Exocytosis of the hormone glucagon-like peptide 1 (GLP-1) by the intestinal L cell is essential for the incretin effect after nutrient ingestion and is critical for the actions of dipeptidyl peptidase 4 inhibitors that enhance GLP-1 levels in patients with type 2 diabetes. Two-photon microscopy revealed that exocytosis of GLP-1 is biphasic, with a first peak at 1-6 min and a second peak at 7-12 min after stimulation with forskolin. Approximately 75% of the exocytotic events were represented by compound granule fusion, and the remainder were accounted for by full fusion of single granules under basal and stimulated conditions. The core SNARE protein syntaxin-1a (syn1a) was expressed by murine ileal L cells. At the single L-cell level, first-phase forskolin-induced exocytosis was reduced to basal ( < 0.05) and second-phase exocytosis abolished ( < 0.05) by syn1a knockout. L cells from intestinal-epithelial syn1a-deficient mice demonstrated a 63% reduction in forskolin-induced GLP-1 release in vitro ( < 0.001) and a 23% reduction in oral glucose-stimulated GLP-1 secretion ( < 0.05) in association with impairments in glucose-stimulated insulin release (by 60%; < 0.01) and glucose tolerance (by 20%; < 0.01). The findings identify an exquisite mechanism of metered secretory output that precisely regulates release of the incretin hormone GLP-1 and hence insulin secretion after a meal.
ObjectivesPostresuscitation debriefing (PRD) is a valuable educational tool in emergency medicine. It is recommended by international resuscitation guidelines, has been shown to improve both patient outcomes and resuscitation team performance, and is frequently requested by medical learners. However, there is limited research comparing standardized debriefing frameworks. Not only does this hinder the ability of interested emergency departments (EDs) to adopt PRD, but it limits the quality of future debriefing research. We sought to identify and compare existing PRD frameworks to inform the implementation of effective PRD in emergency medicine.MethodsWe conducted a systematic review following PRISMA standards to identify debriefing frameworks used in the ED and other acute care settings for further analysis. Identified frameworks were analyzed and compared based on a method previously described in the literature.ResultsOur search identified six frameworks, which ranged from simple tools for immediate feedback to complex, hospital‐wide systems engineering–based approaches to quality improvement. Key findings were the importance of ensuring debriefing facilitators are properly selected and trained and of tailoring framework design to specific organizational targets. However, there is limited validation data for these frameworks, and more study is needed to identify and validate true best practices in PRD.ConclusionsAll six identified frameworks seem to be effective methods of debriefing. Given the breadth in debriefing methods and goals identified, this suggests that there may not be a one‐size‐fits‐all approach to PRD and that organizations should instead identify their own unique needs and barriers and adopt the debriefing framework that best addresses those needs. Other findings were the importance of well‐trained debriefing facilitators and the use of clear roles in organizing debriefings. Further research is needed to assess the effectiveness of postresuscitation frameworks with regard to both team performance and patient outcomes.
Introduction. As serious games are a relatively new phenomenon in medical education, there is little data on end user demographics or usage. In this study our goal was to describe the demographics and usage for purchasers of the GridlockED board game, a serious board game for teaching about a systems approach to managing care in the emergency department. Methods. We conducted a two-phase survey of individuals interested in purchasing GridlockED. Users were asked to complete a brief demographic survey before accessing the purchasing site. A follow-up survey was performed 3-6 months after the initial survey. That survey was to assess participants’ usage, play patterns, and what changes to GridlockED they would like to see. Individuals who did not purchase the board game were asked about their barriers to purchase. Results. After one year of sales, 213 games were purchased, 560 individuals had completed the intake survey with 408 consented to follow-up. Responding purchasers were from 16 different roles in healthcare in 11 countries. Our follow-up survey collated 53 responses (out of 408 individuals, 14% response rate). The majority (63%) of respondents reported having played the game, with the most common use cases being for fun (40%), teaching trainees (21%) or training with colleagues (13%). Price of the game unit was cited as the largest barrier to purchase (60%). Conclusion. GridlockED attracted interest from a wide range of medical professionals around the world. Users reported using the game for fun and for teaching/training purposes. The main barrier to purchase was the game’s price.
Objective: GridlockED gameplay workshops were delivered in Canada. This project investigated workshop attendees' experiences, seeking to identify learning points to inform improvement of the workshop. Methods: GridlockED sessions were held through 2018 and 2019. Workshops targeted medical trainees. After a standardized video, learners played for approximately 90 minutes. Learners completed a postgameplay survey with 7-point Likert scale questions about their experience.Results: Seventy-two participants responded to our survey (41 medical students, 13 physician assistant students, 12 emergency medicine residents, and six faculty members). Trainees rated GridlockED as both enjoyable and a meaningful educational experience, with a mean (±SD) rating of 6.53 (±0.96) of 7 for enjoyment and 6.17 (±1.13) for education. Attendees identified teamwork and communication (49%) as the most helpful learning domain, with patient flow (43%) being second and basics of how the ED worked (31%) being third. The respondents self-identified top areas of learning as resource management (38.9%), improved understanding of various provider roles in the ED (33%), and improved communication skills (33%).
Background Post-resuscitation debriefing (PRD) is the process of facilitated, reflective discussion, enabling team-based interpersonal feedback and identification of systems-level barriers to patient care. The importance and benefits of PRD are well recognized; however, numerous barriers exist, preventing its practical implementation. Use of a debriefing tool can aid with facilitating debriefing, creating realistic objectives, and providing feedback. Objectives To assess utility of two PRD tools, Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN) and Post-Code Pause (PCP), through user preference. Secondary aims included evaluating differences in quality, subject matter, and types of feedback between tools and implications on quality improvement and patient safety. Methods Prospective, crossover study over a 12-month period from February 2019 to January 2020. Two PDR tools were implemented in 8 week-long blocks in acute care settings at a tertiary care children’s hospital. Debriefings were triggered for any intubation, resuscitation, serious/unanticipated patient outcome, or by request for distressing situations. Post-debriefing, team members completed survey evaluations of the PDR tool used. Descriptive statistics were used to analyze survey responses. A thematic analysis was conducted to identify themes that emerged from qualitative responses. Results A total of 114 debriefings took place, representing 655 total survey responses, 327 (49.9%) using PCP and 328 (50.1%) using DISCERN. 65.2% of participants found that PCP provided emotional support while only 50% of respondents reported emotional support from DISCERN. PCP was found to more strongly support clinical education (61.2% vs 56.7%). There were no significant differences in ease of use, support of the debrief process, number of newly identified improvement opportunities, or comfort in making comments or raising questions during debriefs between tools. Thematic analysis revealed six key themes: communication, quality of care, team function & dynamics, resource allocation, preparation and response, and support. Conclusion Both tools provide teams with an opportunity to reflect on critical events. PCP provided a more organized approach to debriefing, guided the conversation to key areas, and discussed team member wellbeing. When implementing a PRD tool, environmental constraints, desired level of emotional support, and the extent to which open ended data is deemed valuable should be considered.
Introduction: GridlockED is an educational (or “serious”) game recently developed by a team at McMaster to teach medical learners about patient flow in the emergency department (ED). Beyond patient flow, we were cognizant that the game could provide additional learning opportunities for learners. The goal of this program evaluation project was to investigate workshop attendees’ experiences and identify what areas they found most educational. Methods: A GridlockED board game workshop was developed and delivered in several locations over the fall of 2018. Workshops targeted medical learners and were organized by local emergency medicine interest groups. After a standardized video-based introduction to the game concept and rules, the learners played GridlockED for approximately 90 minutes. After the play session, learners completed an anonymous survey consisting of 7-point Likert scale questions about their experience. They were also asked to identify the learning domains for which GridlockED was developed (Patient Flow, Communication and Teamwork, and ED Basics), and were asked via free-text to identify learning objectives from their experience. We received an exemption for this study from our institutional review board. Results: We had 25 respondents (24 medical students and 1 resident). Trainees rated GridlockED as both enjoyable to play and as a meaningful educational experience, with an average rating of 6.56 (SD 0.94) for enjoyability and 6.44 (0.92) for education. When asked what targeted learning domain was most helpful, 45% of students identified patient flow, 37% teamwork and communication, and only 18% ED basics. When asked to identify their top three areas of learning in open-ended responses, students actually identified resource management most frequently (48%), with improved communication skills (40%) as the second most prominent learning objective. Other interesting self-identified learning points were: a greater appreciation of the role of various providers (24%), the unpredictability of ED care (12%), and how things can go wrong (12%). Conclusion: Medical learners find GridlockED to be both enjoyable and educational. In our targeted areas of learning they found patient flow to be the most educational, but self-identified multiple other areas for learning. Students identified resource management and communication as key areas of learning, suggesting that future workshops might be designed specifically to teach these skills.
Introduction: In 2016, a team at McMaster began developing GridlockED, an educational (or “serious”) board game designed to teach medical learners about patient flow in the emergency department. As serious board games are a relatively new phenomenon in medical education, there is little data on how marketed games are actually used once received by end-users. In this study our goal was to better understand the demographics and game usage for purchasers of the GridlockED board game, which will inform the further improvement or expansion of the game. Methods: Individuals who expressed interest in purchasing gridlockED via our online storefront were sent an anonymous online survey via Google Form. The survey collected demographic and qualitative data with a focus on the respondent's role in medicine, how they have used GridlockED, who they have played GridlockED with, and what changes or additions to GridlockED they would like to see. We also asked about changes for a potential mass-market version of the game targeted towards non-medical individuals. Individuals who did not purchase the game were asked about their barriers to purchase. We received an exemption for this study from our institutional review board. Results: 42 responses (out of 300 individuals on our mailing list, 14% response rate) were collected. Responding purchasers were from 16 different roles in healthcare and 11 different countries. The top 5 roles were: EM trainee, Community EM MD, Academic EM MD, Physicians from other specialties, and EM program director. The majority of respondents were Canadian (38%), with America (21%), New Zealand (10%), and Turkey (7%) the only other countries to have more than 2 respondents. 50% reported having played the game, with the most common use cases being for fun (76%), for teaching trainees (33%) or training with colleagues (19%). For those who did not purchase, price was the largest barrier (81%). 50% of respondents expressed interest in a disaster scenario expansion pack, with 33% interested in set lesson plans. Conclusion: GridlockED attracted interest from a wide range of medical professionals, both in terms or role and location. Users mainly reported using the game for fun, with fewer users using the game for teaching/training purposes. The main barrier to purchase was the game's price.
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