Right-sizing interprofessional team training for serious-illness communication: A strength-based approach

Objective

Palliative care communication skills help tailor care to patients' goals. With a palliative care physician shortage, non-physicians must gain these serious illness communication skills. Historically, trainings have targeted physician-only groups; our goal was to train interprofessional teams.

Methods

Workshops were conducted to teach palliative care communication skills and interprofessional communication. Participants completed surveys which included questions from the Interpersonal Reactivity Index, the Ekman Faces tool, the Consultation and Relational Empathy measure, open-ended questions about empathy, and measures of effective interprofessional practice.

Results

Participants felt the workshop improved their ability to listen (p < 0.001), understand patients' concerns (p < 0.001), and show compassion (p = 0.008). It increased the perceived value of peer observation (p < 0.001) and ability to reflect (p = 0.02) during complex conversations. Different types of professionals adopted different communication goals, though all affirmed the importance of active listening. Participants felt they improved their ability to work within an interprofessional team.

Conclusions

The course effectively trained 71 clinicians, the majority non-physicians, in serious illness communication and interprofessional team communication skills, and could be reproduced in similar settings.

Innovation

We adapted an approach common to physician-only trainings to diverse interprofessional groups, added a team-based component using Applied Improvisation, and demonstrated its effectiveness.

Application of a time-fractal fractional derivative with a power-law kernel to the Burke-Shaw system based on Newton's interpolation polynomials

This paper proposes some updated and improved numerical schemes based on Newton's interpolation polynomial. A Burke-Shaw system of the time-fractal fractional derivative with a power-law kernel is presented as well as some illustrative examples. To solve the model system, the fractal-fractional derivative operator is used. Under Caputo's fractal-fractional operator, fixed point theory proves Burke-Shaw's existence and uniqueness. Additionally, we have calculated the Lyapunov exponent (LE) of the proposed system. This method is illustrated with a numerical example to demonstrate the applicability and efficiency of the suggested method. To analyze this system numerically, we use a fractal- fractional numerical scheme with a power-law kernel to analyze the variable order fractal- fractional system. Furthermore, the Atangana-Seda numerical scheme, based on Newton polynomials, has been used to solve this problem. This novel method is illustrated with numerical examples. Simulated and analytical results agree. We contribute to real-world mathematical applications. Finally, we applied a numerical successive approximation method to solve the fractional model.•The purpose of this section is to define a mathematical model to study the dynamic behavior of the Burke-Shaw system.•With the Danca algorithm [1,2] and Adams-Bashforth-Moulton numerical scheme, we compute the Lyapunov exponent of the system, which is useful for studying Dissipativity.•In a generalized numerical method, we simulate the solutions of the system using the time-fractal fractional derivative of Atangana-Seda.

Improved recall of handover information in a simulated emergency - A randomised controlled trial

Background

Handovers during medical emergencies are challenging due to time-critical, dynamic and oftentimes unorderly and distracting situations. We evaluated the effect of distraction-reduced clinical surroundings during handover on (1) the recall of handover information, (2) the recall of information from the surroundings and (3) self-reported workload in a simulated in-hospital cardiac arrest scenario.

Methods

In a parallel group design, emergency team leaders were randomly assigned to receive a structured handover of a cardio-pulmonary resuscitation (CPR) either inside the room ("inside group") right next to the ongoing CPR or in front of the room ("outside group") with no audio-visual distractions from the ongoing CPR. Based on the concept of situation awareness, the primary outcome was a handover score for the content of the handover (0-19 points) derived from the pieces of information given during handover. Furthermore, we assessed team leaders' perception of their surroundings during the scenario (0-5 points) and they rated their subjective workload using the NASA Task Load Index.

Results

The outside group (n = 30) showed significant better recall of handover information than the inside group (n = 30; mean difference = 1.86, 95% CI = 0.67 to 3.06, p = 0.003). The perception of the surroundings (n = 60; mean difference = -0.27, 95% CI = -0.85 to 0.32, p = 0.365) and the NASA Task Load Index (n = 58; mean difference = 1.1; p = 0.112) did not differ between the groups.

Conclusions

Concerning in-hospital emergencies, a structured handover in a distraction reduced environment can improve information uptake of the team leader.

The full-length TSH receptor is stabilized by TSH ligand

The receptor for thyroid stimulating hormone (TSHR), a GPCR, is the primary antigen in autoimmune hyperthyroidism (Graves' disease) caused by stimulating TSHR antibodies. While we have previously published a full length model of the TSHR, including its leucine rich domain (LRD), linker region (LR) and transmembrane domain (TMD), to date, only a partial LRD (aa 21-261) stabilized with TSHR autoantibodies has been crystallized. Recently, however, cryo-EM structures of the full-length TSHR have been published but they include only an incomplete LR. We have now utilized the cryo-EM models, added disulfide bonds to the LR and performed longer (3000 ns) molecular dynamic (MD) simulations to update our previous model of the entire full-length TSHR, with and without the presence of TSH ligand. As in our earlier work, the new model was embedded in a lipid membrane and was solvated with water and counterions. We found that the 3000 ns Molecular Dynamic simulations showed that the structure of the LRD and TMD were remarkably constant while the LR, known more commonly as the "hinge region", again showed significant flexibility, forming several transient secondary structural elements. Analysis of the new simulations permitted a detailed examination of the effect of TSH binding on the structure of the TSHR. We found a structure-stabilizing effect of TSH, including increased stability of the LR, which was clearly demonstrated by analyzing several intrinsic receptor properties including hydrogen bonding, fluctuation of the LRD orientation, and radius of gyration. In conclusion, we were able to quantify the flexibility of the TSHR and show its increased stability after TSH binding. These data indicated the important role of ligands in directing the signaling structure of a receptor.

The impact of simultaneous intracranial recordings on scalp EEG: A finite element analysis

BACKGROUND

In this study, we examined the utility of simultaneous scalp and stereotactic intracranial electroencephalography (SSIEEG) in epilepsy patients. Although SSIEEG offers valuable insights into epilepsy and cognitive function, its routine use is uncommon. Challenges include interpreting post-craniotomy scalp EEG due to surgically implanted electrodes.

NEW METHOD

We describe our methodology for conducting SSIEEG recordings. To simulate the potential impact on EEG interpretation, we computed the leadfield of scalp electrodes with and without burrholes using Finite Element Analysis to compare the resulting sensitivity volume and waveforms of simulated intracranial signals between skulls with and without burrholes.

RESULTS

The presence of burr holes in the skull layer of the leadfield models did not discernibly modify simulated waveforms or scalp EEG topology. Using realistic SEEG burr hole diameter, the difference in the average leadfield of scalp electrodes was 0.12% relative to the effect of switching two nearby electrodes, characterized by the cosine similarity difference. No patients experienced adverse events related to SSIEEG.

COMPARISON WITH EXISTING METHODS

Although there is increasing acceptance and interest in SSIEEG, few studies have characterized the technical feasibility. Here, we demonstrate through modelling that scalp recordings from SSIEEG are comparable to that through an intact skull.

CONCLUSION

The placement and simultaneous acquisition of scalp EEG during invasive monitoring through stereotactically inserted EEG electrodes is routinely performed at the Hospital for Sick Children. Scalp EEG recordings may assist with clinical interpretation. Burr holes in the skull layer did not discernibly alter EEG waveforms or topology.

Solid phase microextraction device coupled with miniature mass spectrometry and mathematical model of its ion chronogram

Modern solid phase microextraction (SPME) device linked with mass spectrometry (SPME-MS) has evolved from producing ion chronogram as flat noisy signal to as unimodal-like signal. We designed a SPME device, which is closer in morphology to LC column, linked it with a miniature mass spectrometer (SPME-Mini MS), and proposed a mathematical model that elution of compound from the SPME device is equivalent to overlay of elution of the compound from the infinite LC columns with the lengths between 0 and the length of the device and it can generate an ion chronogram as right-skew unimodal signal. Rhodamine B as analyte was used for experimental verification and its unimodal signal was used to fit the parameters of a computer simulation program based on the model. The experimental results and simulations empirically cross-confirmed that SPME-Mini MS can generate ion chronogram as clean right-skew unimodal signal. Furthermore, the SPME-Mini MS system was used for quantitative analysis of psychotropic drugs (i.e. risperidone and aripiprazole) in artificial urine. The results preliminarily demonstrated that the system can utilize area under unimodal signal for quantitative analysis and has potential to be applied for on-site, fast and accurate quantification of drugs and other compounds.

Using Unannounced Standardized Patients to Assess Clinician Telehealth and Communication Skills at an Urban Student Health Center

PURPOSE

As the COVID-19 pandemic forced most colleges and universities to go online, student health centers rapidly shifted to telehealth platforms without frameworks for virtual care provision. An urban student health center implemented a needs assessment involving unannounced standardized patients (USPs) to evaluate the integration of a new telehealth workflow and clinicians' virtual communication skills.

METHODS

From April to May 2021, USPs conducted two video visits with 12 primary care and four women's health clinicians (N = 16 clinicians; 32 visits). Cases included (1) a 21-year-old female presenting for birth control with a positive Patient Health Questionaire-9 and (2) a 21-year-old male, who vapes regularly, with questions regarding safe sex with men. Clinicians were evaluated using a checklist completed by the USP immediately following the visit and a systematic chart review of the electronic health record.

RESULTS

USP feedback indicates most clinicians received high ratings for general communication skills but may benefit from educational intervention in several key telemedicine skills. Clinicians struggled with using nonverbal signals to enrich communication (47% well done), acknowledging emotions (34% well done), and using video for information gathering (34% well done). Low rates of standard screenings (e.g., 63% administered the PHQ-2, <50% asked about alcohol use) suggested protocols for in-person care were not easily incorporated into telehealth practices, and clinicians may benefit from enhanced care team support. Performance reports were shared with clinicians and leadership postvisit.

DISCUSSION

Results suggest project design and implementation is scalable and feasible for use at other institutions, offering a structured methodology that can improve general student health care.

Virtual reality in experiential pharmacy education: A quasi-experimental study

Introduction

Extended reality (XR) technologies are an umbrella term for simulated-based learning tools that cover 3-dimensional technologies, including virtual reality (VR), augmented reality (AR), and mixed reality (MR). At King Saud University, first-year pharmacy students are required to experience hospital observational training during the Introductory Pharmacy Practice Experience (IPPE). We aimed to measure the effectiveness and satisfaction of the VR learning experience among IPPE students.

Methods

A Quasi-Experimental study was conducted. The experimental arm included first-year PharmD students. VR headset was used to watch three narrated videos capturing 360° views of the outpatient, inpatient pharmacy, and counseling clinic. A test measuring students' general knowledge was required prior to and post the experience, followed by a satisfaction survey. The control arm included second-year PharmD students who had traditional hospital visits and were administered a knowledge test and satisfaction survey.

Results

A total of 336 students were enrolled, 174 in the experimental arm and 162 in the control arm. The results showed improvement in the knowledge scores average among the experimental arm, 1.9 vs 3.5 in the pre-test and post-test. The control arm had a comparable score with an average of 3.7. Regarding self-assessment using four 5-likert scales assessing pharmacist role, skills, and responsibilities, 31.8 % and 42 % in the experimental arm compared to 28.9 % and 28.9 % in the control group answered strongly agree and agree, respectively. Regarding satisfaction, using five 5-Likert scales assessing the experience time, quality, and content, 53 % and 25 % in the experimental group compared to 34 % and 23 % in the control group answered strongly agree and agree, respectively.

Conclusion

VR provides pharmacy students with a standardized and effective learning and training experience. The experimental arm reported higher satisfaction rates and self-reported outcomes. Thus, implementing VR experiences within the pharmacy curriculum will provide students with an advanced educational advantage.

Microscopic chemical characterization of epoxy resin with scanning transmission electron microscopy - electron energy-loss spectroscopy

The structural characterization of epoxy resins is essential to improve the understanding on their structure-property relationship for promising high-performance applications. Among all analytical techniques, scanning transmission electron microscopy-electron energy-loss spectroscopy (STEM-EELS) is a powerful tool for probing the chemical and structural information of various materials at a high spatial resolution. However, for sensitive materials, such as epoxy resins, the structural damage induced by electron-beam irradiation limits the spatial resolution in the STEM-EELS analysis. In this study, we demonstrated the extraction of the intrinsic features and structural characteristics of epoxy resins by STEM-EELS under electron doses below 1 e-/Å2 at room temperature. The reliability of the STEM-EELS analysis was confirmed by X-ray absorption spectroscopy and spectrum simulation as low- or non-damaged reference data. The investigation of the dependence of the epoxy resin on the electron dose and exposure time revealed the structural degradation associated with electron-beam irradiation, exploring the prospect of EELS for examining epoxy resin at low doses. Furthermore, the degradation mechanisms in the epoxy resin owing to electron-beam irradiation were revealed. These findings can promote the structural characterization of epoxy-resin-based composites and other soft materials.

Fostering collaborative practice through interprofessional simulation for occupational therapy, physiotherapy, dietetics, and nursing students

Literature regarding simulation for learning interprofessional collaborative practice (IPCP) indicates a need to include a range of health professions and to focus on students' development of team communication and conflict resolution skills in day-to-day healthcare delivery. This study evaluated the impact of interprofessional simulation for occupational therapy, physiotherapy, dietetics, and nursing students on interprofessional collaboration competencies, specifically collaborative communication and conflict resolution during day-to-day interactions, and their intention for IPCP during placement. A series of simulations featuring the potential for interprofessional conflict and involving explicit coaching on communication and conflict resolution were conducted. A single cohort pre-test post-test design included the Students' Perceptions of Interprofessional Clinical Education Revised (SPICE-R), the Interprofessional Collaborative Competencies Attainment Survey (ICCAS), and an open response survey question on future intended practice. A total of 237 students participated in the simulation experience. Overall scores and scores on all IPCP competencies in the ICASS (n = 193) and SPICE-R (n = 226) improved for all professions post-simulation. The mean score of the ICCAS increased for 98% of the respondents and similarly the mean score of the SPICE-R increased for 71% of the respondents. Open-ended responses indicated students' intentions to pursue self-leadership in IPCP. Students who participated in an interprofessional simulation reported perceived improvements in IPCP competencies and were encouraged to initiate IPCP when on placement in the practice setting.

Current Standards for Training in Robot-assisted Surgery and Endourology: A Systematic Review

BACKGROUND AND OBJECTIVE

Different training programs have been developed to improve trainee outcomes in urology. However, evidence on the optimal training methodology is sparse. Our aim was to provide a comprehensive description of the training programs available for urological robotic surgery and endourology, assess their validity, and highlight the fundamental elements of future training pathways.

METHODS

We systematically reviewed the literature using PubMed/Medline, Embase, and Web of Science databases. The validity of each training model was assessed. The methodological quality of studies on metrics and curricula was graded using the MERSQI scale. The level of evidence (LoE) and level of recommendation for surgical curricula were awarded using the educational Oxford Centre for Evidence-Based Medicine classification.

KEY FINDINGS AND LIMITATIONS

A total of 75 studies were identified. Many simulators have been developed to aid trainees in mastering skills required for both robotic and endourology procedures, but only four demonstrated predictive validity. For assessment of trainee proficiency, we identified 18 in robotics training and six in endourology training; however, the majority are Likert-type scales. Although proficiency-based progression (PBP) curricula demonstrated superior outcomes to traditional training in preclinical settings, only four of six (67%) in robotics and three of nine (33%) in endourology are PBP-based. Among these, the Fundamentals of Robotic Surgery and the SIMULATE curricula have the highest LoE (level 1b). The lack of a quantitative synthesis is the main limitation of our study.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Training curricula that integrate simulators and PBP methodology have been introduced to standardize trainee outcomes in robotics and endourology. However, evidence regarding their educational impact remains restricted to preclinical studies. Efforts should be made to expand these training programs to different surgical procedures and assess their clinical impact.

PATIENT SUMMARY

Simulation-based training and programs in which progression is based on proficiency represent the new standard of quality for achieving surgical proficiency in urology. Studies have demonstrated the educational impact of these approaches. However, there are still no standardized training pathways for several urology procedures.

[Latent safety threats in a pediatric emergency department: Using in situ simulation to test a new trauma room concept]

INTRODUCTION

Structured emergency room concepts have been shown to contribute to patient safety. Until now there has been no uniform emergency room concept for critically ill and seriously injured children and adolescents in the emergency room at the Altona Children's Hospital in Hamburg. This concept has been newly developed in interdisciplinary cooperation and includes the use of new clinical premises as well as new responsibilities and team compositions. The introduction of new processes and rooms for handling emergencies is associated with a risk of overlooking latent safety deficiencies or detecting them only after the process has been implemented. This may have a direct impact on patient safety. Before moving to new clinical premises, in situ simulation can be helpful to identify and to resolve latent safety threats in advance. Therefore, this method was chosen to test the newly created emergency room concept in the future emergency room at the Altona Children's Hospital.

METHODS

Two in situ simulations were carried out in the future real emergency room. Latent safety threats detected by the observation team and the participants (medical and nursing staff of the Altona Children's Hospital from the departments of pediatric surgery, traumatology, orthopedics, pediatrics, anesthesia, intensive care medicine, radiology, emergency medicine) were collected using free text notes after the simulations and evaluated retrospectively. In order to better deal with these latent safety threats, the observations were classified into different categories: working environment (e.g., lack of equipment, unfavorable positioning of material), process (e.g., lack of defined responsibilities in the team) and other safety threats that did not fall into one of the two categories defined.

RESULTS

A total of 51 latent safety threats were identified during the two in situ simulations. Of these, 22 (43.1%) were assigned to the "working environment" category, 20 (39.2%) to the "process" category and 9 (17.7%) to the "other safety threats" category. Of the latent safety threats identified, 46 (90.2 %) could be resolved before the emergency room was put into operation. For the non-recoverable safety threats, safety concepts were developed in order to further minimize the risk of patient hazard.

DISCUSSION

With the help of this study, it could be shown that the implementation of in situ simulation before the commissioning of new clinical premises and the introduction of new processes can contribute to the detection of latent safety threats in an interdisciplinary German pediatric emergency department.

Role of simulation-based training and assessment to improve brachytherapy competency among radiation oncology residents

Simulation is a technique used in healthcare to replicate clinical scenarios and improve patient safety, efficacy, and efficiency. Simulation-based medical education facilitates training and assessment in healthcare without increasing risk to patients, supported by ample evidence from surgical/procedural specialties. Simulation in radiation oncology has been leveraged to an extent, with successful examples of both screen-based and hands-on simulators that have improved confidence and performance in trainees. In the current era, evidence substantiates a significant deficit in brachytherapy procedure education, with radiation oncology residents reporting low confidence in this procedural skill, largely attributable to insufficient caseloads at some centers. Simulation-based medical education can facilitate structured training and competency-based assessment in brachytherapy skills. This review discusses existing advances and future directions in brachytherapy simulation, using examples from simulation in surgical specialties.

A systematic review of the impact of simulation on students' confidence in performing clinical pharmacy activities

BACKGROUND

Although confidence does not automatically imply competence, it does provide pharmacy students with a sense of empowerment to manage a pharmacotherapeutic problem independently. Among the methods used in higher education, there is growing interest in simulation.

AIM

To evaluate the impact of simulation on pharmacy students' confidence in performing clinical pharmacy activities.

METHOD

Articles that reported the use of simulation among pharmacy students with fully described outcomes about confidence were included. Studies for which it was impossible to extract data specific to pharmacy students or simulation were excluded. The search was carried out in Medline, Embase, Lissa and PsycInfo from inception to August the 31th, 2022. The results were synthesized into 4 parts: confidence in collecting information, being an expert in a procedure/pathology, counselling and communicating, and other results. The quality assessment of included studies was conducted using the Mixed Methods Appraisal Tool "MMAT" tool.

RESULTS

Among the 39 included articles, the majority were published in the last 5 years and conducted in the United States. The majority included pharmacy students in years 1 through 3 (69.2%). The most common study design was the pre-post uncontrolled design (66.7%). Studies measuring the effects of human and/or virtual simulation were mainly focused on confidence to counsel and/or communicate with patients and colleagues (n = 20). Evaluations of the effects of these types of simulation on confidence in information gathering by health professionals were also well represented (n = 16).

CONCLUSION

Simulation-based training generally yielded positive impact on improving pharmacy students' confidence in performing clinical pharmacy activities. Rigorous assessment methods and validated confidence questionnaires should be developed for future studies.

Unraveling the mechanisms of Sofosbuvir resistance in HCV NS3/4A protease: Structural and molecular simulation-based insights

Current management of HCV infection is based on Direct-Acting Antiviral Drugs (DAAs). However, resistance-associated mutations, especially in the NS3 and NS5B regions are gradually decreasing the efficacy of DAAs. Among the most effective HCV NS3/4A protease drugs, Sofosbuvir also develops resistance due to mutations in the NS3 and NS5B regions. Four mutations at positions A156Y, L36P, Q41H, and Q80K are classified as high-level resistance mutations. The resistance mechanism of HCV NS3/4A protease toward Sofosbuvir caused by these mutations is still unclear, as there is less information available regarding the structural and functional effects of the mutations against Sofosbuvir. In this work, we combined molecular dynamics simulation, molecular mechanics/Generalized-Born surface area calculation, principal component analysis, and free energy landscape analysis to explore the resistance mechanism of HCV NS3/4A protease due to these mutations, as well as compare interaction changes in wild-type. Subsequently, we identified that the mutant form of HCV NS3/4A protease affects the activity of Sofosbuvir. In this study, the resistance mechanism of Sofosbuvir at the atomic level is proposed. The proposed drug-resistance mechanism will provide valuable guidance for the design of HCV drugs.

High-intensity ultrasound promoted the maturation of high-salt liquid-state soy sauce: A mean of enhancing quality attributes and sensory properties

High-intensity ultrasound was used as a means to promote maturation of soy sauce. The optimal conditions for ultrasound treatment were 90℃ at an ultrasound intensity of 39.48 W/cm2 for 60 min. The total reducing sugars and soluble salt-free solids content was significantly increased after ultrasound-assisted maturation. The free amino acid content was significantly decreased, mainly due to the Maillard reaction (MR). The promoted MR produced several types of flavor compounds, including esters, pyrazines, and ketones, which imparted an attractive aroma to the maturated soy sauce. The proportion of peptides with a molecular weight of 1-5 kDa provided umami as an important flavor characteristic, and the content in the ultrasound-matured soy sauce (10.19 %) was significantly higher than that in the freshly prepared soy sauce (8.34 %) and the thermally treated sample (8.89 %). Ultrasound-assisted maturation would improve product quality and meanwhile, shorten the duration and reduce the cost for the soy sauce industry.

Electric vehicle charging stations: Model, algorithm, simulation, location, and capacity planning

The transition to sustainable transportation is imperative in mitigating environmental impacts, with electric vehicles (EVs) at the forefront of this shift. Despite their environmental benefits, the global adoption of EVs is curtailed by challenges such as nascent battery technology, high costs, and insufficient charging infrastructure. This study addresses the optimizing electric vehicle charging station (EVCS) locations as a critical step toward enhancing EV adoption rates. Thus, establishing efficient charging stations is critical to meet the increasing demand. By integrating location modeling with demand forecasts and market penetration, we propose a comprehensive approach to determine optimal locations and capacities for EVCS. Firstly, review existing literature, highlighting the significance of facility location models in optimizing EV charging infrastructure and identifying gaps in addressing demand and market penetration. Our methodology uses a genetic algorithm to solve the p-median problem for location selection and Arena 14 simulation software to model station traffic and optimize charging unit types and quantities. The model prioritizes public areas, considering potential demand points and station locations to propose optimal charging areas. Results indicate that our model minimizes travel distances and waiting times, offering a scalable solution adaptable to future EV market growth. This study contributes to the field by presenting a sustainable and economical model for EVCS placement and capacity planning, underlining the importance of a robust charging network in the broader adoption of electric transportation. The findings suggest that proactive infrastructure development, guided by accurate demand predictions and optimized location strategies, can significantly enhance the feasibility and attractiveness of EVs, supporting global efforts towards a cleaner, more sustainable transportation system.

Psychologists and Integrated Behavioral Health Simulation Training: A Survey of Medical Educators and Perspectives of Directors of Clinical Training

It is well established that the integration of behavioral healthcare into the medical home model improves patient outcomes, reduces costs, and increases resident learning. As academic health centers increasingly integrate behavioral healthcare, targeted training for interprofessional collaboration around behavioral healthcare is needed. Simulation educational approaches potentially can provide this training. Health service psychologists are well-poised to support this because of their specialized training in integrated healthcare. The present exploratory study aimed to evaluate existing simulation programs and develop recommendations for integrated behavioral health training and evaluation. Directors of ACGME accredited residency programs that are high utilizers of the medical home model (Pediatrics, Internal Medicine, Medicine/Pediatrics, Family Medicine) as well as Psychiatry residencies and medical schools with membership in the Society for Simulation in Healthcare were recruited to complete a 26-item survey to assess program usage of psychologists as part of simulation training for integrated behavioral healthcare services. Of 79 participants who completed initial items describing their training program, only 32 programs completed the entire survey. While many academic health centers offered integrated team and behavioral health simulations, few utilized psychology faculty in design, implementation, and evaluation. Other behavioral health providers (psychiatrists, social workers) were often involved in medical school and pediatric residency simulations. Few institutions use standardized evaluation. Qualitative feedback and faculty-written questionnaires were often used to evaluate efficacy. Survey responses suggest that psychologists play limited roles in integrated behavioral healthcare simulation despite their expertise in interdisciplinary training, integrated behavioral healthcare, and program evaluation.

Simulator-Based Versus Traditional Training of Fundus Biomicroscopy for Medical Students: A Prospective Randomized Trial

INTRODUCTION

Simulation training is an important component of medical education. In former studies, diagnostic simulation training for direct and indirect funduscopy was already proven to be an effective training method. In this prospective controlled trial, we investigated the effect of simulator-based fundus biomicroscopy training.

METHODS

After completing a 1-week ophthalmology clerkship, medical students at Saarland University Medical Center (n = 30) were block-randomized into two groups: The traditional group received supervised training examining the fundus of classmates using a slit lamp; the simulator group was trained using the Slit Lamp Simulator. All participants had to pass an Objective Structured Clinical Examination (OSCE); two masked ophthalmological faculty trainers graded the students' skills when examining patient's fundus using a slit lamp. A subjective assessment form and post-assessment surveys were obtained. Data were described using median (interquartile range [IQR]).

RESULTS

Twenty-five students (n = 14 in the simulator group, n = 11 in the traditional group) (n = 11) were eligible for statistical analysis. Interrater reliability was verified as significant for the overall score as well as for all subtasks (≤ 0.002) except subtask 1 (p = 0.12). The overall performance of medical students in the fundus biomicroscopy OSCE was statistically ranked significantly higher in the simulator group (27.0 [5.25]/28.0 [3.0] vs. 20.0 [7.5]/16.0 [10.0]) by both observers with an interrater reliability of IRR < 0.001 and a significance level of p = 0.003 for observer 1 and p < 0.001 for observer 2. For all subtasks, the scores given to students trained using the simulator were consistently higher than those given to students trained traditionally. The students' post-assessment forms confirmed these results. Students could learn the practical backgrounds of fundus biomicroscopy (p = 0.04), the identification (p < 0.001), and localization (p < 0.001) of pathologies significantly better with the simulator.

CONCLUSIONS

Traditional supervised methods are well complemented by simulation training. Our data indicate that the simulator helps with first patient contacts and enhances students' capacity to examine the fundus biomicroscopically.

Digital twins for cardiac electrophysiology: state of the art and future challenges

Cardiac arrhythmias remain a major cause of death and disability. Current antiarrhythmic therapies are effective to only a limited extent, likely in large part due to their mechanism-independent approach. Precision cardiology aims to deliver targeted therapy for an individual patient to maximize efficacy and minimize adverse effects. In-silico digital twins have emerged as a promising strategy to realize the vision of precision cardiology. While there is no uniform definition of a digital twin, it typically employs digital tools, including simulations of mechanistic computer models, based on patient-specific clinical data to understand arrhythmia mechanisms and/or make clinically relevant predictions. Digital twins have become part of routine clinical practice in the setting of interventional cardiology, where commercially available services use digital twins to non-invasively determine the severity of stenosis (computed tomography-based fractional flow reserve). Although routine clinical application has not been achieved for cardiac arrhythmia management, significant progress towards digital twins for cardiac electrophysiology has been made in recent years. At the same time, significant technical and clinical challenges remain. This article provides a short overview of the history of digital twins for cardiac electrophysiology, including recent applications for the prediction of sudden cardiac death risk and the tailoring of rhythm control in atrial fibrillation. The authors highlight the current challenges for routine clinical application and discuss how overcoming these challenges may allow digital twins to enable a significant precision medicine-based advancement in cardiac arrhythmia management.

Perception of faculty in the community health sciences colleges towards simulation-based education in clinical nutrition undergraduate practical courses

BACKGROUND

Simulation now is widely used for training and education in different fields including healthcare education. Medicine and healthcare students can be trained in a secure, efficient, and engaging setting by Simulation-based Education (SBE). Therefore, this study aimed to assess the perception of faculty members in the community health departments towards SBE to be used in practical subjects for clinical nutrition undergraduate courses.

METHOD

This cross-sectional survey was conducted among community health sciences faculty members. The perception was assessed using a self-administered questionnaire that included three sections.

RESULTS

This questionnaire was completed by 125 faculty members, of whom 36 (28.8%) were male and 89 (71.2%) were female. Overall, faculty members had positive perceptions, with a mean score of 3.86 ± 0.74, but a high level of anxiety toward SBE, with a mean score of 3.42 ± 0.75. There was a statistically significant difference between the responses of the faculty members based on the training they received in simulation (P = 0.001).

CONCLUSION

The study results indicate that community health sciences faculty members' perception of SBE in Saudi Arabia is generally positive. However, the results show high levels of anxiety among faculty members toward SBE.

Challenging the Dogma: Stage migration or negative lymph nodes, which of them is the main player on gastric cancer prognosis?

Expanding loco-regional nodes harvesting is expected to increase survival. This improvement may be associated to stage migration (SM). However, the great bulk of harvested lymph nodes observed in large dissections is negative. M&M: 830 patients who received R0 gastrectomy for adenocarcinoma were included. pN+ patients with <26 nodes (n = 209) were included for a simulation to "offer 26 nodes" - SM (proportional and exponential based) was simulated and analysed through machine learning algorithms. Overall Survival (OS), in native and simulated stages, were compared. OS of extended lymphadenectomies (pN+, D ≥ 26, n = 273) was compared with the simulated curves. OS of patients in the following dissection intervals of negative nodes were compared: <16 (n = 233), 16-25 (n = 258), ≥26 (n = 339). RESULTS: After simulation to 26 nodes (pN+, D < 26 patients, n = 209), staging was recomputed. OS of native vs simulated early-stages (I-II) and advanced stages (III) were not different (p > 0.05). OS of patients with lymphadenectomy (≥26) was better than simulated for early and advanced stages (p = 0.008; p = 0.005). OS of patients included in distinct intervals of negative lymph nodes were different (p < 0.001). These intervals were an independent prognostic factor (multivariate analysis). CONCLUSIONS: The influence of Stage Migration was null in this set of simulations and Will Rogers phenomenon was not observed. Extended dissection performed better in OS. But the influence of the number of negative nodes, even in large dissections, was highlighted. By emphasizing the role of negative nodes, we aim to facilitate more informed decision-making in management of gastric cancer patients, ultimately leading to improved treatment outcomes and patient care.

Modeling of Styl'One Evolution Correction Factors for Multicomponent Mixtures Scaling-up to Roller Compaction

Roll compaction (RC) is a cost-effective dry granulation method, widely implemented in the pharmaceutical industry. In early formulation development however, when the material availability is limited, being able to predict the most important parameters in RC, like gap width and specific compaction force (SCF), to obtain a target ribbon solid fraction (SF) would significantly improve the formulation development efficiency as it would avoid the need of performing experiments on the roller compactor itself. However, at the present state of things, experiments on RC mechanical simulators present an overestimation of the target SF, when compared to roller compactor SF values. Although numerous correction approaches have been developed to improve the predictive performance of different mathematical models applied to the simulation experimental results, no study has collected a database wide enough to demonstrate the validity of a correction factor that allows to accurately simulate the compaction behavior of multicomponent mixtures. Here, 25 different formulations at 40 % drug load are compacted at different SCFs, both on a RC mimicking device (Styl'One Evolution) and on an actual roller compactor (Gerteis Mini-Pactor): following a similar approach as Reimer et al. and implementing a simplified version of the Johanson's mathematical model, 4 different correction factors are calculated, depending on how their material properties and pressure dependencies are considered. In conclusion, one correction factor is identified as the optimal trade-off between the SF prediction accuracy on the Gerteis Mini-Pactor and its applicability to a wide range of formulations, as it is independent of the material properties. This finding is particularly relevant when applied to scale-up to this specific roller compactor or early development processes of new formulations that have not been mechanically characterized yet.

Hepatic steatosis modeling and MRI signal simulations for comparison of single- and dual-R2* models and estimation of fat fraction at 1.5T and 3T

BACKGROUND AND OBJECTIVE

Magnetic resonance imaging (MRI) has emerged as a noninvasive clinical tool for assessment of hepatic steatosis. Multi-spectral fat-water MRI models, incorporating single or dual transverse relaxation decay rate(s) (R2*) have been proposed for accurate fat fraction (FF) estimation. However, it is still unclear whether single- or dual-R2* model accurately mimics in vivo signal decay for precise FF estimation and the impact of signal-to-noise ratio (SNR) on each model performance. Hence, this study aims to construct virtual steatosis models and synthesize MRI signals with different SNRs to systematically evaluate the accuracy of single- and dual-R2* models for FF and R2* estimations at 1.5T and 3.0T.

METHODS

Realistic hepatic steatosis models encompassing clinical FF range (0-60 %) were created using morphological features of fat droplets (FDs) extracted from human liver biopsy samples. MRI signals were synthesized using Monte Carlo simulations for noise-free (SNRideal) and varying SNR conditions (5-100). Fat-water phantoms were scanned with different SNRs to validate simulation results. Fat water toolbox was used to calculate R2* and FF for both single- and dual-R2* models. The model accuracies in R2* and FF estimates were analyzed using linear regression, bias plot and heatmap analysis.

RESULTS

The virtual steatosis model closely mimicked in vivo fat morphology and Monte Carlo simulation produced realistic MRI signals. For SNRideal and moderate-high SNRs, water R2* (R2*W) by dual-R2* and common R2* (R2*com) by single-R2* model showed an excellent agreement with slope close to unity (0.95-1.01) and R2 > 0.98 at both 1.5T and 3.0T. In simulations, the R2*com-FF and R2*W-FF relationships exhibited slopes similar to in vivo calibrations, confirming the accuracy of our virtual models. For SNRideal, fat R2* (R2*F) was similar to R2*W and dual-R2* model showed slightly higher accuracy in FF estimation. However, in the presence of noise, dual-R2* produced higher FF bias with decreasing SNR, while leading to only marginal improvement for high SNRs and in regions dominated by fat and water. In contrast, single-R2* model was robust and produced accurate FF estimations in simulations and phantom scans with clinical SNRs.

CONCLUSION

Our study demonstrates the feasibility of creating virtual steatosis models and generating MRI signals that mimic in vivo morphology and signal behavior. The single-R2* model consistently produced lower FF bias for clinical SNRs across entire FF range compared to dual-R2* model, hence signifying that single-R2* model is optimal for assessing hepatic steatosis.

Long-term, landscape-level assessment of aquatic pesticide exposure to identify amphibian ontological traits affecting vulnerability

Amphibians worldwide are threatened by habitat loss, some of which is driven by a changing climate, as well as exposure to pesticides, among other causes. The timing and duration of the larval development phase vary between species, thereby influencing the relative impacts of stochastic hydroregime conditions as well as potential aquatic pesticide exposure. We describe the stages of breeding through metamorphosis for eight amphibian species, based on optimal hydroregime conditions, and use a model of pesticide fate and exposure representative of central Florida citrus groves to simulate hydrodynamics based on observed weather data over a 54-year period. Using the Pesticide in Water Calculator and Plant Assessment Tool, we estimated daily wetland depth and pyraclostrobin exposure, with label-recommended application quantities. Species' timing and duration of larval development determined the number of years of suitable hydroregime for breeding and the likelihood of exposure to peak aquatic concentrations of pyraclostrobin. Although the timing of pesticide application determined the number of surviving larvae, density-dependent constraints of wetland hydroregime also affected larval survival across species and seasons. Further defining categorical amphibian life history types and habitat requirements supports the development of screening-level assessments by incorporating environmental stochasticity at the appropriate temporal resolution. Subsequent refinement of these screening-level risk assessment strategies to include spatially explicit landscape data along with terrestrial exposure estimates would offer additional insights into species vulnerability to pesticide exposure throughout the life cycle. Computational simulation of ecologically relevant exposure scenarios, such as these, offers a more realistic interpretation of differential agrichemical risk among species based on their phenology and habits and provides a more situation-specific risk assessment perspective for threatened species. Integr Environ Assess Manag 2024;00:1-10. Published 2024. This article is a U.S. Government work and is in the public domain in the USA.

Optimized trans-cranial direct current stimulation for prolonged consciousness disorder in a patient with titanium mesh cranioplasty

BACKGROUND

Transcranial direct current stimulation (tDCS) has been used for the restoration of awareness in patients with a minimal consciousness state (MCS). Most brains of patients in MCS may structurally and electrophysiologically differ from un-damaged brains. Moreover, tDCS is currently contraindicated for patients with craniotomy or skull with metallic implants.

CASE PRESENTATION

We present a case with prolonged MCS over 1 year, who had severe brain damage, ventriculoperitoneal shunt, and cranioplasty with a titanium mesh, which was treated with tDCS which optimized with the simulation of the electric field based on the patient's brain MRI. The patient was resulting in emergence from MCS. Six months later, she ate meals orally and started walking with assistance.

DISCUSSION AND PERSPECTIVE

This personalized simulation based on MRI would make the treatment available even to patients with severe brain structural changes and metallic instrumentation.

A simulation study to assess the potential benefits of MRI-based fetal weight estimation as a second-line test for suspected macrosomia

OBJECTIVE

To simulate the outcomes of Boulvain's trial by using magnetic resonance imaging (MRI) for estimated fetal weight (EFW) as a second-line confirmatory imaging.

STUDY DESIGN

Data derived from the Boulvain's trial and the study PREMACRO (PREdict MACROsomia) were used to simulate a 1000-patient trial. Boulvain's trial compared induction of labor (IOL) to expectant management in suspected macrosomia, whereas PREMACRO study compared the performance of ultrasound-EFW (US-EFW) and MRI-EFW in the prediction of birthweight. The primary outcome was the incidence of significant shoulder dystocia (SD). Cesarean delivery (CD), hyperbilirubinemia (HB), and IOL at < 39 weeks of gestation (WG) were selected as secondary outcomes. A subgroup analysis of the Boulvain's trial was performed to estimate the incidence of the primary and secondary outcomes in the true positive and false positive groups for the two study arms. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) for the prediction of macrosomia by MRI-EFW at 36 WG were calculated, and a decision tree was constructed for each outcome.

RESULTS

The PPV of US-EFW for the prediction of macrosomia in the PREMACRO trial was 56.3 %. MRI-EFW was superior to US-EFW as a predictive tool resulting in lower rates of induction for false-positive cases. Repeating Boulvain's trial using MRI-EFW as a second-line test would result in similar rates of SD (relative risk [RR]:0.36), CD (RR:0.84), and neonatal HB (RR:2.6), as in the original trial. Increasing the sensitivity and specificity of MRI-EFW resulted in a similar relative risk for SD as in Boulvain's trial, but with reduced rates of IOL < 39 WG, and improved the RR of CD in favor of IOL. We found an inverse relationship between IOL rate and incidence of SD for both US-EFW and MRI-EFW, although overall rates of IOL, CD, and neonatal HB would be lower with MRI-derived estimates of fetal weight.

CONCLUSION

The superior accuracy of MRI-EFW over US-EFW for the diagnosis of macrosomia could result in lower rates of IOL without compromising the relative advantages of the intervention but fails to demonstrate a significant benefit to justify a replication of the original trial using MRI-EFW as a second-line test.

Using Mixed Reality Simulation to Improve Junior Medical Trainees' Preparedness to Manage High-Acuity Trauma

High-acuity trauma necessitates experienced and rapid intervention to prevent patient harm. However, upskilling junior trainees through hands-on management of real trauma cases is rarely feasible without compromising patient safety. This quality education report sought to investigate whether a simulation course operated via mixed reality (MR) headset devices (Microsoft HoloLens) could enhance the clinical knowledge recall and preparedness to practice of junior trainees with no prior experience managing trauma.The Plan-Do-Study-Act quality improvement method was used to refine six emergency trauma vignettes compatible with an MR teaching platform. Each vignette was curated by a multidisciplinary team of orthopaedic surgeons, clinical fellows and experts in simulation-based medical education. As a baseline assessment, a 2-hour emergency trauma course was delivered using traditional didactic methods to a cohort of pre-registration medical students with no clinical exposure to high-acuity trauma (n=16). Next, we delivered the MR simulation to an equivalent cohort (n=32). Clinical knowledge scores derived from written test papers were recorded for each group during and 2 weeks after each course. Each attendee's end-of-rotation clinical supervisor appraisal grade was recorded, as determined by a consultant surgeon who supervised participants during a 2-week placement on a major trauma ward. Balancing measures included participant feedback and validated cognitive load questionnaires (National Aeronautics and Space Administration-Task Load Index).Overall, attendees of the MR simulation course achieved and sustained higher clinical knowledge scores and were more likely to receive a positive consultant supervisor appraisal. This project serves as a proof of concept that MR wearable technologies can be used to improve clinical knowledge recall and enhance the preparedness to practice of novice learners with otherwise limited clinical exposure to high-acuity trauma.

Twelve tips for developing and implementing an effective critical care simulation programme

Simulation training in healthcare settings has become a valuable training tool. It provides an ideal formative assessment for interdisciplinary teaching. It provides a high fidelity and highly immersive environment where healthcare staff and students can practice developing their skills in a safe and controlled manner. Simulation training allows staff to practice skills that better prepare them for clinical emergencies, therefore possibly optimising clinical care. While the benefits of simulation education are well understood, establishing a programme for use by critical care staff is complex. Complexities include the highly specialised scenarios that are not typically encountered in non-critical care areas, as well as the need for advanced monitoring equipment, ventilation equipment etc. These 12 tips are intended to assist healthcare educators in navigating the complexities in the establishment of a critical care simulation programme, providing advice on selecting target audiences, learning outcomes, creating a critical care simulation environment and recommendations on evaluation and development of the programme.

Meta-analysis of the Microbial Diversity Cultured in Bioreactors Simulating the Gut Microbiome

Understanding the intricate ecological interactions within the gut microbiome and unravelling its impact on human health is a challenging task. Bioreactors are valuable tools that have contributed to our understanding of gut microbial ecology. However, there is a lack of studies describing and comparing the microbial diversity cultivated in these models. This knowledge is crucial for refining current models to reflect the gastrointestinal microbiome accurately. In this study, we analysed the microbial diversity of 1512 samples from 18 studies available in public repositories that employed cultures performed in batches and various bioreactor models to cultivate faecal microbiota. Community structure comparison between samples using t-distributed stochastic neighbour embedding and the Hellinger distance revealed a high variation between projects. The main driver of these differences was the inter-individual variation between the donor faecal inocula. Moreover, there was no overlap in the structure of the microbial communities between studies using the same bioreactor platform. In addition, α-diversity analysis using Hill numbers showed that highly complex bioreactors did not exhibit higher diversities than simpler designs. However, analyses of five projects in which the samples from the faecal inoculum were also provided revealed an amplicon sequence variants enrichment in bioreactors compared to the inoculum. Finally, a comparative analysis of the taxonomy of the families detected in the projects and the GMRepo database revealed bacterial families exclusively found in the bioreactor models. These findings highlight the potential of bioreactors to enrich low-abundance microorganisms from faecal samples, contributing to uncovering the gut microbial "dark matter".

Evaluation of CRU-JRA gridded meteorological dataset for modeling of wheat production systems in Iran

Meteorological variables are essential inputs for agricultural simulation models and the lack of measured data is a big challenge for the application of these models in many agricultural zones. Studies indicated that gridded meteorological datasets can be proper replacements for measured data. This paper aimed to examine a new gridded meteorological dataset namely CRU-JRA for crop modeling intents. The CRU-JRA is a 6-hourly dataset with a spatial resolution of 0.5° × 0.5° that was primarily constructed for modeling purposes. The CERES-Wheat model in the Decision Support System for Agrotechnology Transfer (DSSAT) was used for the simulation of irrigated and rainfed wheat production systems in Iran. Results showed that the CRU-JRA maximum and minimum temperature values had a relatively fine accuracy with a normalized root mean square error (NRMSE) of 14% for the simulated grain yield. The performance of the CRU-JRA solar radiation values for the simulation of grain yield was similar with a NRMSE of 14.4%. The weakest performance was found for the CRU-JRA precipitation values with a NRMSE of 18.9%. Overall, the CRU-JRA dataset performed comparatively acceptable and similar to existing gridded meteorological datasets for crop modeling purposes in the study area, however further calibrations can improve the accuracy of the next versions of this dataset. More research is necessary for the investigation of the CRU-JRA dataset for agricultural modeling purposes across diverse climates.

Emergency airway management in the prone position: an observational mannequin-based simulation study

INTRODUCTION

Accidental extubation during prone position can be a life-threatening emergency requiring rapid establishment of the airway. However, there is limited evidence of the best airway rescue method for this potentially catastrophic emergency. The aim of this study was to determine the most effective method to recover the airway in case of accidental extubation during prone positioning by comparing three techniques (supraglottic airway, video laryngoscopy, and fiber-optic bronchoscopy) in a simulated environment.

METHODS

Eleven anesthesiologists and 12 anesthesia fellows performed the simulated airway management using 3 different techniques on a mannequin positioned prone in head pins. Time required for definitive airway management and the success rates were measured.

RESULTS

The success rates of airway rescue were 100% with the supraglottic airway device (SAD), 69.6% with the video laryngoscope (CMAC), and 91.3% with the FOB. The mean (SD) time to insertion was 18.1 (4.8) s for the supraglottic airway, 78.3 (32.0) s for the CMAC, and 57.3 (24.6) s for the FOB. There were significant differences in the time required for definitive airway management between the SAD and FOB (t = 5.79, p < 0.001, 95% CI = 25.92-52.38), the SAD and CMAC (t = 8.90, p < 0.001, 95% CI = 46.93-73.40), and the FOB and CMAC (t = 3.11, p = 0.003, 95% CI = 7.78-34.25).

CONCLUSION

The results of this simulation-based study suggest that the SAD I-gel is the best technique to manage accidental extubation during prone position by establishing a temporary airway with excellent success rate and shorter procedure time. When comparing techniques for securing a definitive airway, the FOB was more successful than the CMAC.

Assessing the equivalency of face-to-face and online simulated patient interviews in an educational intervention

BACKGROUND

In adapting to COVID-19, many health professional training programs moved abruptly from in-person to online simulated patient interviews for teaching and evaluation without the benefit of evidence regarding the efficacy of this mode of delivery. This paper reports on a multi-methods research project comparing in-person and online simulated patient interviews conducted by allied health professionals as part of an educational intervention offered at a large university teaching hospital.

METHODS

Twenty-three participants conducted two 15-min interviews with simulated patients using previously validated scenarios of patients presenting with suicide risk. In order to assess the equivalency of the two modalities, physiological and psychological stress were measured using heart rate variability parameters and the State-Trait Anxiety Inventory respectively, and then were compared across cohorts using t-tests. Reflective interviews elicited qualitative impressions of the simulations that were subject to thematic qualitative analysis.

RESULTS

There were no statistical differences in measures of psychological stress or physiological arousal of participant health care professionals who engaged with in-person versus online simulated interviews, suggesting they were equally effective in eliciting reactions commonly found in challenging clinical situations. In reflective interviews, participants commented on the realism of both modalities of simulated patient encounters and that simulated interviews provoked emotional and physiological responses consistent with actual patient encounters.

CONCLUSIONS

These findings provide developing evidence that carefully designed online clinical simulations can be a useful tool for the education and assessment of healthcare professionals.

A rigorous theoretical and numerical analysis of a nonlinear reaction-diffusion epidemic model pertaining dynamics of COVID-19

The spatial movement of the human population from one region to another and the existence of super-spreaders are the main factors that enhanced the disease incidence. Super-spreaders refer to the individuals having transmitting ability to multiple pathogens. In this article, an epidemic model with spatial and temporal effects is formulated to analyze the impact of some preventing measures of COVID-19. The model is developed using six nonlinear partial differential equations. The infectious individuals are sub-divided into symptomatic, asymptomatic and super-spreader classes. In this study, we focused on the rigorous qualitative analysis of the reaction-diffusion model. The fundamental mathematical properties of the proposed COVID-19 epidemic model such as boundedness, positivity, and invariant region of the problem solution are derived, which ensure the validity of the proposed model. The model equilibria and its stability analysis for both local and global cases have been presented. The normalized sensitivity analysis of the model is carried out in order to observe the crucial factors in the transmission of infection. Furthermore, an efficient numerical scheme is applied to solve the proposed model and detailed simulation are performed. Based on the graphical observation, diffusion in the context of confined public gatherings is observed to significantly inhibit the spread of infection when compared to the absence of diffusion. This is especially important in scenarios where super-spreaders may play a major role in transmission. The impact of some non-pharmaceutical interventions are illustrated graphically with and without diffusion. We believe that the present investigation will be beneficial in understanding the complex dynamics and control of COVID-19 under various non-pharmaceutical interventions.

How to HEEAL: A Patient and Peer-Centric Simulation Curriculum for Medical Error Disclosure

Introduction

Medical errors are an unfortunate certainty with emotional and psychological consequences for patients and health care providers. No standardized medical curriculum on how to disclose medical errors to patients or peers exists. The novel HEEAL (honesty/empathy/education/apology-awareness/lessen chance for future errors) curriculum addresses this gap in medical education through a multimodality workshop.

Methods

This 6-hour, two-part curriculum incorporated didactic and standardized patient (SP) simulation education with rapid cycle deliberate practice (RCDP). The morning focused on provider-patient error disclosure; the afternoon applied the same principles to provider-provider (peer) discussion. Summative simulations with SPs evaluated learners' skill baseline and improvement. Formative simulations run by expert simulation educators used RCDP to provide real-time feedback and opportunities for adjustment. Medical knowledge was measured through pre- and postintervention multiple-choice questions. Learners' confidence and attitude towards medical errors disclosure were surveyed pre- and postintervention with assistance of the Barriers to Error Disclosure Assessment tool, revised with the addition of several questions related to provider-provider disclosure.

Results

Fourteen medical students participated in this pilot curriculum. Statistical significance was demonstrated in medical knowledge (p = .01), peer-disclosure skills (p = .001), and confidence in medical error disclosure (p < .001). Although there was improvement in patient-disclosure skills, this did not reach statistical significance (p = .05).

Discussion

This curriculum addresses the need for designated training in medical error disclosure. Learners gained knowledge, skills, and confidence in medical error disclosure. We recommend this curriculum for medical students preparing for transition to residency.

Characterization of Surgical Movements As a Training Tool for Improving Efficiency

INTRODUCTION

Surgical experience is often reflected by efficient, fluid, and well-calculated movements. For a new trainee, learning these characteristics is possible only by observation as there is no quantification system to define these factors. We analyzed surgeons' hand movements with different experience levels to characterize their movements according to experience.

METHODS

Hand motions were recorded by an inertial measurement unit (IMU) mounted on the hands of the surgeons during a simulated surgical procedure. IMU data provided acceleration and Eulerian angles: yaw, roll, and pitch corresponding to hand motions as radial/ulnar deviation, pronation/supination, and extension/flexion, respectively. These variables were graphically depicted and compared between three surgeons.

RESULTS

Participants were assigned to three groups based on years of surgical experience: group 1: >15 y; group 2: 3-10 y; and group 3: 0-1 y. Visualization of the roll motion, being the main motion during suturing, showed the clear difference in fluidity and regularity of the movements between the groups, showing minimal wasted movements for group 1. The angle of the roll motion, measured at the minimum, midpoint, and maximum points was significantly different between the groups. As expected, the experienced group completed the procedure first; however, the acceleration was not different between the groups.

CONCLUSIONS

Surgeons' hand movements can be easily characterized and quantified by an IMU device for automatic assessment of surgical skills. These characteristics graphically visualize a surgeon's regularity, fluidity, economy, and efficiency. The characteristics of an experienced surgeon can serve as a training model and as a reference tool for trainees.

Evaluation of driver navigational errors and acceptance of a simulated J-turn intersection

The J-turn intersection is a novel roadway design which decreases the points of conflict at an intersection, by restricting straight crossing and left-turning movements from the minor road across the highway. The novelty of the intersection design may lead to driver errors and dissatisfaction. This study provides an examination of how naïve or first-time drivers may initially navigate J-turns during their first and early exposures to the novel intersection design. Thirty-six participants with limited previous experience and knowledge of J-turns participated in a simulation study to examine their acceptance of J-turns and left turning navigational performance at three simulated J-turn intersections in counterbalanced order, each featuring one of three signage levels. Results revealed participants committed slightly more frequent minor errors (e.g., inefficient lane selection) and significantly more major errors (e.g., missed U-turn) during the first J-turn exposure and these errors tended to decline during subsequent exposures, while moderate severity errors (e.g., risky lane change) slightly increased. Participants' J-turn acceptance significantly declined following simulated driving exposure. The decline in J-turn acceptance was found to be greater among participants who experienced major severity errors; however, more frequent minor errors were associated with increased acceptance. Signage level had little effect on errors, but participants preferred improved signage or on-road markings to guide crossing movements. This work suggests that advanced educational programs and community initiatives should be utilized to prepare drivers for how to navigate J-turns rather than only rely on J-turn exposure to improve driver performance and acceptance.

Multimodal human motion dataset of 3D anatomical landmarks and pose keypoints

In this paper, we present a dataset that takes 2D and 3D human pose keypoints estimated from images and relates them to the location of 3D anatomical landmarks. The dataset contains 51,051 poses obtained from 71 persons in A-Pose while performing 7 movements (walking, running, squatting, and four types of jumping). These poses were scanned to build a collection of 3D moving textured meshes with anatomical correspondence. Each mesh in that collection was used to obtain the 3D locations of 53 anatomical landmarks, and 48 images were created using virtual cameras with different perspectives. 2D pose keypoints from those images were obtained using the MediaPipe Human Pose Landmarker, and their corresponding 3D keypoints were calculated by linear triangulation. The dataset consists of a folder for each participant containing two Track Row Column (TRC) files and one JSON file for each movement sequence. One TRC file is used to store the 3D data of the triangulated 3D keypoints while the other contains the 3D anatomical landmarks. The JSON file is used to store the 2D keypoints and the calibration parameters of the virtual cameras. The anthropometric characteristics of the participants are annotated in a single CSV file. These data are intended to be used in developments that require the transformation of existing human pose solutions in computer vision into biomechanical applications or simulations. This dataset can also be used in other applications related to training neural networks for human motion analysis and studying their influence on anthropometric characteristics.

The pseudoentropy of allele frequency trajectories, the persistence of variation, and the effective population size

To concisely describe how genetic variation, at individual loci or across whole genomes, changes over time, and to follow transitory allelic changes, we introduce a quantity related to entropy, that we term pseudoentropy. This quantity emerges in a diffusion analysis of the mean time a mutation segregates in a population. For a neutral locus with an arbitrary number of alleles, the mean time of segregation is generally proportional to the pseudoentropy of initial allele frequencies. After the initial time point, pseudoentropy generally decreases, but other behaviours are possible, depending on the genetic diversity and selective forces present. For a biallelic locus, pseudoentropy and entropy coincide, but they are distinct quantities with more than two alleles. Thus for populations with multiple biallelic loci, the language of entropy suffices. Then entropy, combined across loci, serves as a concise description of genetic variation. We used individual based simulations to explore how this entropy behaves under different evolutionary scenarios. In agreement with predictions, the entropy associated with unlinked neutral loci decreases over time. However, deviations from free recombination and neutrality have clear and informative effects on the entropy's behaviour over time. Analysis of publicly available data of a natural D. melanogaster population, that had been sampled over seven years, using a sliding-window approach, yielded considerable variation in entropy trajectories of different genomic regions. These mostly follow a pattern that suggests a substantial effective population size and a limited effect of positive selection on genome-wide diversity over short time scales.

Limitations of two time point data for understanding individual differences in longitudinal modeling - What can difference reveal about change?

Emerging neuroimaging studies investigating changes in the brain aim to collect sufficient data points to examine trajectories of change across key developmental periods. Yet, current studies are often constrained by the number of time points available now. We demonstrate that these constraints should be taken seriously and that studies with two time points should focus on particular questions (e.g., group-level or intervention effects), while complex questions of individual differences and investigations into causes and consequences of those differences should be deferred until additional time points can be incorporated into models of change. We generated underlying longitudinal data and fit models with 2, 3, 4, and 5 time points across 1000 samples. While fixed effects could be recovered on average even with few time points, recovery of individual differences was particularly poor for the two time point model, correlating at r = 0.41 with the true individual parameters - meaning these scores share only 16.8% of variance As expected, models with more time points recovered the growth parameter more accurately; yet parameter recovery for the three time point model was still low, correlating around r = 0.57. We argue that preliminary analyses on early subsets of time points in longitudinal analyses should focus on these average or group-level effects and that individual difference questions should be addressed in samples that maximize the number of time points available. We conclude with recommendations for researchers using early time point models, including ideas for preregistration, careful interpretation of 2 time point results, and treating longitudinal analyses as dynamic, where early findings are updated as additional information becomes available.

Good eutrophication status is a challenging goal for coastal waters

Our objective is to understand the effectiveness of local and international nutrient pollution mitigation efforts when targeting better water quality in the region's coastal waters. To this end, we developed an integrated modeling framework for the Archipelago Sea located in the Baltic Sea in Northern Europe, conducted what-if analyses for various ambition levels of nutrient abatement, and studied the long-term consequences at the sea basin scale. We demonstrate that in outer parts of the Archipelago Sea, a good eutrophication status can be achieved if the current internationally agreed policy goals for nutrient abatement are successfully met. In inner coastal areas, current goals for phytoplankton biomass could be reached only through extreme mitigation efforts in all polluting sectors and large-scale application of yet poorly tested ecological engineering methods. This result calls for carefully considering the relevance of current threshold values for phytoplankton and its role as a dominant indicator of good ecological status.

Variable practice is superior to self-directed training for laparoscopic simulator training: a randomized trial

BACKGROUND

Mastering laparoscopy is challenging-it requires specific psychomotor skills which are difficult to obtain in the operating room without potentially compromising patient safety. Proficiency-based training programs using virtual reality simulators allow novices to practice and develop their skills in a patient-safe learning environment. Variable practice leads to stronger retention and skills transfer in a non-surgical setting. The objective of this trial was to investigate if variable practice was superior to self-directed training.

METHODS

A randomized trial where participants (n = 36) were randomized to proficiency-based laparoscopic simulator training of basic skills using either variable practice or self-directed training, followed by a transfer test with proficiency-based training on a procedural task (a salpingectomy). All participants returned after a period of 3-5 weeks to perform a retention test.

RESULTS

The mean time to proficiency for the basic skills tasks were 119 min (SD: 93) for the variable practice group versus 182 min (SD: 46) for the self-directed training group (p = 0.015). The time to reach proficiency during the transfer test was 103 min (SD: 57) versus 183 min (SD: 64) for the variable practice group versus the self-directed training group, respectively (p < 0.001). The mean time to proficiency for the retention test was 51 min (SD: 26) and 109 min (SD: 53) for the variable practice group and self-directed training group, respectively (p < 0.001).

CONCLUSION

Variable practice is superior to self-directed training for proficiency-based laparoscopic training. With variable time to practice proficiency is reduced, there is higher transfer to a procedural task, and retention is improved.

Analysis of the dynamics of common industrial solid waste based on input-output: A case study of Shanghai international metropolis in China

Rapid economic development inevitably leads to the discharge of a large amount of common industrial solid waste (CISW), which not only pollutes the environment but also restricts economic development in turn. In this study, a dynamic common industrial solid waste (DCISW) model is developed to analyze the retrospectively CISW development in Shanghai from 2000 to 2017 and simulate prospectively multi-perspective emission reduction measures. Specifically, the dynamic linkages between CISW and socio-economics are established at both the systematic and sectoral levels through input-output analysis, ecological network analysis, and related socio-economic indicators. Abatement measure simulations are conducted using RAS and other methods. The findings reveal that the growth of CISW in Shanghai is closely related to its fast-growing economy. The Others sector (OS) receives the most CISW from other sectors, while the Mining industry (MI) sends the most CISW to others. From production-based, consumption-based, and income-based perspectives, Chemical Products (CP) consistently remain the largest contributors. For the proposed waste generation intensity (WGI) indicator, the Mining industry (MI) is regarded as the main sector in all three perspectives. Moreover, the MI consistently emerges as the key sector of the system. CISW simulations indicate that improving the MI emission technology and increasing the MI output value will be top priorities for CISW emission reduction in Shanghai. This study is expected to provide scientific support to address the CISW problem in Shanghai and other similar fast-growing metropolises.

Cost-benefit ratio of modern medical education using micro-costing: a model calculation using the example of an innovative breast brachytherapy workshop

BACKGROUND AND PURPOSE

Radiation oncology is an essential component of therapeutic oncology and necessitates well-trained personnel. Multicatheter brachytherapy (MCBT) is one radiotherapeutic option for early-stage breast cancer treatment. However, specialized hands-on training for MCBT is not currently included in the curriculum for residents. A recently developed hands-on brachytherapy workshop has demonstrated promising results in enhancing knowledge and practical skills. Nevertheless, these simulation-based teaching formats necessitate more time and financial resources. Our analyses include computational models for the implementation and delivery of this workshop and can serve as a basis for similar educational initiatives.

METHODS

This study aimed to assess the cost-effectiveness of a previously developed and evaluated breast brachytherapy simulation workshop. Using a micro-costing approach, we estimated costs at a detailed level by considering supplies, soft- and hardware, and personnel time for each task. This method also allows for a comprehensive evaluation of the costs associated with implementing new medical techniques. The workshop costs were divided into two categories: development and workshop execution. The cost analysis was conducted on a per-participant basis, and the impact on knowledge improvement was measured using a questionnaire.

RESULTS

The total workshop costs were determined by considering the initial workshop setup expenses including the development and conceptualization of the course with all involved collaborators, as well as the costs incurred for each individual course. The workshop was found to be financially efficient, with a per-participant cost of € 39, considering the industrial sponsorship provided for brachytherapy equipment. In addition, we assessed the workshop's efficacy by analyzing participant feedback using Likert scale evaluations. The findings indicated a notable enhancement in both theoretical and practical skills among the participants. Moreover, the cost-to-benefit ratio (CBFR) analysis demonstrated a CBFR of € 13.53 for each Likert point increment.

CONCLUSION

The hands-on brachytherapy workshop proved to be a valuable and approximately cost-effective educational program, leading to a significant enhancement in the knowledge and skills of the participants. Without the support of industrial sponsorship, the costs would have been unattainable.

In your skin? Somatosensory cortex is purposely recruited to situate but not simulate vicarious touch

Previous studies of vicarious touch suggest that we automatically simulate observed touch experiences in our own body representation including primary and secondary somatosensory cortex (SCx). However, whether these early sensory areas are activated in a reflexive manner and the extent with which such SCx activations represent touch qualities, like texture, remains unclear. We measured event-related potentials (ERPs) of SCx's hierarchical processing stages, which map onto successive somatosensory ERP components, to investigate the timing of vicarious touch effects. In the first experiment, participants (n = 43) merely observed touch or no-touch to a hand; in the second, participants saw different touch textures (soft foam and hard rubber) either touching a hand (other-directed) or they were instructed that the touch was self-directed and to feel the touch. Each touch sequence was followed by a go/no-go task. We probed SCx activity and isolated SCx vicarious touch activations from visual carry over effects. We found that vicarious touch conditions (touch versus no-touch and soft versus hard) did not modulate early sensory ERP components (i.e. P50, N80); but we found effects on behavioural responses to the subsequent go/no-go stimulus consistent with post-perceptual effects. When comparing other- with self-directed touch conditions, we found that early and mid-latency components (i.e. P50, N80, P100, N140) were modulated consistent with early SCx activations. Importantly, these early sensory activations were not modulated by touch texture. Therefore, SCx is purposely recruited when participants are instructed to attend to touch; but such activation only situates, rather than fully simulates, the seen tactile experience in SCx.

Digitally enhanced hands-on surgical training (DEHST) enhances the performance during freehand nail distal interlocking

PURPOSE

Freehand distal interlocking of intramedullary nails remains a challenging task. Recently, a new training device for digitally enhanced hands-on surgical training (DEHST) was introduced, potentially improving surgical skills needed for distal interlocking.

AIM

To evaluate whether training with DEHST enhances the performance of novices (first-year residents without surgical experience in freehand distal nail interlocking).

METHODS

Twenty novices were randomly assigned to two groups and performed distal interlocking of a tibia nail in mock operation under operation-room-like conditions. Participants in Group 1 were trained with DEHST (five distal interlocking attempts, 1 h of training), while those in Group 2 did not receive training. Time, number of X-rays shots, hole roundness in the X-rays projection and hit rates were compared between the groups.

RESULTS

Time to complete the task [414.7 s (range 290-615)] and X-rays exposure [17.8 µGcm2 (range 9.8-26.4)] were significantly lower in Group 1 compared to Group 2 [623.4 s (range 339-1215), p = 0.041 and 32.6 µGcm2 (range 16.1-55.3), p = 0.003]. Hole projections were significantly rounder in Group 1 [95.0% (range 91.1-98.0) vs. 80.8% (range 70.1-88.9), p < 0.001]. In Group 1, 90% of the participants achieved successful completion of the task in contrast to a 60% success rate in Group 2. This difference was not statistically significant (p = 0.121).

CONCLUSIONS

In a mock-operational setting, training with DEHST significantly enhanced the performance of novices without surgical experience in distal interlocking of intramedullary nails and hence carries potential to improve safety and efficacy of this important and demanding surgical task to steepen the learning curve without endangering patients.

LEVEL OF EVIDENCE

II.

Formation mechanism of α particles in glycogen: Testing the budding hypothesis by Monte-Carlo simulation

Glycogen, a complex branched glucose polymer and a blood-sugar reservoir in animals, comprises small β particles joined together into composite α particles. In diabetic animals, α particles fragment more easily than those in healthy animals. Finding evidence for or against postulated mechanisms for α-particle formation is thus important for diabetes research. Insight into this is obtained here using Monte-Carlo simulations, including addition and loss of glucose monomer, branching and debranching, based on earlier simulations which were in acceptable agreement with experiment [Zhang et al., Int J Biol Macromolecules 2018, 116, 264]. One postulated mechanism for α-particle formation is "budding": occasionally a glucan chain temporarily protrudes from the particle, and if its growing end is sufficiently far from its parent particle, it propagates to a new linked particle. We tested this by simulations in which an "artificial" bud (a chain extending well outside the average particle radius) is added to a glycogen molecule in a dynamic steady state, and the system allowed to evolve. In some simulations, the particle reached a new steady state having an irregular dumbbell shape: a rudimentary α particle. Thus 'budding' is a possible mechanism for α particles to form. If no simulations had shown this behaviour, it would have refuted the postulate.

Computational modeling of neuron-glia signaling interactions to unravel cellular and neural circuit functioning

Glial cells have been shown to be vital for various brain functions, including homeostasis, information processing, and cognition. Over the past 30 years, various signaling interactions between neuronal and glial cells have been shown to underlie these functions. This review summarizes the interactions, particularly between neurons and astrocytes, which are types of glial cells. Some of the interactions remain controversial in part due to the nature of experimental methods and preparations used. Based on the accumulated data, computational models of the neuron-astrocyte interactions have been developed to explain the complex functions of astrocytes in neural circuits and to test conflicting hypotheses. This review presents the most significant recent models, modeling methods and simulation tools for neuron-astrocyte interactions. In the future, we will especially need more experimental research on awake animals in vivo and new computational models of neuron-glia interactions to advance our understanding of cellular dynamics and the functioning of neural circuits in different brain regions.

An assessment of radiology resident competency in identifying suppurative retropharyngeal lymphadenitis: an examination using the WIDI SIM platform

BACKGROUND AND PURPOSE

Suppurative retropharyngeal lymphadenitis is a retropharyngeal space infection almost exclusively seen in the young (4-8 years old) pediatric population. It can be misdiagnosed as a retropharyngeal abscess, leading to unnecessary invasive treatment procedures. This retrospective study aims to assess radiology residents' ability to independently identify CT imaging findings and make a definitive diagnosis of suppurative retropharyngeal lymphadenitis in a simulated call environment.

MATERIALS AND METHODS

The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a computer-aided emergency imaging simulation proven to be a reliable method for assessing resident preparedness for independent radiology call. The simulation included 65 cases across various imaging modalities of varying complexity, including normal studies, with one case specifically targeting suppurative retropharyngeal adenitis identification. Residents' free text responses were manually scored by faculty members using a standardized grading rubric, with errors subsequently classified by type.

RESULTS

A total of 543 radiology residents were tested in three separate years on the imaging findings of suppurative retropharyngeal lymphadenitis using the Wisdom in Diagnostic Imaging simulation web-based testing platform. Suppurative retropharyngeal lymphadenitis was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. On average, only 3.5% of radiology residents were able to correctly identify suppurative retropharyngeal lymphadenitis on a contrast-enhanced computed tomography (CT).

CONCLUSIONS

Our findings underscore a potential gap in radiology residency training related to the accurate identification of suppurative retropharyngeal lymphadenitis, highlighting the potential need for enhanced educational efforts in this area.

Soft tissue simulant materials in X-ray-based imaging in dentomaxillofacial radiology: a scoping review

INTRODUCTION

In in-vitro dental radiographic research, simulation of soft tissue is required to replicate the clinical condition as close as possible. This study aimed to find out which soft tissue simulation material have been studied to use in dentomaxillofacial radiology and showed similarity in radiodensity to the soft tissues of the maxillofacial region.

METHODS

In this scoping review, Web of Science, Embase, Scopus, Google scholar and PubMed databases were searched on April 9, 2023, considering the following PICOS: Population: soft tissue simulants, Intervention: X-ray-based imaging, Comparison: -, Outcome: properties of the soft tissue simulants, Study design: in-vitro studies. Screening, study selection, and data extraction were performed by two independent researchers. A third team member was consulted in the case of disagreement. Quality assessment of the included studies was made using Quality Assessment Tool For In-Vitro Studies (QUIN Tool).

RESULTS

Of the initial 1172 articles retrieved in the database search, 13 studies were included in the review. Seven studies had a low risk of bias. In 8 studies, computed tomography (CT) or cone beam computed tomography (CBCT), in 4 studies intraoral radiography, and in 2 studies panoramic radiography was used (one study has used CT/CBCT and panoramic radiography). The studies varied in the radiographic modality, acquisition parameters, selected outcomes, and gold standard. In the majority of the studies (n = 10, 77%), acrylic resin derivatives were used in the soft tissue simulant formula alone or as a major component. Wax was used in the simulant material in 8 studies (62%). In addition, in 3 studies (23%) ice/water was used as the main simulant.

CONCLUSION

Ballistic gelatin, expanded 2-cm thick polystyrene with or without 1-cm utility wax, and 0.5 cm of acrylic resin were shown to have a radiographic density similar to soft tissue in standardized studies employing CBCT scanning. For intraoral radiographs, using self-polymerizing acrylic resin, utility wax, and wood, as well as a polymethylmethacrylate box filled with water in thicknesses ranging from 4 to 45 mm, provides suitable radiographic contrast. However, for 4 and 8 mm of wax and 4 mm of water, the radiographic contrast is not appropriate. In addition, 13-17 mm wax and 14.5 mm acrylic resin showed acceptable soft tissue densities in intraoral radiography. Further studies using different imaging modalities with standardized conditions and objective metrics are required to confirm the most appropriate soft tissue simulant material for in-vitro dental radiographic research.