessels and the forming heart. In addition, they are expressed in somites, limb bud and branchial arches. This expression pattern is distinct from that of the Flk1 gene and suggests that the msr/apj gene is expressed in a subpopulation of endothelial precursors and a mesenchymal population derived from paraaxial mesoderm.

[Expression of a new family of receptors similar to CXC chemokine receptors in endothelial cell precursors]

Characterization of a new family of G protein-coupled receptors is reported. Expression of these receptors is associated with endothelial lineage. Cloning of the Xenope X-msr receptor allowed to show that embryonic expression of this receptor occurred in the heart and developing primary blood vessels. Furthermore, within these cardiovascular structures, expression was restricted to the endothelial layer. Because structural similarities with the human orphan receptor h-APJ were found, the msr/apj receptor was cloned in mice. This showed that embryonic expression of this receptor was also confirmed to endothelial precursors. Thus, this receptor is the orthological equivalent in mice to the amphibian receptor X-msr. Molecular phylogenesis studies showed that the X-msr, msr/apj, and h-APJ receptors shared considerable homology with two CXC chemokine receptors, namely LCR1, whose name was recently changed to CXCR4, and RDC1, which is structurally similar to the CXCR2 receptor. The human h-APJ receptor is a co-receptor for entry of the HIV into T cells, a property associated only with CXC chemokine receptors in the lymphocyte population. These data suggest that this new signaling system may participate in endothelial precursor migration during developmental angiogenesis and in endothelial cell migration and proliferation during neoangiogenesis in adults.

JCAHO educational strategies that work! Joint Commission on Accreditation of Healthcare Organizations

Preparing a large hospital for a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey is always a challenging endeavor. Because staff members have diverse learning needs it is important that staff be educated in the JCAHO standards. In this article, the author describes the educational strategies used to prepare a healthcare organization for an impending JCAHO survey. Learning styles, the domains of learning, and the accessibility to education by the satellite facilities were determining factors in the selection of the various educational strategies.

Joint Commission preparation in a large academic medical center: a framework for success

A large urban university medical center used a unique set of strategies in preparation for its triennial survey conducted by the Joint Commission on Accreditation of Healthcare Organizations. Although the medical center had experienced many Joint Commission surveys, this particular survey was the first to include associated physician offices in multiple diverse settings. To address these challenges, the hospital developed a structure and process that engaged all levels of staff and ensured a successful survey outcome.