Six habits to enhance MET performance under stress: A discussion paper reviewing team mechanisms for improved patient outcomes

Effective team decision making has the potential to improve the quality of health care outcomes. Medical Emergency Teams (METs), a specific type of team led by either critical care nurses or physicians, must respond to and improve the outcomes of deteriorating patients. METs routinely make decisions under conditions of uncertainty and suboptimal care outcomes still occur. In response, the development and use of Shared Mental Models (SMMs), which have been shown to promote higher team performance under stress, may enhance patient outcomes. This discussion paper specifically focuses on the development and use of SMMs in the context of METs. Within this process, the psychological mechanisms promoting enhanced team performance are examined and the utility of this model is discussed through the narrative of six habits applied to MET interactions.A two stage, reciprocal model of both nonanalytic decision making within the acute care environment and analytic decision making during reflective action learning was developed. These habits are explored within the context of a MET, illustrating how applying SMMs and action learning processes may enhance team-based problem solving under stress. Based on this model, we make recommendations to enhance MET decision making under stress. It is suggested that the corresponding habits embedded within this model could be imparted to MET members and tested by health care researchers to assess the efficacy of this integrated decision making approach in respect to enhanced team performance and patient outcomes.     

Effect of soft tissue thickness over the posterior border of the vertebral body and disc space on cage placement during posterior lumbar interbody fusion: A cadaveric study

In the present study, we investigated whether there is a difference between visual depth (VD) and radiological image depth (RD) of cages (i.e., structural interbody support devices) placed in disc spaces during posterior lumbar interbody fusion and whether soft tissues covering the posterior border of the vertebral body and associated disc space are the cause of any observed differences. Using digital calipers, cages were inserted at a depth of 5 mm from the soft tissues covering the posterior border of the vertebral body and disc space under direct vision; this depth was defined as VD. After insertion, RD was measured in triplicate. The reliability of RD measurements was evaluated using an intraclass coefficient test. To identify the cause of differences between VD and RD, the thicknesses of soft tissues were measured microscopically. A total of 40 lumbar intervertebral disc spaces with cages were evaluated. The mean RD of cages was 3.12 mm, while the mean difference between the VD and RD of cages (DVRD) was 1.91 mm. On histological examination, the mean thickness of the soft tissue was 2.02 mm. Comparative analysis between histological values and DVRD showed no statistical difference (P = 1.14, 1.55, 0.06). There was a significant difference between VD and RD during cage placement, and soft tissue structure appeared to be responsible for the DVRD of inserted cages. Therefore, cages should be inserted deeper to account for differences between visual and radiological image depths. Clin. Anat. 25:1066–1073, 2012. © 2012 Wiley Periodicals, Inc.     

Myology of the forelimb of Majungasaurus crenatissimus (Theropoda,Abelisauridae) and the morphological consequences of extreme limb reduction

Forelimb reduction occurred independently in multiple lineages of theropod dinosaurs. Although tyrannosaurs are renowned for their tiny, two‐fingered forelimbs, the degree of their reduction in length is surpassed by abelisaurids, which possess an unusual morphology distinct from that of other theropods. The forelimbs of abelisaurids are short but robust and exhibit numerous crests, tubercles, and scars that allow for inferences of muscle attachment sites. Phylogenetically based reconstructions of the musculature were used in combination with close examination of the osteology in the Malagasy abelisaurid Majungasaurus to create detailed muscle maps of the forelimbs, and patterns of the muscular and bony morphology were compared with those of extant tetrapods with reduced or vestigial limbs. The lever arms of muscles crossing the glenohumeral joint are shortened relative to the basal condition, reducing the torque of these muscles but increasing the excursion of the humerus. Fusion of the antebrachial muscles into a set of flexors and extensors is common in other tetrapods and occurred to some extent in Majungasaurus. However, the presence of tubercles on the antebrachial and manual elements of abelisaurids indicates that many of the individual distal muscles acting on the wrist and digits were retained. Majungasaurus shows some signs of the advanced stages of forelimb reduction preceding limb loss, while also exhibiting features suggesting that the forelimb was not completely functionless. The conformation of abelisaurid forelimb musculature was unique among theropods and further emphasizes the unusual morphology of the forelimbs in this clade.     

结核分枝杆菌感染对痰液菌群结构的影响

目的 探索健康人、结核分枝杆菌潜伏感染者和活动性肺结核患者痰液菌群的差异。方法 搜集2016年11月至2017年12月深圳市慢性病防治中心健康体检者53名作为A组,登记确诊的结核分枝杆菌潜伏感染(LTBI)者41例作为B组,初治活动性肺结核患者54例作为C组。研究对象均于清晨空腹状态下收集下呼吸道痰液样本(以干酪痰和黏液痰为佳)3~5ml,共148份。痰液样本提取总DNA,对16S rRNA V4~V5区基因进行高通量测序,并对测序结果进行生物信息学分析。结果 通过对148份痰液样本进行高通量测序分析,获得有效序列14136502.0条,获得操作分类单元(operational taxonomic units,OTU)21712.00个。Alpha多样性分析显示,A组Pielou_e指数为0.85(0.82,0.88),明显高于C组[0.83(0.78,0.86)],差异有统计学意义(H=4.462,P=0.035)。Beta多样性分析发现,三组人群痰液菌群组成存在差异(H=2.027,P=0.002)。菌群组间差异物种分析发现,三组人群在3个门(厚壁菌门、梭杆菌门、螺旋体门)、3个纲(黄杆菌纲、梭杆菌纲、螺旋体纲)、5个目(黄杆菌目、乳杆菌目、梭杆菌目、伯克霍尔德菌目、螺旋体目)、6个科(紫单胞菌科、黄杆菌科、梭杆菌科、纤毛菌科、伯克菌科、螺旋体科)、5个属(二氧化碳噬纤维菌属、卟啉单胞菌属、梭杆菌属、纤毛菌属、密螺旋体属)和2个种(Nanceiensis和Parvula)水平上均存在差异;其中,C组中伯克霍尔德菌目(Burkholderiales)[0.01(0.00,0.02)]和伯克菌科(Burkholderiaceae)[0.01(0.00,0.01)]的丰富度较A组[丰富度分别为0.00(0.00,0.01)和0.00(0.00,0.00)]和B组[丰富度分别为0.00(0.00,0.01)和0.00(0.00,0.00)]明显增加,差异均有统计学意义(C组与A组比较:H值分别为9.733和4.799,P值分别为0.002和0.028;C组与B组比较:H值分别为12.134和8.152,P值均<0.01)。结论 结核分枝杆菌感染未改变人痰液菌群的丰富度,但造成菌群结构组成上产生差异。     

Surgical anatomy of hepatoduodenal ligament and hepatic hilus

The anatomical situation and variations of structures in the hepatoduodenal ligament and hepatic hilus are a legacy of their embryological development. The vascular, biliary, and lymphatic structures contribute to the functioning of blood and bile flow as well as lymph drainage of the liver. Connective tissue, fatty tissue, and the peritoneal sheet are enveloping underlying structures. Their position, shape, and relation to neighboring structures influence the situation during operative procedures. The cystic artery origin is variable, as is the number; and its recognition is important for safe cholecystectomy. Venous drainage of the gallbladder goes into the portal system of adjacent segments 4 and 5 and influences the spread of gallbladder pathology. There are some surgically important variations in the course and distribution of bile ducts and arteries in the hepatoduodenal ligament. The biliary anatomical variations significantly influence the incidence of bile ducts injuries during laparoscopic cholecystectomy. The arterial supply of extrahepatic bile ducts is delicate and variable and should be considered when trying to prevent ischemic injuries to the bile ducts. Inflammation and the combination of inflammation and anatomical variation are thought to contribute to a dangerous situation in regard to eventual injury to the bile ducts and vascular structures during operative procedures. This paper explores these questions.     

Cyclic contact fatigue resistance of ceramics for monolithic and multilayer dental restorations

ObjectiveTo evaluate the cyclic contact fatigue resistance and failure mode of ceramics for monolithic and multilayer restorations.MethodsCeramic structures (10 mm × 1.8 mm) were fabricated as follows (n = 28): (1) CAD-on- trilayer structure composed of Y-TZP (yttria stabilized tetragonal zirconia polycrystal- IPS e.max ZirCAD) infrastructure, fusion glass–ceramic (IPS e.max CAD Crystall/Connect) and lithium disilicate-based glass–ceramic (IPS e.max CAD); (2) ZFC- bilayer structure composed of Y-TZP infrastructure veneered by a fluorapatite glass–ceramic (IPS e.max Ceram); (3) LDC- monolithic lithium-disilicate glass–ceramic (IPS e.max CAD); and (4) YZW- monolithic Y-TZP (Zenostar Zr Translucent). All ceramics structures were bonded to a dentin analog substrate (G10). Specimens were submitted to cyclic contact fatigue test in a pneumatic cycling machine with 80 N load and 2 Hz frequency in distilled water at 37 °C. Test was interrupted after 10⁴, 10⁵, 5 × 10⁵ and 10⁶ cycles and the presence or absence of failure was recorded. Fatigue data were analyzed using Kaplan–Meier (log rank) and Holm–Sidak tests (α = 0.05). The relationship between the type of crack leading to failure and the experimental group was analyzed using chi-square test (α = 0.05).ResultsThere was no statistical difference between CAD-on and YZW groups (p = 0.516), which presented the highest survival rates after cyclic loading, followed by ZFC and LDC groups (p < 0.01). There was a significant relationship between type of crack and experimental group (p < 0.001). LDC specimens showed the greatest frequency of radial cracks, while cone cracks were more prevalent for ZFC and CAD-on specimens.SignificanceMonolithic Y-TZP (YZW) showed similar fatigue resistance to CAD-on multilayer specimens, but different failure mode. Monolithic lithium disilicate glass–ceramic (LDC) and Y-TZP conventionally veneered by glass–ceramic (ZFC) showed lower survival time under fatigue.     

以解决实际问题为导向的药物分析教学模式

为了适应应用型药学本科人才的培养需求,针对药物分析学科的特点,构建新的药物分析教学模式。在教学中通过重组章节顺序并建立模块教学结构,提高教学的逻辑性;通过不同学科及章节的知识迁移,培养学生掌握有意义的学习方法,加深对药品标准的理解,拓展教学深度;通过案例教学,培养学生综合运用知识能力、自学能力与解决实际问题能力。     

Intra-tumoral tertiary lymphoid structures are associated with a low risk of early recurrence of hepatocellular carcinoma

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