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Despite decades of research and training, adverse physiological events continue to present a significant risk to pilots. This paper describes a naturalistic study of fighter pilot experiences with disorienting physiological events such as gravity-induced loss of consciousness (G-LOC), hypoxia, and spatial disorientation. We conducted a cognitive task analysis with 10 experienced fighter pilots to elicit incidents in which the pilot or another pilot in the flight experienced a physiological event, exploring how they recognized something was wrong, assessed the level of impairment, and regained situation awareness. We describe cognitive requirements, specific cues and strategies, as well as complexities associated with managing these disorienting physiological events. Implications for decision support design and training are discussed.

Objectives. It is prescribed to determine blue-light hazard (BLH) weighted radiances, $ {L_\textrm{B}} $ LB, for an assessment of spotlights with an angular subtense $ \alpha \ge 11{\mkern 1mu} \,\textrm{mrad} $ α≥11mrad. The BLH weighted irradiance, $ {E_\textrm{B}} $ EB, can be used alternatively for smaller sources. Appropriate instruments are not common among persons commissioned with risk assessment (RA), and especially $ {L_\textrm{B}} $ LBmeasurements may be challenging. Therefore, a practical BLH RA approach is proposed that is based on illuminance, $ {E_\textrm{v}} $ Ev, pre-calculated blackbody BLH efficacies of luminous radiation, $ K_{\textrm{B,v}}^{\textrm{Planck}} $ KB,vPlanck, and solid angle considerations. Methods. The practicality of this method was examined and compared against other RA approaches. Results. To ensure comparability of the applied instruments, measurements were performed close to a radiance standard, showing deviations within the lamp’s expanded uncertainties ( $ \lt 4{\mkern 1mu} \% $ <4%), whereas the deviations were $ \pm 15\% $ ±15%for longer distances. Focusing on a complex light-emitting diode (LED) spotlight, all detected values could be converted to $ {L_\textrm{B}} $ LBby means of the RA methods within $ \pm 20\% $ ±20%. Two field tests with several spotlights yielded maximum permissible exposure durations (MPED) obtained from the different RA approaches that agreed among each other within uncertainties largely below $ \pm 30\% $ ±30%. Conclusion. The general practicality of the proposed $ {E_\textrm{v}} $ Evmethod can be concluded for a workplace BLH RA of white-light sources.

Purpose of Review: Social media provides an accessible and increasingly popular avenue for sharing healthcare information, networking, and outreach in dermatology. We provide an overview of prominent social media platforms, also known as applications or apps, as well as a discussion of their influence and implications for the field. Recent Findings: The various collaborative features of Facebook, Twitter, Instagram, TikTok, YouTube, Snapchat, and other emerging platforms have proven appealing to organizations and users seeking dermatology-related content and medical advice. However, the potential for propagation of inaccurate or even dangerous information is high. Summary: Despite the risks associated with social media usage, dermatology can benefit from opportunities to connect and engage with audiences through these platforms. Dermatologists should be encouraged to increase their presence on multiple social media apps to dispel and counteract misleading posts with evidence-based knowledge.

Purpose of Review: The purpose of review is to provide guidance on the use of social media within the context of dermatology and discuss its ethical, professional, and legal implications in education, mentorship, networking, business, and clinical settings. Recent Findings: Despite its fundamental value as a means of communication and knowledge sharing, social media carries legal, ethical, and professional challenges. Healthcare providers have run into issues such as misinformation, conflicts of interest, and overstepping patient-physician boundaries when using social media. An interesting finding is that dermatologists commonly engage with an online audience through social media marketing or being an influencer to improve business and extend their reach to clients; however, this warrants formal training and the need to monitor their own online presence to prevent legal consequences. Summary: Social media has become integral in everyday life; billions of people now receive information and stay connected with each other through social platforms. Within medicine, social media has enhanced various aspects of healthcare, such as professional networking, patient care, and patient education. In dermatology, social media allows dermatologists to promote their businesses and services through patient testimonials, posting advice on blogs, and networking with a large audience of potential patients. However, having a social media presence must be exercised with care, purpose, and transparency to maximize benefits and minimize harmful consequences. This is especially important when inappropriate social media posts by physicians can be scrutinized for breaching patient confidentiality, violating privacy, financial conflicts of interest, and possibly disseminating incorrect information.

Cognitive task analysis (CTA) methods are traditionally used to conduct small-sample, in-depth studies. In this case study, CTA methods were adapted for a large multi-site study in which 102 anesthesiologists worked through four different high-fidelity simulated high-consequence incidents. Cognitive interviews were used to elicit decision processes following each simulated incident. In this paper, we highlight three practical challenges that arose: (1) standardizing the interview techniques for use across a large, distributed team of diverse backgrounds; (2) developing effective training; and (3) developing a strategy to analyze the resulting large amount of qualitative data. We reflect on how we addressed these challenges by increasing standardization, developing focused training, overcoming social norms that hindered interview effectiveness, and conducting a staged analysis. We share findings from a preliminary analysis that provides early validation of the strategy employed. Analysis of a subset of 64 interview transcripts using a decompositional analysis approach suggests that interviewers successfully elicited descriptions of decision processes that varied due to the different challenges presented by the four simulated incidents. A holistic analysis of the same 64 transcripts revealed individual differences in how anesthesiologists interpreted and managed the same case.

Background: Essential to the coagulation pathway, vitamin K (phytonadione) is used to correct clotting factor deficiencies and for reversal of warfarin-induced bleeding. In practice, high-dose intravenous (IV) vitamin K is often used, despite limited evidence supporting repeated dosing.Objective: This study sought to characterize differences in responders and nonresponders to high-dose vitamin K to guide dosing strategies.Methods: This was a case-control study of hospitalized adults who received vitamin K 10 mg IV daily for 3 days. Cases were represented by patients who responded to the first dose of IV vitamin K and controls were nonresponders. The primary outcome was change in international normalized ratio (INR) over time with subsequent vitamin K doses. Secondary outcomes included factors associated with response to vitamin K and incidence of safety events. The Cleveland Clinic Institutional Review Board approved this study.Results: There were 497 patients included, and 182 were responders. Most patients had underlying cirrhosis (91.5%). In responders, the INR decreased from 1.89 at baseline (95% CI = [1.74-2.04]) to 1.40 on day 3 (95% CI = [1.30-1.50]). In nonresponders, the INR decreased from 1.97 (95% CI = [1.83-2.13]) to 1.85 ([1.72-1.99]). Factors associated with response included lower body weight, absence of cirrhosis, and lower bilirubin. There was a low incidence of safety events observed.Conclusions: In this study of mainly patients with cirrhosis, the overall adjusted decrease in INR over 3 days was 0.3, which may have minimal clinical impact. Additional studies are needed to identify populations who may benefit from repeated daily doses of high-dose IV vitamin K.

This paper presents the results of a project to articulate a theory–based framework for characterizing the decision making and situation awareness (SA) of Army Aviators. This was the first step toward developing strategies for evaluating the impact of emerging technologies on cognitive performance. The team conducted a literature review of decision making and SA models along with a review of Army Aviation cognitive requirements and identified key decision making concepts. The team synthesized a framework of decision making based on key concepts from the literature tailored to Army Aviation. The framework guided a literature review of evaluation methods and measures. Evaluation literature review findings included the use of scenario-based evaluation with a range of complexities, and multiple, complementary measures. The synthesized framework served as a useful tool to describe aviator decision making and how technology can influence decision making and SA, and may be useful beyond the Army Aviation context.

The prevalence of artificial intelligence (AI) is rapidly growing across industries including in health care. AI has the potential to improve patient safety (e.g., diagnostic error) and reduce clinician workload (e.g., documentation burden) and healthcare costs. Yet, many questions remain about how clinicians will interact with and use AI to support their work and how these technologies will impact clinician workflow, decision-making, and teamwork. It is also uncertain how patients will interact with AI, with a recent report suggesting 60 percent of US adults are uncomfortable with their health care providers using AI. In this panel, we will discuss AI applications across differing health care contexts and describe how AI influences clinician (and patient) workflows. We will outline considerations for the design and implementation of AI-based technologies in health care and needed areas of future research.

This expert panel is the second of a two-panel series marking the 40thanniversary of “Cognitive Systems Engineering: New Wine in New Bottles” by Hollnagel and Woods (1983) and, arguably, the beginning of Cognitive Systems Engineering (CSE). These experts were there at (or near) the beginning. They wrestled with the daunting issues of how to apply new CSE findings, many of which they themselves discovered, into workable solutions that actually improved systems performance in high-uncertainty, high-stakes settings. Their work has been implemented in a number of fields, including aviation, healthcare, power generation, and defense. They will each answer the question, “What ideas and perspectives are important about Cognitive Systems Engineering, and why?”

Creating and communicating effective safety protocols is important to the well-being of healthcare workers, patients, and all who interact with health systems. Although protocols have been used to support healthcare teams in providing care for decades, there is limited consensus about what constitutes an effective protocol (Myburgh, 2008). In fact, there is considerable ambiguity about what constitutes a protocol versus a policy versus a guideline versus a standard operating procedure. This panel uses the term protocol as an umbrella term to represent a range of strategies used to mandate and/or guide personnel in implementing safe practices. Panelists will discuss their perspectives and latest research characterizing challenges to effective safety protocols, as well as future directions for improving protocols in healthcare.

This panel brings together a diverse set of experts to discuss training for high-stakes domains such as emergency medicine, law enforcement, combat medicine, and others. Work in these domains typically involves managing uncertainty, time pressure, and often life and death risk. These high-stakes domains are often leaders in simulation-based training, creating virtual environments and seeking the right types of fidelity to prepare personnel to develop the perceptual, sensemaking, and stress management skills needed to perform in some of the toughest situations. Panelists will discuss some of the challenges for training and evaluating the effectiveness of training in these complex domains. They will share examples of successful strategies and lessons learned from less-than-successful strategies.

Purpose Investigate the associations between psychosocial factors and physical activity.Design Secondary data analysis utilizing baseline data of a large-scale community-based randomized controlled lifestyle behavior intervention.Setting The Special Supplemental Program for Women, Infants, and Children in Michigan, USA.Subjects Low-income overweight or obese mothers with young children (N = 740, 65% response rate).Measures Survey data were collected via phone interview. Predictors included self-efficacy, autonomous motivation, emotional coping, and social support. Self-reported leisure physical activity was the outcome variable. Covariates were age, race, smoking, employment, education, body mass index, and postpartum status.Analysis A multiple linear regression model was applied.Results Self-efficacy (β= .32, 95% CI = .11, .52, P = .003) and autonomous motivation (β= .10, 95% CI = .03, .17, P= .005) were positively associated with physical activity. However, emotional coping and social support were not associated with physical activity.Conclusion Future research should examine the longitudinal association of key psychosocial factors with physical activity.

Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.

In recent years, there has been growing recognition of the active role of patients in healthcare, highlighting the need to support patient work by designing systems, processes, and communications that are patient-centered. Patients are called upon to make consequential decisions based on complex cognitive and perceptual cues. Some patients may even possess deep knowledge about their condition and its management. However, there is little research applying naturalistic decision making (NDM) to study patient cognition and decision making. This application may have the potential to help understand and support patients to more effectively manage their health, wellness, and safety. In this panel, we address the relevance and applicability of NDM in terms of theory, terminology, and methods to the design of patient-centered solutions.

The Learn, Experience, Reflect framework for training design provides a structure for communication and collaboration among researchers, trainers, training designers, and technology developers. The framework was articulated in the context of efforts to develop effective recognition skills training for combat medics using augmented reality technology. The Learncomponent presents didactic information to extend and refine learners’ existing mental models. The Experiencecomponent leverages augmented reality to provide opportunities to practice applying learned concepts in context. The Reflectcomponent is designed to help learners reflect on their own knowledge to highlight and address knowledge gaps.

Introduction: Unfractionated heparin is the most commonly utilized anticoagulant in extracorporeal membrane oxygenation (ECMO) due to clinician familiarity, ease of reversal, and low cost compared to alternative agents. However, heparin’s anticoagulant effect can be unpredictable and its use accompanies a risk of heparin induced thrombocytopenia (HIT). Successful use of bivalirudin as an alternative to heparin in non-HIT ECMO patients has previously been described. However, there is a paucity of data regarding its utilization in patients with confirmed HIT on ECMO.Methods: This single-center retrospective chart review at Cleveland Clinic Main Campus included 12 ECMO patients who were managed with bivalirudin for a new diagnosis of HIT. Descriptive statistical analyses were performed utilizing median with interquartile range and number with percent as appropriate.Results: Of the 12 patients included, median ECMO duration was 328.5 (218.8–502.1) h and venoarterial ECMO was the most common configuration. No patients experienced the primary outcome of in-circuit thrombosis while on bivalirudin. One patient developed a deep vein thrombosis 22.5 h after switching from heparin to bivalirudin. Major bleeding occurred during bivalirudin therapy in 8 (66.7%) patients.Conclusions: Overall, our study results suggest that bivalirudin is effective for the management of HIT and did not show evidence of in-circuit thrombosis. A high incidence of major bleeding was observed with bivalirudin use within this study. Clinicians should view bivalirudin as an acceptable agent for the treatment of HIT in the ECMO population, but must consider bleeding risk given the lack of effective reversal agents.

An honest dialogue regarding how children and teens continue to use various technologies is critical to pediatric primary care and health supervision. Technology use among children and teens exceeds current guidelines. The authors highlight opportunities for health care providers to reconcile expert recommendations with real-world technology use. Providers are encouraged to assess technology use in families, identify both positive and at-risk behaviors, and guide positive technology adoption among children, teens, and families.

Breast cancer (BC) is the second cause of cancer-related deceases in the worldwide female population. Despite the successful treatment advances, 25% of BC develops resistance to current therapeutic regimens, thereby remaining a major hurdle for patient management. Current therapies, targeting the molecular events underpinning the adaptive resistance, still require effort to improve BC treatment. Using BC sphere cells (BCSphCs) as a model, here we showed that BC stem-like cells express high levels of Myc, which requires the presence of the multifunctional DNA/RNA binding protein Sam68 for the DNA-damage repair. Analysis of a cohort of BC patients displayed that Sam68 is an independent negative factor correlated with the progression of the disease. Genetic inhibition of Sam68 caused a defect in PARP-induced PAR chain synthesis upon DNA-damaging insults, resulting in cell death of TNBC cells. In contrast, BC stem-like cells were able to survive due to an upregulation of Rad51. Importantly, the inhibition of Rad51 showed synthetic lethal effect with the silencing of Sam68, hampering the cell viability of patient-derived BCSphCs and stabilizing the growth of tumor xenografts, including those TNBC carrying BRCAmutation. Moreover, the analysis of Myc, Sam68 and Rad51 expression demarcated a signature of a poor outcome in a large cohort of BC patients. Thus, our findings suggest the importance of targeting Sam68-PARP1 axis and Rad51 as potential therapeutic candidates to counteract the expansion of BC cells with an aggressive phenotype.

As greater emphasis is placed on addressing critical school issues such as school-based mental health, violence prevention, and the effects of trauma, the utilization of school counselors should be examined to ensure that these uniquely-trained professionals are mobilized by school administrators to engage these issues. Q methodology was employed to explore how a convenience sampling of 32 current principals across varying demographics and grade levels conceptualize the role of the school counselor. The results of this study provide a rich understanding of how principals view school counselors in relation to the needs of their respective school communities. Evident is a clear and consistent emphasis of principals on the need for school counselors to have a strong rapport with their students. Discussed are additional steps that may be considered in further advancing the relationships between these two types of professionals, as well as insights to inform school principal preparation programs in how school leaders can appropriately utilize student services personnel.

Surfactants, many of which are used as detergents, can be found in many common household items, such as shampoos, conditioners, soaps, and cosmetics. One should recognize the multitude of surfactants that are used in today's products to identify any potential allergic contact dermatitis (ACD) or irritant contact dermatitis (ICD). Given their abundance in everyday products, it is understandable that many cases of occupational contact dermatitis that arise can be attributed to surfactants. The products most connected with ACD are cocamidopropyl betaine, oleamidopropyl dimethylamine, decyl glucoside, 3-dimethylaminopropylamine, amidoamine, and cocamide diethanolamine. Similarly, the most common surfactant-related causes of ICD are sodium lauryl sulfate and benzalkonium chloride. It is important for dermatologists to identify the causes and differentiate between the two, to adjust treatments and products accordingly. Here, the most frequently used surfactants, as well as their correlation between ACD and ICD, will be reviewed.

Training focused on recognizing when a medical procedure has not been implemented effectively may reduce preventable battlefield deaths. Although important research has been conducted about a range of error recovery training strategies, few studies have been conducted in the context of training for high stakes, dynamic domains such as combat medic training. We conducted a literature review to examine how error recovery training has been designed in other contexts, with the intent of abstracting recommendations for designing error recovery training to support military personnel providing emergency field medicine. Implications for combat medic training include: 1) a focus on error management rather than error avoidance, 2) a didactic training component may support training engagement and mental model development, 3) an experiential component may be designed to support perceptual skill development and anomaly detection, and 4) feedback should focus on allowing learners to make errors and encouraging them to learn from errors.

While there is an extensive and established history of research that demonstrates the unfortunate capacity of exam room computing and electronic health records (EHRs) to negatively impact provider-patient communication and interaction, recent trends in exam room computing are promising in that there may be an opportunity for the EHR to improve patient engagement. The logical evolution of this research is to flip the narrative to understand strategies for using exam room computing as a mediator or facilitator of provider-patient communication and interaction, rather than simply establishing ways to mitigate the documented barriers. Panelists will present and discuss their latest research and experiences that may contribute to the evolution of using exam room computing as a tool to enhance provider-patient communication and interaction. We will also discuss how a thoughtful exam room design with patient-centered exam room computing technologies and practices may positively impact specific human factors, safety, and bias outcomes.

End-of-shift handoffs occur when physicians transfer care responsibilities from one shift to another. Typically viewed as a straightforward exchange of information, we argue that several contextually relevant factors shape the communication behaviors of outgoing and incoming residents during handoffs. Digital recordings and transcripts of resident handoffs in medicine and surgery were made at three VA Medical Centers. They were triangulated with cognitive task interviews that elicited residents’ reconstructions of their work practices. Analyses revealed clear distinctions among “day-to-night,” “night-to-day,” and “double handoffs” that involve transitions between day and night teams. Although residents preferred handing off in dedicated, quiet spaces, few (16%) occurred in such settings; 28% contained significant interruptions. The quality handoff artifacts (notes and forms) influenced interactions, especially in cases where multiple residents from different teams were involved, requiring incoming residents to adjust “on the fly.” This study demonstrated that there are multiple contextual factors that affect, and are affected by, handoff interactions. The findings suggest that handoffs are less like the delivery of a telegram (unidirectional) and more like complex adaptive systems (products of interactional co-construction). Teaching communication practices based on interaction complexity may reduce errors and adverse outcomes for hospitalized patients.

Recent developments in the portability, flexibility, and affordability of augmented reality technology allow it to address some limitations of current medical training. This pilot study aims to determine whether augmented reality can enhance the detection and identification of subtle cues used to make accurate medical diagnoses. We randomly assigned five participants to a control group, where they received diagnostic training by reading a standard textbook, and an experimental group, where they received diagnostic training by a combination of reading a standard textbook and augmented reality-based training. All participants were tested with a tension pneumothorax scenario, where they listed symptoms and made a diagnosis. We recorded the time until a final diagnosis was made and categorized the diagnosis and symptoms as accurate or inaccurate. A two-tailed t-test was used to assess differences between groups. The experimental group correctly identified more symptoms than the control group (average 12 vs. 5). These results indicate the potential of AR-based training to enhance detection and identification of cues in medical diagnostics.

The Impella device is a percutaneous ventricular assist devices that requires administration of heparin via a continuous purge solution. Patients on Impella device support may experience hemolysis with accompanying thrombocytopenia generating suspicion for heparin-induced thrombocytopenia (HIT). However, data and recommendations for use of non-heparin anticoagulants with Impella device are lacking. Therefore, we performed a retrospective cohort analysis of patients requiring bivalirudin during Impella device support to describe the safety and efficacy of bivalirudin as an alternative anticoagulant during Impella device support. Nine patients were included in the evaluation which analyzed Impella device purge flow and purge pressure along with bivalirudin dosing requirements, incidence of thrombosis, and incidence of pump failure. All patients had a positive platelet factor-4 IgG ELISA test, and the serotonin release assay was positive in four patients. After initiation of bivalirudin, the median (15th, 85th percentile) nadir purge flow decreased by 76% (5%, 88%) and the median (15th, 85th percentile) peak purge pressure increased by 86% (21%, 143%). At the time of bivalirudin discontinuation, the median final purge flow and pressure were 2.4 mL/h (74% decrease) and 969 mmHg (89% increase), respectively. Zero patients experienced catastrophic pump failure. Adding low concentration bivalirudin to the purge solution along with systemic bivalirudin may be a reasonable approach.