Ken Tegtmeyer

Twitter as a tool for communication and knowledge exchange in academic medicine: A guide for skeptics and novices

Abstract Twitter is a tool for physicians to increase engagement of learners and the public, share scientific information, crowdsource new ideas, conduct, discuss and challenge emerging research, pursue professional development and continuing medical education, expand networks around specialized topics and provide moral support to colleagues. However, new users or skeptics may well be wary of its potential pitfalls. The aims of this commentary are to discuss the potential advantages of the Twitter platform for dialogue among physicians, to explore the barriers to accurate and high-quality healthcare discourse and, finally, to recommend potential safeguards physicians may employ against these threats in order to participate productively.

Validation of a gene expression-based subclassification strategy for pediatric septic shock

Objective:Septic shock heterogeneity has important implications for clinical trial implementation and patient management. We previously addressed this heterogeneity by identifying three putative subclasses of children with septic shock based exclusively on a 100-gene expression signature. Here we attempted to prospectively validate the existence of these gene expression-based subclasses in a validation cohort. Design:Prospective observational study involving microarray-based bioinformatics. Setting:Multiple pediatric intensive care units in the United States. Patients:Separate derivation (n = 98) and validation (n = 82) cohorts of children with septic shock. Interventions:None other than standard care. Measurements and Main Results:Gene expression mosaics of the 100 class-defining genes were generated for 82 individual patients in the validation cohort. Using computer-based image analysis, patients were classified into one of three subclasses (“A,” “B,” or “C”) based on color and pattern similarity relative to reference mosaics generated from the original derivation cohort. After subclassification, the clinical database was mined for phenotyping. Subclass A patients had higher illness severity relative to subclasses B and C as measured by maximal organ failure, fewer intensive care unit-free days, and a higher Pediatric Risk of Mortality score. Patients in subclass A were characterized by repression of genes corresponding to adaptive immunity and glucocorticoid receptor signaling. Separate subclass assignments were conducted by 21 individual clinicians using visual inspection. The consensus classification of the clinicians had modest agreement with the computer algorithm. Conclusions:We have validated the existence of subclasses of children with septic shock based on a biologically relevant, 100-gene expression signature. The subclasses have relevant clinical differences.

Bone Marrow Aspiration and Biopsy

Bone marrow aspiration is performed to assess cellular morphology and to conduct tests on the bone marrow. Bone marrow biopsy is often performed in tandem to provide information about the marrow and the extent of disease. This video demonstrates both procedures.

Toward a clinically feasible gene expression-based subclassification strategy for septic shock: proof of concept.

Objective:To develop a clinically feasible stratification strategy for pediatric septic shock, using gene expression mosaics and a 100-gene signature representing the first 24 hrs of admission to the pediatric intensive care unit. Design:Prospective, observational study involving microarray-based bioinformatics. Setting:Multiple pediatric intensive care units in the United States. Patients:Ninety-eight children with septic shock. Interventions:None other than standard care. Measurements and Main Results:Patients were classified into three previously published, genome-wide, expression-based subclasses (subclasses A, B, and C) having clinically relevant phenotypic differences. The class-defining 100-gene signature was depicted for each individual patient, using mosaics generated by the Gene Expression Dynamics Inspector (GEDI). Composite mosaics were generated representing the average expression patterns for each of the three subclasses. Nine individual clinicians served as blinded evaluators. Each evaluator was shown the 98 individual patient mosaics and asked to classify each patient into one of the three subclasses, using the composite mosaics as the reference point. The respective sensitivities, specificities, positive predictive values, and negative predictive values of the subclassification strategy were ≥84% across the three subclasses. The classification strategy also generated positive likelihood ratios of ≥16.8 and negative likelihood ratios of ≤0.2 across the three subclasses. The &kgr; coefficient across all possible interevaluator comparisons was 0.81. Conclusions:We have provided initial evidence (proof of concept) for a clinically feasible and robust stratification strategy for pediatric septic shock based on a 100-gene signature and gene expression mosaics.

Umbilical Vascular Catheterization

Placement of umbilical catheters is an important skill for the treatment of critically ill neonates. Catheters can provide vascular access for resuscitation, monitoring, fluid administration, blood...

Computer-assisted learning in critical care: from ENIAC to HAL.

Computers are commonly used to serve many functions in today’s modern intensive care unit. One of the most intriguing and perhaps most challenging applications of computers has been to attempt to improve medical education. With the introduction of the first computer, medical educators began looking for ways to incorporate their use into the modern curriculum. Prior limitations of cost and complexity of computers have consistently decreased since their introduction, making it increasingly feasible to incorporate computers into medical education. Simultaneously, the capabilities and capacities of computers have increased. Combining the computer with other modern digital technology has allowed the development of more intricate and realistic educational tools. The purpose of this article is to briefly describe the history and use of computers in medical education with special reference to critical care medicine. In addition, we will examine the role of computers in teaching and learning and discuss the types of interaction between the computer user and the computer.

Developing and evaluating the success of a family activated medical emergency team: a quality improvement report

Background Family-activated medical emergency teams (MET) have the potential to improve the timely recognition of clinical deterioration and reduce preventable adverse events. Adoption of family-activated METs is hindered by concerns that the calls may substantially increase MET workload. We aimed to develop a reliable process for family activated METs and to evaluate its effect on MET call rate and subsequent transfer to the intensive care unit (ICU). Methods The setting was our free-standing childrens hospital. We partnered with families to develop and test an educational intervention for clinicians and families, an informational poster in each patient room and a redesigned process with hospital operators who handle MET calls. We tracked our primary outcome of count of family-activated MET calls on a statistical process control chart. Additionally, we determined the association between family-activated versus clinician-activated MET and transfer to the ICU. Finally, we compared the reason for MET activation between family calls and a 2:1 matched sample of clinician calls. Results Over our 6-year study period, we had a total of 83 family-activated MET calls. Families made an average of 1.2 calls per month, which represented 2.9% of all MET calls. Children with family-activated METs were transferred to the ICU less commonly than those with clinician MET calls (24% vs 60%, p<0.001). Families, like clinicians, most commonly called MET for concerns of clinical deterioration. Families also identified lack of response from clinicians and a dismissive interaction between team and family as reasons. Conclusions Family MET activations were uncommon and not a burden on responders. These calls recognised clinical deterioration and communication failures. Family activated METs should be tested and implemented in hospitals that care for children.

Using Simulation to Develop Care Models for Rapid Response and Code Teams at a Satellite Facility

BACKGROUND Our institution recently completed an expansion of an acute care inpatient unit within a satellite hospital that does not include an on-site ICU or PICU. Because of expected increases in volume and acuity, new care models for Rapid Response Teams (RRTs) and Code Blue Teams were necessary. OBJECTIVES Using simulation-based training, our objectives were to define the optimal roles and responsibilities for team members (including ICU physicians via telemedicine), refine the staffing of RRTs and code Teams, and identify latent safety threats (LSTs) before opening the expanded inpatient unit. METHODS The laboratory-based intervention consisted of 8 scenarios anticipated to occur at the new campus, with each simulation followed by an iterative debriefing process and a 30-minute safety talk delivered within 4-hour interprofessional sessions. In situ sessions were delivered after construction and before patients were admitted. RESULTS A total of 175 clinicians completed a 4-hour course in 17 sessions. Over 60 clinicians participated during 2 in situ sessions before the opening of the unit. Eleven team-level knowledge deficits, 19 LSTs, and 25 system-level issues were identified, which directly informed changes and refinements in care models at the bedside and via telemedicine consultation. CONCLUSIONS Simulation-based training can assist in developing staffing models, refining the RRT and code processes, and identify LSTs in a new pediatric acute care unit. This training model could be used as a template for other facilities looking to expand pediatric acute care at outlying smaller, more resource-limited facilities to evaluate new teams and environments before patient exposure.

PDAs in the ICU: Beyond the Alphabet Soup—Part 3: Documentation

In the previous two columns I discussed basic necessities for your portable digital assistant (PDA) and some essential or useful utilities. In this column I will discuss the issues surrounding the most hopeful goal of the PDA in the intensive care unit (ICU) to decrease the amount of time we spend documenting in accordance with Health Care Finance Administration (HCFA) rules and billing. The goals are fairly straightforward: guarantee the inclusion of the “key” elements of a note to allow adequate billing, and then combine with diagnosis and procedure codes to produce billing and note documentation simultaneously. There are several commercial products on the market for physician documentation and/or billing. Unfortunately, since we are a relatively small market, there are not currently any products for intensivists. Most of the products available are either geared toward medical students, residents, or clinic-based physicians or have been specially developed from within, such as emergency medicine. Since the categories of information and the level of detail needed for documentation vary so much among specialties, these products are rarely applicable in other areas. Such products include Patientkeeper (Patientkeeper. com) and Patient-tracker (Handheldmed.com). Tim Timmons, MD and Baobab Systems will be releasing a beta test version of an ICU product tentatively called Ticdoc in the next few months. Written by intensivists, for intensivists, the initial release will be geared toward the pediatric ICU, with future versions for adult intensivists and neonatologists. It includes 179 different elements organized by organ system allowing for inclusion or exclusion of individual elements or organ systems. Ticdoc will synchronize with Microsoft Access and convert discreet data from the PDA into sentences to produce readable notes. What about creating your own PDA database? There are possibilities for the individual intensivist who wants to generate his or her own database system without learning the PalmOS programming language. HanDBase (DDH Software, www.ddhsoftware.com) and Jfile (Land-J Technologies, www.land-j.com) are two of the more popular and more versatile PDA-based database programs. HanDBase is a relational database that allows organization between different databases, such as diagnoses and billing codes. JFile is not relational but is very straightforward to use. Both allow synchronization with traditional desktop databases such as Access or Filemaker, but JFile is better at allowing creation of pop-up menus on the desktop and transferring them to the PDA. Using the database in coordination with a desktop version broadens the formatting, recovery, and manipulation opportunities with the information gathered. Finally, don’t forget to keep within the 1996 Health Insurance Portability and Accountability Act guidelines regarding the accessibility and privacy of patient medical records. When entering data into any palm application you will quickly find the limitations of Graffiti for data entry. Purchasing a fold-away keyboard that allows for easy text entry into your PDA can greatly speed up data entry. Targus (Targus.com) and Landware (landware.com) both produce keyboards for PDAs that fold up to a size only slightly larger than the PDA itself. Ultimately the heterogeneity of intensivists’ documentation and billing practices may lead to the development of many more databases.

PDAs in the ICU: Beyond the Alphabet Soup—Part 1

Tegtmeyer K. PDAs in the ICU: Beyond the Alphabet Soup—Part 1. J Intensive Care Med 2001; 16:294.