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Handoffs are critical points in transitioning care between multidisciplinary teams, yet data regarding intensive care unit (ICU) handoffs in pediatric noncardiac surgical patients are lacking. We hypothesized that standardized handoffs from the pediatric operating room (OR) to the ICU would improve physician presence, communication, and patient care parameters.This quality improvement initiative was performed at a tertiary children's hospital. Stakeholders (anesthesiologists, nurses, intensivists, and surgeons) developed a standardized OR to pediatric and neonatal ICU handoff process based on common goals and outcomes of interest. Baseline data were collected before intervention. Implementation was carried out in 2 phases, phase 1 with a written handoff and Phase 2 with a scripted handoff process. Data collected by trained observers included handoff attendance, distractions, and transfer of essential patient information. As a surrogate for outcomes, patient care parameter data were collected for 6 hours after transfer.After phase 1, surgery and ICU physician attendance increased significantly, distractions decreased, and communication of essential patient data improved. In phase 2 (scripted handoff), attendance continued to rise, distractions remained decreased, and transfer of essential information was still improved compared with baseline. Mean handoff duration did not significantly change throughout the study. Certain patient care parameters (escalation of respiratory support, additional laboratory studies, vasopressor administration, antibiotic administration and timing) remained unchanged compared with baseline. However, the need for resuscitative fluid bolus or blood products significantly decreased after implementation phase 2.Standardized handoffs for pediatric noncardiac surgical patients from the OR to the ICU can improve provider attendance and communication.

Portal venous thrombosis (PVT) is an uncommon disease associated with highly morbid conditions such as intestinal ischemia and portal hypertension. Patients at higher risk of developing PVT include those with cirrhosis, malignancy, or prothrombotic states. The mainstay of treatment is early initiation of anticoagulation. The first case is a 49-year-old female diagnosed with a cecal mass and PVT. She was started on anticoagulation and underwent a right hemicolectomy with several small bowel resections. She developed portal hypertension that required TIPS and mechanical thrombectomy. The second patient is a 65-year-old female found to have PVT. She was anticoagulated with heparin and given systemic TPA. She developed intestinal ischemia and portal hypertension requiring small bowel resection, TIPS, and mechanical thrombectomy. These cases give insight into the impact of a multidisciplinary team approach to PVT. The role and timing of endovascular treatment is not well established and needs to be further investigated.

We find evidence for a strong thermal inversion in the dayside atmosphere of the highly irradiated hot Jupiter WASP-18b (T$_{eq}=2411K$, $M=10.3M_{J}$) based on emission spectroscopy from Hubble Space Telescope secondary eclipse observations and Spitzer eclipse photometry. We demonstrate a lack of water vapor in either absorption or emission at 1.4$\mu$m. However, we infer emission at 4.5$\mu$m and absorption at 1.6$\mu$m that we attribute to CO, as well as a non-detection of all other relevant species (e.g., TiO, VO). The most probable atmospheric retrieval solution indicates a C/O ratio of 1 and a high metallicity (C/H=$283^{+395}_{-138}\times$ solar). The derived composition and T/P profile suggest that WASP-18b is the first example of both a planet with a non-oxide driven thermal inversion and a planet with an atmospheric metallicity inconsistent with that predicted for Jupiter-mass planets at $>2\sigma$. Future observations are necessary to confirm the unusual planetary properties implied by these results., Comment: 7 pages, 4 figures, 1 table, published in ApJ Letters 11/29

We re-visit the principles of transmission spectroscopy for transiting extrasolar planets, focusing on the overlap between the planetary spectrum and the illuminating stellar spectrum. Virtually all current models of exoplanetary transmission spectra utilize an approximation that is inaccurate when the spectrum of the illuminating star has a complex line structure, such as molecular bands in M-dwarf spectra. In those cases, it is desirable to model the observations using a coupled stellar-planetary radiative transfer model calculated at high spectral resolving power, followed by convolution to the observed resolution. Not consistently accounting for overlap of stellar M-dwarf and planetary lines at high spectral resolution can bias the modeled amplitude of the exoplanetary transmission spectrum, producing modeled absorption that is too strong. We illustrate this bias using the exoplanet TRAPPIST-1b, as observed using HST/WFC3. The bias in this case is about 250 parts-per-million, 12% of the modeled transit absorption. Transit spectroscopy using JWST will have access to longer wavelengths where the water bands are intrinsically stronger, and the observed signal-to-noise ratios will be higher than currently possible. We therefore expect that this resolution-linked bias will be especially important for future JWST observations of TESS-discovered super-Earths and mini Neptunes transiting M-dwarfs., Comment: Accepted for ApJ Letters

1Division of Infectious Diseases, St Mary’s Hospital, Montreal, Quebec; 2Faculty of Medicine, McGill University, Montreal, Quebec Correspondence: Dr J Dylewski, St Mary’s Hospital, 3830 Lacombe Avenue, Montreal, Quebec H3T 1M5. Telephone 514-345-3511 ext 3075, fax 514-734-2607, e-mail joe.dylewski@ssss.gouv.qc.ca A woman was admitted to hospital with a sixday history of fever as high as 40°C, chills, sweats and headache. She also complained of generalized weakness, sore throat and a nonproductive cough. These symptoms had been evaluated in the emergency room three days previously, at which time a small cutaneous lesion on the upper medial portion of the left breast was noted. She was given a prescription for cefuroxime 500 mg twice daily, which she took, but she did not improve. She returned on the day of admission because of a new nonpruritic rash over her entire body, including the palms of her hands and the soles of her feet. The patient was a schoolteacher and had no significant past medical history. She had returned from a one-month vacation in Portugal one day before the onset of her symptoms. No family members were ill. She had stayed mainly in the countryside and had gone hiking in wooded areas. On examination, she appeared to be ill with a temperature of 38.9°C, a pulse of 145 beats/min, a blood pressure of 110/50 mmHg and a respiratory rate of 18 breaths/min. There was a slight conjunctival injection. The cardiorespiratory examination was normal and no organomegaly or adenopathy was present. Her body was covered with a nonblanching erythematous and ecchymotic maculopapular rash that involved the palms and soles. A small (1 to 2 mm) crusted cutaneous ulceration was present on the left breast. Relevant laboratory data included a hemoglobin level of 118 g/L, leukocyte count of 6.3×109/L, platelet count of 124×109/L, alkaline phosphatase level of 341 IU/L (three times the normal level), alanine aminotransferase level of 350 IU/L (nine times the normal level), aspartate aminotransferase level of 385 IU/L (nine times the normal level), gamma-glutamyl transpeptidase level of 208 (four times the normal level), and a normal chest radiograph and abdominal ultrasound. She continued to have daily fevers up to 39°C and her leukocyte count rose to 16.8×109/L. Serological tests for hepatitis A immunoglobulin M (IgM), hepatitis B surface antigen, rubella IgM and measles IgM were all negative. What is your diagnosis and what therapy would you initiate?