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Background: Streptococcus pneumoniae is a common pathogen associated with bloodstream infections, respiratory infections, peritonitis, infective endocarditis, and meningitis. Literature assessing duration of antibiotic therapy for a S pneumoniae bacteremia secondary to common infection is scarce, leading to variability in practice. Therefore, this study evaluated the effectiveness of short (5-10 days) versus long (11-16 days) antibiotic durations for S pneumoniae bacteremia. Methods: This retrospective, single-center cohort study assessed hospitalized patients with S pneumoniae-positive blood cultures, who received active antibiotics within 48 hours of first positive blood culture collection and achieved clinical stability by day 10 of the first positive blood culture collection. Exclusion criteria included treatment duration <5 or >16 days, death before completion of 10 days of therapy, polymicrobial bloodstream infection, and invasive infection. Rates of clinical failure (composite of 30-day hospital readmission, bacteremia recurrence, and mortality) were compared between the groups. Results: A total of 162 patients were included, with 51 patients in the short- and 111 patients in the long-duration group. Pneumonia was the suspected source of bacteremia in 90.1% of patients. Rates of clinical failure were not significantly different between the 2 groups. Patients received a median antibiotic course of 7 days in the short group compared to 14 days in the long group; however, there was no significant difference observed in the median hospital length of stay, median intensive care unit length of stay, or rate of Clostridioides difficile infection. Conclusions: Shorter antibiotic courses may be appropriate in patients with S pneumoniae bacteremia secondary to community-acquired pneumonia.

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Transplant patients are at risk of infections due to long-term immunosuppression contributing to morbidity and mortality in this population. Post-transplant testing guidelines were established to monitor and guide therapeutic interventions in transplant recipients. We hypothesize that there are gaps in adherence to the recommended frequency of laboratory testing in post-transplant patients. We analyzed national reference laboratory data to compare viral post-transplant infection (PTI) testing frequency with their respective published guidelines to understand patient uptake and compliance. We evaluated the ordering patterns, positivity rates, and frequency of molecular infectious disease tests (MIDTs). We included 345 patients with International Classification of Diseases (ICD)-10 codes for transplant (Z940-Z942, Z944, Z9481, Z9483, Z9484) with at least two tests (within 7 days) in January 2019 and at least one test in December 2020 to find patients in the post-transplant period. We analyzed two cohorts: kidney transplant recipients (KTRs; 40%) and non-KTR (60%) then followed them longitudinally for the study period. In KTR cohort, high-to-low proportion of ordered MIDT was blood BK virus (bBKV) followed by cytomegalovirus (CMV); in non-KTR cohort, CMV was followed by Epstein-Barr virus (EBV). KTR cohort positivity was highest for urine BK virus (uBKV; 58%) followed by EBV (46%), bBKV (40%), and CMV (31%). Non-KTR cohort positivity was highest for uBKV (64%), EBV (51%), CMV (30%), bBKV (8%), and adenovirus (7%). All patients were tested at progressively longer intervals from the date of the first post-transplant ICD-10-coded test. More than 40% of the KTR cohort were tested less frequently for EBV and bBKV, and more than 20% of the non-KTR cohort were tested for EBV less frequently than published guidelines 4 months after transplant. Despite regular testing, the results of MIDT testing for KTR and non-KTR patients in the post-transplant period are not aligned with published guidelines.IMPORTANCEGuidance for post-transplant infectious disease testing is established, however, for certain infections it allows for clinician discretion. This leads to transplant center policies developing their own testing/surveillance strategies based on their specific transplant patient population (kidney, stem cell, etc.). The Organ Procurement and Transplant Network (OPTN) has developed a strategic plan to improve and standardize the transplant process in the US to improve outcomes of living donors and recipients. Publishing national reference lab data on the testing frequency and its alignment with the recommended guidelines for post-transplant infectious diseases can inform patient uptake and compliance for these strategic OPTN efforts.

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OBJECTIVE: Emergency department thoracotomy (EDT) is an uncommon but potentially lifesaving procedure that warrants familiarity with anatomy, instruments, and indications necessary for completion. To address this need, we developed a low-cost EDT trainer. The primary objective of this study was to compare the effectiveness of a low-cost EDT trainer to teach emergency department thoracotomy with a discussion-based teaching session. Secondary objective was to study the face validity of the low-cost EDT trainer. DESIGN: A prospective 2-phase randomized control study was conducted. Participants were randomly divided into two groups. In phase one, baseline medical knowledge for both groups was assessed using a multiple-choice question pretest. In Group 1, each participant was taught EDT using a one-on-one discussion with a trauma surgeon, whereas Group 2 used the EDT trainer and debriefing for training. In phase 2 (1 month later), all participants completed a knowledge retention test and performed a videoed EDT using our EDT trainer, the video recordings were later reviewed by content experts blinded to the study participants using a checklist with a maximum score of 22. The participants also completed a reaction survey at the end of phase 2 of the study. SETTING: OhioHealth Riverside Methodist Hospital, an urban tertiary care academic hospital in Columbus, Ohio. PARTICIPANTS: Nine senior surgery residents from training years 3 to 5. RESULTS: The mean score for the performance of the procedure for the simulation-based (Group 2) was significantly higher than that of the discussion-based (Group 1) (Rater 1: 21.2 ± 0.8 vs. 19.0 ± 2.0, p = 0.05, Rater 2: 20.4 ± 1.5 vs. 18.3±1.0, p = 0.04). Group 2 also was quicker than Group 1 in deciding to start the procedure by approximately 56 seconds. When comparing the mean pretest knowledge score to the mean knowledge retention score 30 days after training, the discussion-based group improved from 58.33% to 81.25% (p = 0.01); the simulation-trained group's scores remained at 68.33%. All the participants agreed or strongly agreed that the simulator provided a realistic opportunity to perform EDT and improved their confidence. CONCLUSIONS: The results of this pilot study support our hypothesis that using a low-cost EDT trainer effectively improves general surgery residents' confidence and procedural skills scores in a simulated environment. Further training with low-cost simulators may provide surgical residents with deliberate practice opportunities and improve performance when learning low-frequency procedures.

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Cyclin-dependent kinases (CDK) regulate cell cycle and transcriptional activity. Pan-CDK inhibitors demonstrated early efficacy in lymphoid malignancies, but also have been associated with narrow therapeutic index. Among transcriptional CDKs, CDK7 and CDK9 emerged as promising targets. CDK9 serves as a component of P-TEFb elongation complex and thus is indispensable in mRNA transcription. Selective CDK9 inhibitors demonstrated pre-clinical efficacy in in vitro and in vivo models of B-cell non-Hodgkin lymphoma. CDK9 inhibition results in transcriptional pausing with rapid downmodulation of short-lived oncogenic proteins, e.g. Myc and Mcl-1, followed by cell apoptosis. Early phase clinical trials established safety of CDK9 inhibitors, with manageable neutropenia, infections and gastrointestinal toxicities. In this review, we summarize the rationale of targeting CDK9 in lymphoid malignancies, as well as pre-clinical and early clinical data with pan-CDK and selective CDK9 inhibitors.

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Diffuse large B-cell lymphoma (DLBCL) exhibits significant genetic heterogeneity which contributes to drug resistance, necessitating development of novel therapeutic approaches. Pharmacological inhibitors of cyclin-dependent kinases (CDK) demonstrated pre-clinical activity in DLBCL, however many stalled in clinical development. Here we show that AZD4573, a selective inhibitor of CDK9, restricted growth of DLBCL cells. CDK9 inhibition (CDK9i) resulted in rapid changes in the transcriptome and proteome, with downmodulation of multiple oncoproteins (eg, MYC, Mcl-1, JunB, PIM3) and deregulation of phosphoinotiside-3 kinase (PI3K) and senescence pathways. Following initial transcriptional repression due to RNAPII pausing, we observed transcriptional recovery of several oncogenes, including MYC and PIM3. ATAC-Seq and ChIP-Seq experiments revealed that CDK9i induced epigenetic remodeling with bi-directional changes in chromatin accessibility, suppressed promoter activation and led to sustained reprograming of the super-enhancer landscape. A CRISPR library screen suggested that SE-associated genes in the Mediator complex, as well as AKT1, confer resistance to CDK9i. Consistent with this, sgRNA-mediated knockout of MED12 sensitized cells to CDK9i. Informed by our mechanistic findings, we combined AZD4573 with either PIM kinase or PI3K inhibitors. Both combinations decreased proliferation and induced apoptosis in DLBCL and primary lymphoma cells in vitro as well as resulted in delayed tumor progression and extended survival of mice xenografted with DLBCL in vivo. Thus, CDK9i induces reprogramming of the epigenetic landscape, and super-enhancer driven recovery of select oncogenes may contribute to resistance to CDK9i. PIM and PI3K represent potential targets to circumvent resistance to CDK9i in the heterogeneous landscape of DLBCL.

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Epidemiological studies suggest cigarette smoking as a probable environmental factor for a variety of congenital anomalies, including low bone mass, increased fracture risk and poor skeletal health. Human and animal in vitro models have confirmed hypomineralization of differentiating cell lines with sidestream smoke being more harmful to developing cells than mainstream smoke. Furthermore, first reports are emerging to suggest a differential impact of conventional versus harm-reduction tobacco products on bone tissue as it develops in the embryo or in vitro. To gather first insight into the molecular mechanism of such differences, we assessed the effect of sidestream smoke solutions from Camel (conventional) and Camel Blue (harm-reduction) cigarettes using a human embryonic stem cell osteogenic differentiation model. Sidestream smoke from the conventional Camel cigarettes concentration-dependently inhibited in vitro calcification triggered by high levels of mitochondrially generated oxidative stress, loss of mitochondrial membrane potential, and reduced ATP production. Camel sidestream smoke also induced DNA damage and caspase 9-dependent apoptosis. Camel Blue-exposed cells, in contrast, invoked only intermediate levels of reactive oxygen species insufficient to activate caspase 3/7. Despite the absence of apoptotic gene activation, damage to the mitochondrial phenotype was still noted concomitant with activation of an anti-inflammatory gene signature and inhibited mineralization. Collectively, the presented findings in differentiating pluripotent stem cells imply that embryos may exhibit low bone mineral density if exposed to environmental smoke during development.

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Background: Antibiotic exposure is a primary predictor of subsequent antibiotic resistance; however, development of cross-resistance between antibiotic classes is also observed. The impact of changing to a different antibiotic from that of previous exposure is not established. Methods: This was a retrospective, single-center cohort study of hospitalized adult patients previously exposed to an antipseudomonal ß-lactam (APBL) for at least 48 hours in the 90 days prior to the index infection with a gram-negative bloodstream or respiratory infection. Susceptibility rates to empiric therapy were compared between patients receiving the same (repeat group) versus a different antibiotic from prior exposure (change group). Results: A total of 197 patients were included (n = 94 [repeat group] and n = 103 [change group]). Pathogen susceptibility to empiric therapy was higher in the repeat group compared to the change group (76.6% vs 60.2%; P = .014). After multivariable logistic regression, repeat APBL was associated with an increased likelihood of pathogen susceptibility (adjusted odds ratio, 2.513; P = .012). In contrast, there was no difference in susceptibility rates between the repeat group and the subgroup of change patients who received an empiric APBL (76.6% vs 78.5%; P = .900). Longer APBL exposure duration (P = .012) and chronic kidney disease (P = .002) were associated with higher nonsusceptibility to the exposure APBL. In-hospital mortality was not significantly different between the repeat and change groups (18.1% vs 23.3%; P = .368). Conclusions: The common practice of changing to a different APBL from that of recent exposure may not be warranted.

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Objectives: Knowledge, attitude, and practices (KAP) have been widely used during times of pandemic to quantify and locate gaps of care during pandemics. Using this tool, we can identify and target populations who underwent solid organ transplant (SOT) to bolster preventative practices in these patients during COVID-19. Materials and methods: An institution-based cross-sectional study was conducted between June 1, 2020 and June 30, 2021 on patients who underwent a liver and/or kidney transplant at Methodist Dallas Medical Center in Dallas, Texas, USA. A KAP questionnaire of 26 questions about COVID-19 was designed based on the clinical and community management guidelines published by the WHO. The participant's overall KAP was categorized using Bloom's cut-off point. A KAP domain was considered sufficient if the score was between 60 and 100% and insufficient if the score was <60%. The strength of association was assessed by using odds ratio (OR); only significant independent factors in each tested area were assessed. Results: Respondents with children in the household were less likely to have sufficient practices than those who did not [OR = 0.2491, 95% Confidence Interval (0.0893-0.6120), p = 0.001]. We also found that sufficient levels of knowledge correlated with higher likelihood of sufficient levels of practices [OR = 4.94, 95% CI (1.646-14.2159), p < 0.005]. Interestingly, we found that sufficient levels of attitude did not correlate with sufficient levels of practice (p = 0.201). Conclusion: Our study found that knowledge and having children in the household correlated with higher levels of practice.

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Pulmonary diseases alter lung mechanical properties, can cause loss of function, and necessitate use of mechanical ventilation, which can be detrimental. Investigations of lung tissue (local) scale mechanical properties are sparse compared to that of the whole organ (global) level, despite connections between regional strain injury and ventilation. We examine ex vivo mouse lung mechanics by investigating strain values, local compliance, tissue surface heterogeneity, and strain evolutionary behavior for various inflation rates and volumes. A custom electromechanical, pressure-volume ventilator is coupled with digital image correlation to measure regional lung strains and associate local to global mechanics by analyzing novel pressure-strain evolutionary measures. Mean strains at 5 breaths per minute (BPM) for applied volumes of 0.3, 0.5, and 0.7 ml are 5.0, 7.8, and 11.3%, respectively, and 4.7, 8.8, and 12.2% for 20 BPM. Similarly, maximum strains among all rate and volume combinations range 10.7%-22.4%. Strain values (mean, range, mode, and maximum) at peak inflation often exhibit significant volume dependencies. Additionally, select evolutionary behavior (e.g., local lung compliance quantification) and tissue heterogeneity show significant volume dependence. Rate dependencies are generally found to be insignificant; however, strain values and surface lobe heterogeneity tend to increase with increasing rates. By quantifying strain evolutionary behavior in relation to pressure-volume measures, we associate time-continuous local to global mouse lung mechanics for the first time and further examine the role of volume and rate dependency. The interplay of multiscale deformations evaluated in this work can offer insights for clinical applications, such as ventilator-induced lung injury.

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Lung cancer is the leading cause of cancer-related deaths worldwide, with increased risk being associated with unresolved or chronic inflammation. Agricultural and livestock workers endure significant exposure to agricultural dusts on a routine basis; however, the chronic inflammatory and carcinogenic effects of these dust exposure is unclear. We have developed a chronic dust exposure model of lung carcinogenesis in which mice were intranasally challenged three times a week for 24 weeks, using an aqueous dust extract (HDE) made from dust collected in swine confinement facilities. We also treated mice with the omega-3-fatty acid lipid mediator, aspirin-triggered resolvin D1 (AT-RvD1) to provide a novel therapeutic strategy for mitigating the inflammatory and carcinogenic effects of HDE. Exposure to HDE resulted in significant immune cell influx into the lungs, enhanced lung tumorigenesis, severe tissue pathogenesis, and a pro-inflammatory and carcinogenic gene signature, relative to saline-exposed mice. AT-RvD1 treatment mitigated the dust-induced inflammatory response but did not protect against HDE + NNK-enhanced tumorigenesis. Our data suggest that chronic HDE exposure induces a significant inflammatory and pro-carcinogenic response, whereas treatment with AT-RvD1 dampens the inflammatory responses, providing a strong argument for the therapeutic use of AT-RvD1 to mitigate chronic inflammation.

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Agricultural workers are at risk for the development of acute and chronic lung diseases due to their exposure to organic agricultural dusts. A diet intervention using the omega-3 fatty acid docosahexaenoic acid (DHA) has been shown to be an effective therapeutic approach for alleviating a dust-induced inflammatory response. We thus hypothesized a high-DHA diet would alter the dust-induced inflammatory response through the increased production of specialized pro-resolving mediators (SPMs). Mice were pre-treated with a DHA-rich diet 4 weeks before being intranasally challenged with a single dose of an extract made from dust collected from a concentrated swine feeding operation (HDE). This omega-3-fatty-acid-rich diet led to reduced arachidonic acid levels in the blood, enhanced macrophage recruitment, and increased the production of the DHA-derived SPM Resolvin D1 (RvD1) in the lung following HDE exposure. An assessment of transcript-level changes in the immune response demonstrated significant differences in immune pathway activation and alterations of numerous macrophage-associated genes among HDE-challenged mice fed a high DHA diet. Our data indicate that consuming a DHA-rich diet leads to the enhanced production of SPMs during an acute inflammatory challenge to dust, supporting a role for dietary DHA supplementation as a potential therapeutic strategy for reducing dust-induced lung inflammation.

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These updated AST-IDCOP guidelines review the epidemiology, diagnosis, and management of emerging fungi after organ transplantation. Infections due to numerous generally innocuous fungi are increasingly recognized in solid organ transplant (SOT) recipients, comprising about 7%-10% of fungal infections in this setting. Such infections are collectively referred to as emerging fungal infections and include Mucormycetes, Fusarium, Scedosporium, and dematiaceous fungi among others. The causative organisms are diverse in their pathophysiology, uncommon in the clinical setting, have evolving nomenclature, and are often resistant to multiple commonly used antifungal agents. In recent years significant advances have been made in understanding of the epidemiology of these emerging fungal infections, with improved diagnosis and expanded treatment options. Still, treatment guidelines are generally informed by and limited to experience from cohorts of patients with hematological malignancies and/or solid and stem cell transplants. While multicenter randomized controlled trials are not feasible for these uncommon infections in SOT recipients, collaborative prospective studies can be valuable in providing information on the epidemiology, clinical manifestations, treatment strategies, and outcomes associated with the more commonly encountered infections.

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BACKGROUND: There is a critical relationship between team communication and patient safety in the operating room (OR), but limited opportunities are available to help OR trainees develop the communication skills needed to be good team players. The purpose of this study was to evaluate the effectiveness of a simulation-based communication-training program developed for general surgery and obstetrics and gynecology residents. METHODS: Following a group lecture on diagnostic laparoscopy, 34 residents independently completed a laparoscopy case on a patient simulator followed by a structured debrief that targeted team-based communication skills. Integrated into the case were 2 events (bradycardia and OR fire) that provided additional opportunities for the resident to communicate with his/her team. The mean Likert scale score for 11 post-training survey questions were calculated to determine residents' reaction to the training. Additionally, mean scores of observer ratings of communication performance after the simulation were calculated and analyzed using separate Wilcoxon Sign-Rank tests and kappa statistics. RESULTS: Of the 41 GS and ObGyn residents, 34 (83%) participated in the training. 18 (53%) residents completed the simulation once and 16 (47%) completed it twice. Overall, residents had a positive reaction to the training program (average survey score = 4.56 of 5) and participation in the program improved their ability to use effective communication techniques during the bradycardia and OR fire events (p < 0.05, κ = 0.61). CONCLUSIONS: Residents had a positive reaction to the training program and participation in the program improved their ability to use effective communication techniques throughout the procedure.

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Emergence of tumor resistance to an anti-cancer therapy directed against a putative target raises several questions including: (1) do mutations in the target/pathway confer resistance? (2) Are these mutations pre-existing? (3) What is the relative fitness of cells with/without the mutation? We addressed these questions in patients with metastatic colorectal cancer (mCRC). We conducted an exhaustive review of published data to establish a median doubling time for CRCs and stained a cohort of CRCs to document mitotic indices. We analyzed published data and our own data to calculate rates of growth (g) and regression (d, decay) of tumors in patients with CRC correlating these results with the detection of circulating MT-KRAS DNA. Additionally we estimated mathematically the caloric burden of such tumors using data on mitotic and apoptotic indices. We conclude outgrowth of cells harboring intrinsic or acquired MT-KRAS cannot explain resistance to anti-EGFR (epidermal growth factor receptor) antibodies. Rates of tumor growth with panitumumab are unaffected by presence/absence of MT-KRAS. While MT-KRAS cells may be resistant to anti-EGFR antibodies, WT-KRAS cells also rapidly bypass this blockade suggesting inherent resistance mechanisms are responsible and a neutral evolution model is most appropriate. Using the above clinical data on tumor doubling times and mitotic and apoptotic indices we estimated the caloric intake required to support tumor growth and suggest it may explain in part cancer-associated cachexia.

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BACKGROUND: Recent healthcare policy changes have emphasized pay-for-performance. Previous studies have not examined outcome differences between primary presenting appendicitis patients and transferred patients. METHODS: A retrospective cohort design examined appendicitis patients between March 2011 and 2013. Patients < age 18, were scheduled for an elective appendectomy, who were pregnant or had an interval appendectomy were excluded. RESULTS: The transfer cohort (n = 59) had more comorbidities, more severe American Society of Anesthesiologists status, a higher rate of pre-operative abscess/rupture as well as higher rates of perforation, gangrene, intra-operative drain placement and open conversion versus primary presenting patients (n = 622). After statistical regression adjustment, a higher open conversion rate in the transfer cohort, OR = 3.48 (95%CI: 1.04-11.61) and higher total costs $672.47 (95%CI: $68.75-$1276.19) remained. CONCLUSIONS: Adjustments in clinical outcome/reimbursement metrics may be needed to address the complexity of transfers and the subsequent higher in-hospital costs on tertiary facilities. LEVEL OF EVIDENCE: IV.

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BACKGROUND: Current surgical education relies on simulated educational experiences or didactic sessions to teach low-frequency clinical events such as abdominal compartment syndrome (ACS). The purpose of this pilot study was to evaluate if simulation would improve performance and knowledge retention of ACS better than a didactic lecture. METHODS: Nineteen general surgery residents were block randomized by postgraduate year level to a didactic or a simulation session. After 3 months, all residents completed a knowledge assessment before participating in an additional simulation. Two independent reviewers assessed resident performance via audio-video recordings. RESULTS: No baseline differences in ACS experience were noted between groups. The observational evaluation demonstrated a significant difference in performance between the didactic and simulation groups: 9.9 vs 12.5, P = .037 (effect size = 1.15). Knowledge retention was equivalent between groups. CONCLUSIONS: This pilot study suggests that simulation-based education may be more effective for teaching the basic concepts of ACS.

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OBJETIVOS: Auditar la calidad de la atención brindada por nuestra consulta externa (CE) de Cuidados Paliativos (CP) tras su creación mediante la incorporación de un modelo de trabajo de cuidados paliativos precoces (CPP), y comparar nuestra experiencia con la recogida en la literatura. MATERIAL Y MÉTODOS: Presentamos un estudio descriptivo observacional retrospectivo en el que analizamos a 100 pacientes consecutivos con cáncer avanzado atendidos en nuestra CE en 2013. Se analizan los casos a través de 20 variables seleccionadas por consenso, y agrupadas en 6 categorías (datos demográficos [2], datos del tumor [1], derivación a CE [1], diagnósticos clínicos CE [6], datos de actividad CE [7], datos de impacto CE [3]). RESULTADOS: La edad media de los pacientes atendidos fue de 75 años, y el 38% padecía cáncer de pulmón. Un 17% de los pacientes cumplía criterios completos de CPP y otro 26%, criterios parciales. Tan solo un 33% de los pacientes cumplía criterios tradicionales de cáncer en situación terminal. Se han detectado diagnósticos clínicos novedosos en la muestra: hipovitaminosis D 35%, insuficiencia suprarrenal 18%, hipogonadismo 5%, encefalopatía quimioterápica y rádica 4%, conductas aberrantes asociadas al consumo de opioides 2%. Los pacientes precisaron una media de 3,5 visitas a la CE y 1,14 revisiones telefónicas, y la supervivencia media hasta el fallecimiento fue de 3,7 meses. Los pacientes derivados en tratamiento con quimioterapia (QTP) que cumplían criterios completos de CPP precisaron de más revisiones presenciales (media 6,12), y presentaron una supervivencia media de 7,7 meses. El 82% de los pacientes precisó de procedimientos diagnósticos o terapéuticos de ámbito hospitalario y el 31% recibió radioterapia paliativa. Dos tercios de los pacientes precisaron de ingreso en las camas de la Unidad de Cuidados Paliativos de agudos en algún momento en su evolución, y la mayoría fallecieron en la misma (44 pacientes para 56 fallecimientos). El número de visitas a Urgencias en el último mes de vida fue bajo (39 visitas para 56 pacientes), siendo bajo también el número de pacientes tratados con QTP en el último mes de vida (5,3%). DISCUSIÓN: El análisis no estadístico sugiere que la CE atiende a una población de procedencia y supervivencia variadas, pero con la característica común de una elevada complejidad en sus necesidades paliativas. Los datos preliminares no contradicen la hipótesis vigente, que afirma que los CPP pueden generar ahorros en el gasto sanitario. CONCLUSIONES: Nuestra experiencia inicial con una CE de CP sugiere que la aplicación de los CPP es posible en nuestro entorno. Por otro lado, nuestros resultados preliminares no parecen poner en tela de juicio ninguno de los posibles beneficios ya conocidos con la implementación de los novedosos programas de CPP

OBJECTIVE: To audit the quality of care delivered in our Outpatient Clinic (OC) after its inception following an early palliative care (EPC) model, and to compare our experience with the relevant literature. MATERIAL AND METHODS: A descriptive observational retrospective study was conducted on 100 consecutive advanced cancer patients who attended our OC in 2013. The cases are analyzed using 20 variables selected by consensus, and grouped into 6 categories (demographics [2], primary tumor [1], access to OC [1], OC clinical diagnoses [6], OC activity [7], impact [3]) RESULTS: The mean age of the patients was 75 years, and 38% suffered from lung cancer. EPC criteria were completely fulfilled by 17%, and a further 26% partially fulfilled them. Only 33% of the patients would be considered traditional terminal cancer PATIENTS: Emerging clinical diagnoses were found in the sample: vitamin D deficiency 35%, adrenal insufficiency 18%, hypogonadism 5%, chemotherapy and radiotherapy induced encephalopathy 4%, aberrant opioid related behaviors 2%. The average number of visits to the OC was 3.5, plus an average of 1.14 telephone consultations, and the median follow-up among patients who died was 3.7 months. Patients on chemotherapy (CTP) who completely fulfilled EPC criteria had a higher average number of visits (6.12), and survived longer until death (7.7) months.complex hospital diagnostic and therapeutic procedures were required in 82% of the patients, and 31% received palliative radiotherapy. Two thirds of the patients were admitted to the inpatient acute Palliative Care Unit at any given point during follow-up, and the majority died in the Unit beds (44 patients out of 56 deaths). The number of visits to the emergency department within 30 days of death was low (39 visits for 56 patients), and CTP within 30 days of death was also low (5.3%). DISCUSSION: The non-statistical analysis suggests that the OC attends a population with a varied survival and origin, but with the common characteristics of complex palliative care needs. Our preliminary data do not contradict current hypothesis suggesting that EPC might be cost saving. CONCLUSIONS: Our initial experience with an OC suggests that an EPC model is feasible in our own environment. On the other hand, our preliminary data does not fail to support the potential benefits associated with the implementation of EPC

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OBJECTIVE: Simulation is a technique recommended for teaching and measuring teamwork, but few published methodologies are available on how best to design simulation for teamwork training in surgery and health care in general. The purpose of this article is to describe a general methodology, called event-based approach to training (EBAT), to guide the design of simulation for teamwork training and discuss its application to surgery. DESIGN: The EBAT methodology draws on the science of training by systematically introducing training exercise events that are linked to training requirements (i.e., competencies being trained and learning objectives) and performance assessment. The EBAT process involves: RESULTS: Of the 4 teamwork competencies endorsed by the Agency for Healthcare Research Quality and Department of Defense, "communication" was chosen to be the focus of our training efforts. A total of 5 learning objectives were defined based on 5 validated teamwork and communication techniques. Diagnostic laparoscopy was chosen as the clinical context to frame the training scenario, and 29 KSAs were defined based on review of published literature on patient safety and input from subject matter experts. Critical events included those that correspond to a specific phase in the normal flow of a surgical procedure as well as clinical events that may occur when performing the operation. Similar to the targeted KSAs, targeted responses to the critical events were developed based on existing literature and gathering input from content experts. Finally, a 29-item EBAT-derived checklist was created to assess communication performance. CONCLUSION: Like any instructional tool, simulation is only effective if it is designed and implemented appropriately. It is recognized that the effectiveness of simulation depends on whether (1) it is built upon a theoretical framework, (2) it uses preplanned structured exercises or events to allow learners the opportunity to exhibit the targeted KSAs, (3) it assesses performance, and (4) it provides formative and constructive feedback to bridge the gap between the learners' KSAs and the targeted KSAs. The EBAT methodology guides the design of simulation that incorporates these 4 features and, thus, enhances training effectiveness with simulation.

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OBJECTIVE: Failures in nontechnical skills (NTS) rather than technical expertise are frequently at the root of medical errors in the operating room (OR). NTS are the cognitive (decision making and situation awareness) and interpersonal (communication and teamwork) skills that are recognized but are not formally addressed in surgical training. The purpose of the study was to examine the effect of simulation-based training (SBT) on NTS performance of surgical residents during simulated laparoscopic cholecystectomy (LC). SETTING: The study was performed in a simulated OR at the Center for Medical Education and Innovation at Riverside Methodist Hospital, Columbus, OH. The simulated OR was arranged with standard equipment for LC, a high-fidelity patient simulator, and a real OR team. DESIGN: General surgical residents completed 2 identical SBT sessions. For each session, residents were briefed on the LC case, completed the case in the simulated OR, and debriefed their videotaped simulation performance with a content expert. The video recordings were reviewed and the residents' NTS were scored using a perioperative time-out checklist and an intraoperative checklist for LC by 4 raters who were blinded to both the residents' postgraduate year level and the order of the videotaped simulation sessions. RESULTS: Residents showed a significant improvement in completeness of the perioperative time-out checklist from session 1 (mean score = 1.27 ± 1.00) to session 2 (mean score = 5.00 ± 1.28), p < 0.001. Residents' scores on the intraoperative checklist also improved from session 1 to session 2, p < 0.05. Overall, residents felt that the simulation was a valuable teaching and training tool and recommend that it be incorporated into residency training. CONCLUSION: SBT appears to be an effective technique for improving NTS of surgical residents during the perioperative and intraoperative phases of surgery. As surgical proficiency is 75% nontechnical and 25% technical, it could be reasonably argued that improved NTS of surgeons could improve surgical outcomes.

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BACKGROUND: The Organ Procurement Transplant Network Disease Transmission Advisory Committee (DTAC), a multidisciplinary committee, evaluates potential donor-derived transmission events (PDDTE), including infections and malignancies, to assess for donor transmitted events. METHODS: Reports of unexpected PDDTE to Organ Procurement Transplant Network in 2013 were fully reviewed by DTAC. A standardized algorithm was used to assess each PDDTE from a given donor and to classify each individual recipient from that donor. RESULTS: Of 443 total PDDTE submitted, 159 were triaged and not sent out to the full DTAC. Of 284 fully evaluated reports, 32 (11.3%) resulted in a proven/probable (P/P) transmission of infection, malignancy or other conditions to 42 recipients. Of 204 infection events, 24 were classified as P/P affecting 30 recipients, with four deaths. Bacteria were the most frequently reported type of infection, accounting for 99 reports but only 12 recipients from 11 donors experienced P/P transmission. There were 65 donors reported with potential malignancy events and 5 were classified as P/P transmissions with 8 affected recipients and 2 deaths. Additionally, there were 16 noninfection, nonmalignancy reports resulting in 3 P/P transmissions to 4 recipients and 1 death. CONCLUSIONS: There was a 43% increase in the number of PDDTE reported and reviewed in 2013 over 2012. However, the percent with P/P transmission remains low, affecting recipients from 32 donors especially when compared with the more than 14,000 donors recovered annually in the United States. The continued use of the new standard algorithm and triaging process will enhance the reproducibility of DTAC assessments and allow more robust analysis of our aggregate DTAC experience.

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