Grand Rounds Presentation Research Articles

Annals for Educators - 3 April 2018.

Annals for Educators - 3 April 2018.

Annals for Educators - 5 December 2017

Annals for Educators - 5 December 2017

Use of Twitter to Educate and Engage Surgeons in Infectious Diseases and Antimicrobial Stewardship

Background As more surgeons use Twitter, it is vital to understand how to engage users. Surgeons need timely education on multidrug-resistant organisms to prescribe effective antibiotics. We evaluated Twitter as a tool to engage and educate surgeons in emerging infectious disease (ID) topics on antibiotic resistance and antimicrobial stewardship. Methods This was a 3-month prospective cohort study with surgeons who volunteered after attending Twitter Grand Rounds presentation and workshop. Pharmacists tweeted ID topics relevant to surgeons, and each tweet's reach, impressions, and engagement were calculated. Results A total of 5117 tweets were sent: 4089 by 21 surgeons and 1028 by study pharmacists. Pharmacists sent 451 ID tweets, and surgeons engaged in 72 ID tweets: 31 retweeted, 29 replied, and 12 “liked” for a potential reach of 5101, potential impressions of 38 784, and actual impressions of 15,895. The top ID tweet topics by actual impressions were antibiotic resistance (3005), global antibiotic stewardship (2257), “superbugs” (2121), and Clostridium difficile (1181). Of the 31 ID retweets by surgeons, 81% had links to articles versus 19% without links (P = 0.54). Grand Rounds evaluations identified that 81% rated the presentation topic as excellent and 77% felt Twitter was relevant to their practice. The conference hashtag #TwitterGrandRounds engaged surgeons tweeting from other institutions and generated an additional 217,317 potential impressions. Conclusions Twitter engaged surgeons in ID and antimicrobial stewardship topics and provided real-time education around antimicrobial resistance. Future studies should evaluate whether engagement and education via tweets impact actual antimicrobial use and the rates of antimicrobial resistance.

Abstract: Vascular Anomalies of the Lip Challenge the Reconstructive Rule of Thirds

INTRODUCTION: Vascular malformations of the lip often require reconstructive surgery for both aesthetic and functional purposes. The lip reconstructive rule of thirds suggests that lower lip defects involving 1/3-2/3 total lip width require closure with lip switch or local advancement flap techniques.1–3 We sought to characterize the lip reconstructive rule of thirds in a patient cohort whose lip defects resulted from surgical excision of vascular anomalies. METHODS: Retrospective review of patients requiring reconstructive surgery for vascular anomalies of the lip between 2005–2015. RESULTS: 65 patients with vascular anomalies of the lip were identified for a total of 67 lesions. Female-to-male ratio was 1.7:1. Clinical diagnoses included hemangiomas (66%), venous malformations (14%), capillary malformations (5%), lymphatic malformations (5%) and unspecified types of vascular malformations (11%). Median age at surgery was 5.5 years (range, 1.2–86). None of the patients required flap closure. The lower lip was most frequently involved (63%, 42/67). Lower lip lesions were more likely to cause labial dysfunction (p<0.001), involve the vermillion border (p<0.001) and require full thickness excision (p<0.001) than upper lip lesions. Postoperatively, 17% (11/65) of patients experienced minor issues with wound healing or infection. Median follow-up time was 5.5 months (range, 0 days-11.5 years). CONCLUSION: In this patient cohort, lower lip vascular malformations, compared to upper lip lesions, were more common and significantly more likely to result in labial dysfunction, involve the vermillion border and require full thickness excision. None of the patients who underwent surgical excision of vascular lesions resulting in defects 1/3-2/3 total lip width required lip switch or local advancement flap-mediated reconstruction. Therefore, these data challenge the lip reconstructive rule of thirds in the setting of vascular anomalies. We posit that vascular malformations expand normal lip tissue enabling reconstruction by primary closure. DISCLOSURE:None of the authors has a financial interest to disclose related to this manuscript. REFERENCES: 1. Anvar, B. A., Evans, B. C., Evans, G. R. Lip reconstruction. Plast Reconstr Surg 120: 57e-64e, 2007. 2. Nichols, M. Lip Reconstruction. Grand Rounds Presentation. Galveston: University of Texas Medical Branch, 1989. 3. Persing, J. A., Evans, G. R. Soft-Tissue Surgery of the Craniofacial Region: CRC Press, 2007.

The Babinski sign

You cannot have completed your training as a neurologist unless you can make the plantar response go up or down. Or so the apocryphal story goes. Of all the neurologists...

National survey of Canadian ophthalmology residency education

ObjectiveTo describe the current clinical, surgical, and other educational activities of Canadian ophthalmology residents. DesignCross-sectional study. ParticipantsCanadian ophthalmology residents postgraduate year (PGY) 2 to 5. MethodsAn online survey was sent to residents in 2011 and 2014. The data sets were merged and analyzed using descriptive statistics. ResultsThe response rate was 41% with an equal distribution across sexes and PGY level. Residents from each program responded. Clinical rotations were led by emergency and comprehensive ophthalmology. The least number of days were spent in oncology, refractive, and low-vision clinics. The mean number of full cases performed by PGY5 was 324 cataracts, 9 trabeculectomies, and 48 horizontal muscles. Most PGY2 to PGY5 students performed more than 10 laser procedures of each type surveyed. Subspecialty surgical volumes varied and were lowest for scleral buckle, refractive laser, penetrating keratoplasty, and floor fracture. The majority of residents received up to 10 hours per week of teaching and 4 to 6 weeks of Royal College study time. Most respondents attended at least 1 funded conference annually and met with program directors twice a year. Research time and grand rounds presentations varied greatly. Forty-six percent of residents had fellowship plans. ConclusionsThis study describes the current clinical, surgical, and other educational activities across Canadian ophthalmology residency programs. The data allows individual programs to evaluate their training models in relation to broader national trends.

Does Self-Assessment Improve the Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital?

To determine whether use of self-assessment (SA) questions affects the effectiveness of weekly didactic grand rounds presentations. From 26 consecutive grand rounds presentations from August 2013 to April 2014, a 52-question multiple-choice test was administered based on 2 questions from each presentation. Community teaching institution. General surgery residents, students, and attending physicians. The test was administered to 66 participants. The mean score was 41.8%. There was no difference in test score based on experience with similar scores for junior residents, senior residents, and attending surgeons (43%, 46%, and 44%; p = 0.13). Most participants felt they would be most interested in presentations directly related to their surgical specialty. Participants, however, did not score differently on topics which were the focus of the program (40% vs. 42%; p = 0.85). Journal club presentations (39% vs. others 42%; p = 0.33) also did not affect the score. The Pearson correlation coefficient for attendance was 0.49 (p < 0.0001) demonstrated that attendance was very important. Participation in the weekly SA was significantly associated with improved score as those who participated in SA scored over 20% higher than those who did not (59% vs. 38%; p < 0.0001). Based on multiple linear regression for mean score, SA explained the variation in score more than attendance. The current study found that without preparation approximately 40% of material presented is retained after 10 months. Participation in weekly SA significantly improved retention of information from grand rounds presentations.

Physicians' attitudes toward pharmacogenetic testing before and after pharmacogenetic education.

Our aim was to evaluate physicians' attitudes toward pharmacogenetic testing before and after pharmacogenetic education. In total, 12 physicians (˜40% response rate) completed a survey with eight questions on 10-point scales on their attitudes toward pharmacogenetic testing before and after a 1-h grand rounds presentation on pharmacogenetics. Differences in question scores overall, among training levels (resident/fellow/attending), and specific drugs (clopidogrel/simvastatin/warfarin) were assessed using Wilcoxon signed-rank and exact Kruskal-Wallis tests. The scores for all eight questions increased, with statistically significant (p < 0.05) increases for four out of eight questions. The scores were similar among training levels, but the postscores for clopidogrel were significantly higher than for simvastatin and warfarin. In conclusion, brief pharmacogenetic education can significantly affect physicians' attitudes toward pharmacogenetic testing.

Tools for Successful Weight Management in Primary Care

Obesity is one of the most pervasive and costly public health problems. Clinicians need effective tools to address weight management in primary care, including evaluation and communication methods, guideline-based weight management interventions and safe and effective weight loss medications and surgery. The objective of this Grand Rounds presentation is to provide practicing clinicians with the latest information regarding effective ways to care for and communicate with patients about weight loss; evidence-based guidelines for selecting weight management therapies and safety, efficacy and adverse effects of weight loss medications and surgery.

271 Qualitative Study: Cost of Emergency Care From the Providers’ Perspective

271 Qualitative Study: Cost of Emergency Care From the Providers’ Perspective

Henry Marsh in His World.

English neurosurgeon Henry Marsh has written a memoir Do No Harm Stories of Life, Death, and Brain Surgery (St. Martin’s. New York, 2015) deserving of attention from a broad range of readers: clinicians, administrators, a general public interested in what the practice of medicine and surgery is really like, and those who seek to write honestly about the course of their lives and careers. In a recent issue of this Journal (53[6], pp. 1923–1929) I wrote an essay entitled Harvey Cushing, M.D., in his World based on the life and historical context of one of the great pioneers in the field of neurosurgery Harvey Cushing (1869–1939). It was first given as a Grand Rounds presentation made to the Department of Neurosurgery at the New York Presbyterian Hospital Weill Cornell Center in New York in 2006. Before and since that occasion I have spent a good deal of time and effort thinking and talking about writing with friends, colleagues, and contributors to the Journal. From that perspective I have come to believe how necessary it is for those who write to keep in mind the words of Ernest Hemingway, ‘‘All you have to do is to write one true sentence.’’ Reading Henry Marsh’s Do No Harm only confirms for me Hemingway’s admonition. Henry Marsh did not come to his vocation as a neurosurgeon easily or quickly. He was schooled in a very traditional British way in a public (for them private) school and then Oxford where he did not study the sciences but instead pursued a degree in Politics, Philosophy, and Economics. It was only after an extended period of searching that he engaged in course work that would make it possible for him to attend medical school. In the USA this is popularly known as a ‘‘post baccalaureate’’ course of study where those who previously have shown no interest in attending medical school pursue a program that will allow them, like Henry Marsh, to go forward and apply to medical school after all. He then would undergo the rigors of what we know here in the USA as residency training. Even then the path toward satisfaction was not altogether clear. Perhaps surgery would be

G542(P) Planning ahead: implementation of respiratory support for bronchiolitis at designated ward areas outside picu before the season

Context The General Paediatric department in the major children’s teaching hospital is a large and busy unit with Paediatric intensive care unit (PICU) on-site. There are approximately 4300 admissions per annum. In-patient numbers vary considerably between the seasons with an average range of 80 ± 10 in the winter. Problem A significant number of winter admissions where infants with bronchiolitis and a proportion require respiratory support with high flow nasal cannula oxygen therapy (HFNC). Assessment of problem and analysis of its causes With this in mind we analysed the existing bronchiolitis patient pathway. We identified HFNC is only provided in PICU due to staff competencies. This has lead to loss of PICU bed resulting in cancellation of elective cardiac surgeries and refusal of retrievals. Intervention A focus group was formed following the analysis to look at the feasibility of HFNC outside PICU. A strategy with a combined focus on safety and effective treatment with HFNC for children with bronchiolitis, nursed in designated Medical High Dependency Unit (MHDU) beds was developed. Study design The ‘Plan Do Study Act’(PDSA) cycle guided iterative stages of the HFNC project development. The normalisation process theory helped to introduce the new intervention providing the right treatment for the right patient at the right time without delay. Strategy for change The equipment designed specifically for delivering humidified nasal high flow with in-built safety alarm was identified and it was procured for the HFNC project. The designated MHDU beds were identified on the same floor at one place rather than spreading it out across. We identified the optimum and relevant staffs; nurses, doctors and advance nurse practitioners (ANP); to be trained after estimating the capacity and demand for services to manage the new change safely. More than 90% of medical team was trained and all nurses in designated areas were also trained over the period with multiple dedicated sessions by three trainers supported by the representative from the company. A hospital grand round presentation was done before starting the project. An intranet hospital link was developed with training materials and standard operating procedure (SOP). A DVD guide showing all aspects of HFNC was also developed and included in the link. Measurement of improvement We are currently in the stage of seeing the positive effects of HFNC project and data is being collected prospectively. Effects of changes A collaborative approach was undertaken for the improvement of HFNC for bronchiolitis outside PICU. The process involved clinicians, nurses and managers in the redesign of bronchiolitis treatment pathway. By maintaining and adhering to a standardised operating document, a culture of continuous re-inforcement and support with clear guideline and consistency helped in the implementation of this new change and effective treatment successfully in the bronchiolitis patient pathway. Lessons learnt There were barriers like competing priority of the professionals involved to achieve the same goal, clarity of role in delivering change and accountability and training of relatively large number the staff. Message for others It is important to ensure stakeholder engagement from the outset at the start. Having trust, rapport and confidence with the wider team have hugely helped for the acceptance without any hindrance. It is very crucial to recognise the potential pitfalls and develop preventative actions accordingly. The task for this project was not to fixate on the cost side of the equation—saving money or making cuts—but to improve the productivity. The focus was on the benefits side of providing the right treatment for the right patient at designated place safely thereby increasing the value of care to patients.

Scope, Focus, and Relevance of Ophthalmology Grand Rounds

Purpose The aim of the study is to analyze the scope, focus, and educational relevance of resident grand presentations in relation to the community prevalence and impact of the diseases discussed. Design This study is a retrospective review of grand rounds (GR) presentations at Tulane University School of Medicine's Department of Ophthalmology over a 3-year period. Methods The topic of each GR presentation between 2009 and 2012 was categorized by subject matter, prevalence, and impact in a retrospective review of saved PowerPoint files and surgical videos. Results Two hundred and eighty-four presentations were analyzed. Retina, glaucoma, cornea and external disease, and neuro-ophthalmology each comprised approximately one-sixth (17%) of topics discussed. Cataract and oculoplastics each comprised 9%, with the remaining cases distributed among other subjects. Sixty-five percent of discussed diseases were rare, while 19% were uncommon and 15% were common. Seventy-eight percent of diagnoses had impact on life (30%) or vision (48%). While diseases with minimal impact were distributed fairly evenly across prevalence categories, 64% of vision-threatening and 79% of life-threatening diseases were rare. Conclusions Our cohort of residents spontaneously divided their topics across most subjects within ophthalmology fairly evenly. Rare diseases comprised a majority of the GR discussions, so the average GR session did not address diagnoses likely seen in an average clinic. However, these rare diseases were much more likely to be vision- or life threatening. Encouraging a greater emphasis on more commonly encountered pathology could improve GR's daily clinical relevance for resident education, but care must be taken to continue discussion of rare diseases of critical importance.

The Morbidity and Mortality Conference (MMC) in Oncology: A patient safety and root cause analysis (RCA)-driven approach at the Cleveland Clinic Taussig Cancer Institute (TCI).

191 Background: MMC has been traditionally viewed as an educational tool. However, negative associations with MMC include emphasis on individual error and assigning blame, with little attention to improving patient safety and quality of care. MMC at the TCI has been designed to provide an opportunity to discuss MMC cases in an open, non-judgmental setting. Methods: Since September 2013, a monthly MMC, open to all caregivers, not just physicians, has been held as part of CME certified oncology grand rounds. Two cases are discussed per session and are obtained from nursing, pharmacy, and physician recommendation through the hospital Safety Event Reporting System or direct communication. Fellows investigate and present cases with patient and provider information de-identified to assure the discussion occurs in a blame-free setting. RCA is performed to determine action items. Process and safety improvements are recommended where applicable. Ongoing follow-up and improvement tracking is reported at future MMCs. The MMC governance committee, composed of the TCI quality officer, quality director, fellow representative, and a multi-disciplinary group of providers, meets quarterly to review cases and follow up action items under the guidance of the TCI MMC charter. The MMC governance committee reports to the TCI Quality Steering Committee. Results: Cases reviewed to date include chemotherapy dosing/administration errors (23%), hospital acquired medical complications (31%), communication breakdown between caregivers (15%), and end of life care (31%). An average of 3.5 action items has resulted from each case with 75% addressed within 90 days. Physician attendance is 59% higher and 23% more physicians report that they are very likely to change their practice behaviors from MMC than other grand rounds presentations. Conclusions: A patient safety driven MMC, delivered in an open setting, can be an effective tool to improve quality of care and caregiver communication in a large academic cancer center. High provider attendance and survey feedback reflects engagement in the process and will be essential to sustaining a meaningful and productive MMC.

Surgical teaching program for our senior medical students: room for improvement.

BackgroundTo ensure the quality of surgical teaching within our graduate entry medical program, a distinctive surgical teaching program has been developed at Sydney Medical School-Central. Spanning 2 years, the program includes lectures, small group surgical clinical tutorials, and formal student surgical grand rounds presentations, plus clinical placements and attendance in operating theaters. We sought to evaluate the effectiveness of the program.MethodsIn 2013, at the completion of year 4, all graduating students (n=54) were asked to complete an open and closed-ended questionnaire regarding their experience of the surgical program.ResultsA total of 44/54 (81%) students completed the questionnaire. Students reported a high level of engagement with their experience in clinical tutorials, and a moderate level of engagement in surgical lectures. Students found the clinical attachment to be the least useful method of teaching, with the surgical grand rounds presentation also eliciting a poor response from students.ConclusionWhile both large group lectures and small group learner-centered teaching methods were highly valued by students, changes are needed to enhance clinical attachments for students in surgical wards. The benefits of students being made to feel part of a team during their surgical clinical attachments, along with adequate inpatient contact and formative feedback, should not be underestimated.

Harvey Cushing, M.D., in his world.

Harvey Cushing, M.D. (1869-1939), is the acknowledged father of the discipline of neurosurgery who inspired others to join him in this new field. He was a prolific researcher in the area of human growth disturbances. And he was among the most literary of doctors having won the Pulitzer Prize for his two-volume biography of his mentor and teacher William Osler, M.D. A driven man, he both inspired and intimidated others. This essay explores Cushing's character and background along with his relationship to Osler. It seeks to understand why and how he may be considered a great figure in spite and because of his demanding and often problematic character. It further seeks to place Cushing in the context of the transition of American society and American medicine in the latter decades of the nineteenth and early decades of the twentieth century. Portions of this essay were originally delivered as part of a Grand Rounds presentation for the Department of Neurosurgery at the New York Presbyterian Hospital Weill Cornell Center.

Anesthesia Scholarship, Research, and Publication

Anesthesia Scholarship, Research, and Publication

Inhibitor κB Kinase

At a recent Grand Rounds presentation, the topic of discussion was introduced as regarding “…the most important muscle of the body that nobody knows about.” Although it is clear to clinicians and physiologists that smooth muscle controls the dimensions of nearly all hollow organs of the body, and that alterations in this control system participate in diverse and debilitating disorders such as hypertension, vasospasm, vasodilatory shock, asthma, overactive bladder, and irritable bowel syndrome, the muscle type that has garnered the majority of the limelight for generations has cross-striations. Article, see p 562 No single reason can explain smooth muscle’s limited exposition in general textbooks to account for its apparent second-class status behind striated muscle. However, a goal of science is to clarify by reduction, whereas complexity only recently has been embraced, leading to newer disciplines, such as systems biology. Studies during the past 40 years certainly indicate that smooth muscles display astounding complexity and diversity in biomechanical behavior and in regulation of contractile protein activation. Regarding the latter, the study by Ying et al1 in this issue of Circulation Research has added one more kinase to a growing number of regulatory proteins known to play a role in causing smooth muscle contraction. More than 100 years ago, Ringer2 showed that calcium was required for heart contraction. Calcium and the thin filament protein troponin are the central players in the regulation of striated muscle contraction, permitting active myosin from continuing through its actomyosin cross-bridge …

Congenital C1 arch deficiency: Grand Round presentation

We present an uncommon and yet interesting congenital anomaly and discuss the difficulties with diagnosis and controversies in management. C1 arch deficiency is an important consideration in the differential diagnosis of neck pain in children. A 12-year-old girl presented initially with a loud clicking emanating from the cervical spine during nappy changes in early childhood. Subsequent investigation by way of CT and MRI revealed her to have a deficient posterior arch of the C1 vertebra, and due to persistent and painful clicking she was placed into a cervical brace, which was worn for approximately 1 year. At age 12, her clicking had all but completely resolved but she continued to complain of minor neck pain. She is advised to avoid contact sports and her parents are instructed to observe any new worrying symptoms. No definitive guidelines exist for the management of this congenital anomaly. Indications for surgical intervention prior to any neurological disturbance are unclear, and restricting a child from partaking in healthy activity may not be necessary. We discuss the anomaly and identified management strategies as reported in the literature so far.

A multimethod approach for cross-cultural training in an internal medicine residency program

BackgroundCultural competence training in residency is important to improve learners’ confidence in cross-cultural encounters. Recognition of cultural diversity and avoidance of cultural stereotypes are essential for health care providers.MethodsWe developed a multimethod approach for cross-cultural training of Internal Medicine residents and evaluated participants’ preparedness for cultural encounters. The multimethod approach included (1) a conference series, (2) a webinar with a national expert, (3) small group sessions, (4) a multicultural social gathering, (5) a Grand Rounds presentation on cross-cultural training, and (6) an interactive, online case-based program.ResultsThe program had 35 participants, 28 of whom responded to the survey. Of those, 16 were white (62%), and residents comprised 71% of respondents (n=25). Following training, 89% of participants were more comfortable obtaining a social history. However, prior to the course only 27% were comfortable caring for patients who distrust the US system and 35% could identify religious beliefs and customs which impact care. Most (71%) believed that the training would help them give better care for patients from different cultures, and 63% felt more comfortable negotiating a treatment plan following the course.ConclusionsMultimethod training may improve learners’ confidence and comfort with cross-cultural encounters, as well as lay the foundation for ongoing learning. Follow-up is needed to assess whether residents’ perceived comfort will translate into improved patient outcomes.