A Web Platform (MOSAICO) to Design, Perform, and Assess Collaborative Clinical Scenarios for Medical Students: Viewpoint

BACKGROUND

The collaborative clinical simulation (CCS) model is a structured method for the development and assessment of clinical competencies through small groups working collaboratively in simulated environments. From 2016 onward, the CCS model has been applied successfully among undergraduate and graduate medical students from the Universidad de Talca, Chile; the Universität de Barcelona, Spain; and the Universidad de Vic-Manresa, Spain. All the templates for building the clinical cases and the assessment instruments with CCS were printed on paper. Considering the large number of CCS sessions and the number of participating students that are required throughout the medical degree curriculum, it is impossible to keep an organized record when the instruments are printed on paper. Moreover, with the COVID-19 pandemic, web platforms have become important as safe training environments for students and medical faculties; this new educational environment should include the consolidation and adaptation of didactic sessions that create and use available virtual cases and use different web platforms.

OBJECTIVE

The goal of this study is to describe the design and development of a web platform that was created to strengthen the CCS model.

METHODS

The design of the web platform aimed to support each phase of the CCS by incorporating functional requirements (ie, features that the web platform will be able to perform) and nonfunctional requirements (ie, how the web platform should behave) that are needed to run collaborative sessions. The software was developed under the Model-View-Controller architecture to separate the views from the data model and the business logic.

RESULTS

MOSAICO is a web platform used to design, perform, and assess collaborative clinical scenarios for medical students. MOSAICO has four modules: educational design, students' collaborative design, collaborative simulation, and collaborative debriefing. The web platform has three different user profiles: academic simulation unit, teacher, and student. These users interact under different roles in collaborative simulations. MOSAICO enables a collaborative environment, which is connected via the internet, to design clinical scenarios guided by the teacher and enables the use of all data generated to be discussed in the debriefing session with the teacher as a guide. The web platform is running at the Universidad de Talca in Chile and is supporting collaborative simulation activities via the internet for two medical courses: (1) Semiology for third-year students (70 students in total) and (2) Medical Genetics for fifth-year students (30 students in total).

CONCLUSIONS

MOSAICO is applicable within the CCS model and is used frequently in different simulation sessions at the Universidad de Talca, where medical students can work collaboratively via the internet. MOSAICO simplifies the application and reuse of clinical simulation scenarios, allowing its use in multiple simulation centers. Moreover, its applications in different courses (ie, a large part of the medical curriculum) support the automatic tracking of simulation activities and their assessment.

Left ventricular assist device (LVAD) program in Chile: first successful experience in South America

Background

The need to have a variety of tools to deal with end-stage heart failure (ES-HF), along with the limited heart transplantation availability encouraged us to create a pilot Left ventricular assist device (LVAD) program in a public health care system hospital in Chile.

Methods

A retrospective analysis of the first nine patients of an ongoing LVAD program initiated on August 2013 was performed, completing an average of 30 months of follow-up. The most important events regarding to morbidity and mortality are described.

Results

Nine patients with ES-HF underwent LVAD implantation surgery; one of them died 23 days after surgery and another died after 11 months. One patient successfully underwent heart transplantation after 16 months of HeartWare ventricular assist device (HVAD) support; the other six patients remain in the program and have an average follow-up of 846 days at the time of this study (range, 23-1,481 days). The survival rate at 6, 12 and 18 months follow-up was 89%, 78% and 78% respectively.

Conclusions

This new pioneering LVAD program in Chile has been successful and now constitutes a vital adjunct to all who work in heart transplantation and ES-HF programs. It offers an effective therapeutic alternative when there is a severe donor shortage, in cases of atypical blood types, emergencies, exceptional cases with contraindication for heart transplantation or when there is important donor-receiver size mismatch.

Preparation of human resources for future nuclear energy using FBNR as the instrument of learning

An increasing number of developing countries are showing interest to become the emerging countries to nuclear energy. Most of these countries lack human resources and adequate infrastructures to enter such a venture. The principle objective of activities of FBNR Group is to train human resources for the countries that at the present lack the necessary conditions, but aim at the future clean and safe nuclear energy through the fourth generation and INPRO compatible nuclear reactors. The preparation for the future nuclear energy is done through development of innovative nuclear reactor that meets the INPRO philosophies and criteria. These countries may or may not have decided as yet to utilize nuclear energy, but are interested to gain a strong educational foundation for their future. The research and development of a small innovative nuclear reactor FBNR is used as the instrument for learning. The young scientists will learn how to be innovative with the vision of INPRO philosophy and criteria.

Ontogenetic and spatiotemporal variability in anchoveta Engraulis ringens diet off Peru

In this study, historical data available since 1954 were used to get new insight to ontogenetic and spatiotemporal variability in Peruvian anchovy or anchoveta Engraulis ringens diet. Whatever the period, E. ringens foraged mainly on macrozooplankton and the importance of euphausiids in E. ringens diet appears directly related to euphausiids abundance. This bottom-up effect is also observed at smaller scale because the euphausiids fraction increased with E. ringens total length and euphausiids accessibility. Selecting the largest prey, the euphausiids, provides an energetic advantage for E. ringens in its ecosystem where oxygen depletion imposes strong metabolic constraints on pelagic fishes. This study illustrates the plasticity of E. ringens that allows it to cope with its highly variable environment.

Repeated Pap smear screening among Mexican-American women

The factors that influence repeated cervical cancer screening among Latina women are not well understood. Studies of compliance in this population over-emphasize initial or recent screening and under-emphasize how this practice is repeated over time. The purpose of this study was to identify the demographic and psychosocial factors associated with repeated Pap smear screening among low-income Mexican-American women living in two urban communities in Texas. A total of 1804 Mexican-American women were interviewed as part of a community survey. Multiple regression results indicate that demographic characteristics such as age, marital status, level of acculturation and health insurance were associated with the total number of Pap smears reported for the 5 years prior to the interview. Pap smear beliefs were the strongest predictor of repeated screening, while global beliefs about cancer did not significantly explain the results. Health promotion interventions should take into consideration the cultural and psychosocial needs of Mexican-American women, placing emphasis on their specific screening-related beliefs, if they are to succeed in promoting repeated compliance with Pap smear screening guidelines.

Sentinel monitoring of general community health during the 1998 World Football Cup

BACKGROUND

Present knowledge of the consequences of mass gatherings for the health of the community is scant. Our objective was to determine the impact of the 1998 World Football Cup on general community health.

METHODS

We set up an electronic sentinel disease surveillance, before, during and after the World Football Cup tournament held in France from June 10 to July 12, 1998. Medical activity, and the daily number of cases of communicable, environmental, and societal diseases relating to mass gatherings were surveyed. The incidence of the pathologies surveyed in real time during and after the World Cup versus the pre-Cup reference period was the main outcome measure. Five sentinel networks participated, comprising 553 general practitioners, 60 hospital adult emergency departments, 19 private emergency community services, 4 community health centres, and the medical centre of the Paris airports.

RESULTS

Throughout the 66-day study period, physicians reported 558,829 medical encounters via 21,532 connections to the computer. Compared to the reference period, the level of medical activity reflected by the pathological items surveyed remained stable during the study period.

CONCLUSION

The 1998 World Football Cup had no epidemiological impact on general community health, as observed by sentinel networks located downstream of the specific health services provided by the French authorities to ensure high standards of safety.

[Total eclipse of the sun in August 11, 1999: a program of prevention and surveillance of ocular complications]

Watching directly at the sun without appropriate protection, particularly during a solar eclipse, can cause severe retinal injuries. On 11 August 1999, a total solar eclipse crossed France. The Direction Générale de la Santé implemented a prevention strategy. A formal agreement was developed with manufacturers and importers of protective glasses and more than 30 million glasses, conformed with safety standards, were distributed in France. Information campaign reach the whole population in France. In order to evaluate the impact of this campaign, The National Institute of Public Health in France implemented a nation-wide surveillance of ocular complications related to the eclipse. Information on patients was collected using a standardised questionnaire. The questionnaire was sent to the 5,600 private and public sector ophthalmologists practising in France and to five hundred hospital emergency units. A total of 147 patients were reported to have had a retinal injury associated with viewing the eclipse. Seventeen cases were severe (visual acuity < 2/10th) of whom 7 had bilateral injury. Forty-four per cent of patients were aged 15 to 29 years and 46% viewed the eclipse in three regions in the south of France which were sunny on 11th August. One hundred and six patients (67% aged 30 years and more) presented with keratitis. Thirty-six per cent occurred in 2 northern regions of France, which were overcast on the day. A hundred patients watched the whole eclipse without any protection, 74 reported to have removed their EC glasses, and 32 used non-appropriate devices. Only 4 patients presenting with retinal injury reported having used the EC glasses the whole time whilst viewing the eclipse. France is the only country in Europe to have implemented an exhaustive prospective surveillance of ocular injuries related to the solar eclipse. According to current data, the quality and availability of EC glasses did not contribute significantly to ocular injuries. Clinical and epidemiological studies are being conducted in order to further document the evolution of patients presenting with retinal injuries, the circumstances of observation, and their comprehension of preventive messages.

Health hazards in international tourists visiting Paris in August: a five-year retrospective epidemiologic survey

BACKGROUND

Travel-related illnesses have been studied in visitors to developing countries, but no studies have examined the incidence of health problems in visitors to developed countries.

METHODS

4, 093 foreign tourists visiting Paris in August and attending to emergency medical care for acute health problems were included in an epidemiological survey conducted over 5 consecutive years. The objective was to determine what types of acute health problems occur in a foreign tourist population and to estimate the incidence of the main health hazards.

RESULTS

Gastroenteritis represented the main cause of medical care in that population (from 14.5-21.9%) followed by traumatology, ENT problem, viral syndrome and dermatology which represented altogether 60-64% of all medical problems. Two factors were related to the distribution of diseases observed: age and nationality. The monthly incidence of gastroenteritis was estimated to be between 1.33 to 2.92 per 10,000 visitors, and the overall incidence of health problems between 8 to 10 per 10,000.

CONCLUSIONS

Even if the incidence rate of gastroenteritis is low compared with developing countries, further studies are needed to support the hypothesis that gastroenteritis could be attributed to sanitary conditions in some restaurants of the French capital.

Urine benzodiazepines screening of involuntarily drugged and robbed or raped patients

OBJECTIVE

This study involved 35 patients who claimed to have been drugged before being robbed or raped, despite urine negative toxicologic screening by immunoenzymatic methods. The urines were frozen for further investigations, including enzymatic hydrolysis of urinary conjugates, liquid-solid extraction and, finally, immunoenzymatic screening of concentrated urine extract.

METHODS

Urine benzodiazepines were analyzed by immunoenzymatic assay before and after enzymatic hydrolysis combined with extraction.

RESULTS

On direct immunoenzymatic screening, 17 of the 35 urine samples were benzodiazepine positive. Enrichment of preserved specimens improved the detection threshold from 200 ng/mL to 50 ng/mL and 10 of the 18 negative urines became positive.

CONCLUSION

This method allowed us to demonstrate the benzodiazepines in half of previously negative urine samples. Benzodiazepine screening is particularly problematic because of low dosage, rapid elimination, failure to detect conjugated metabolites by immunoenzymatic reagents and high threshold of sensitivity for certain substances.

[Tuberculin reaction in healthy infants vaccinated with BCG at birth]

Tuberculin test with PPD RT-23 with Tween 80 (2 TU strength), was performed to 228 infants under two years of age. None of them had any history of contact with tuberculosis. All were healthy, well-nourished infants, and had been vaccinated with BCG at birth. A positive PPD reaction (greater than 6 mm), was found only in 8.8%, of them and 16.2% had no BCG scar on examination; 14.9% of the studied infants had negative PPD (0-5 mm) reactions together with absent BCG scars. These findings are significantly different from those previously reported by chilean authors, which showed higher proportion of positive (greater than = 6 mm) reaction to 2 TU PPD in infants from similar populations that had been vaccinated with different BCG preparations than our patients. These results suggest the need to evaluate the efficacy of the BCG vaccines that are currently being used in our country to determine the factors that may affect it and the protection that they afford.

Idiopathic thrombocytopenic purpura in patients at risk for acquired immunodeficiency syndrome. Histopathologic study, immunohistochemistry, and ultrastructural study on six spleens

Some cases of idiopathic thrombocytopenic purpura (ITP) may be related to the prodromal phase of the acquired immunodeficiency syndrome (AIDS). The morphologic features of six spleens removed in this context were studied. In the white pulp, lymphoid follicular hyperplasia was constant but hardly distinguishable from that of control ITP on routine light microscopic grounds. Moreover, its bland appearance contrasted with the major histopathologic changes usually described in lymph node biopsy specimens from patients with AIDS-related complex. Immunohistochemistry and electron microscopy demonstrated, respectively, an excess of cytotoxic-suppressor lymphocytes with a decreased CD4/CD8 ratio in the germinal centers and viral particles of the human immunodeficiency virus. The immunohistochemical and ultrastructural studies were more helpful than light microscopy in presenting histopathologic arguments in favor of the human immunodeficiency virus infection.

[B virus, delta agent and human immunodeficiency virus infections in drug addicts]

Infections with the B, D, A, NANB viruses and with the human immunodeficiency virus (HIV) are very common among drug addicts, some of whom may harbour several of these pathogens. The serum of 90 per cent of drug addicts contains one of the HBV markers, and 20 per cent of them carry an anti-D antibody which is more often present in HBs Ag-positive subjects but may also be found in those who are positive for anti-HBs and anti HBc antibodies. The presence of an anti-delta antibody increases the risk of severe histological lesions (chronic active hepatitis, cirrhosis), as does chronic alcoholism associated with drug addiction. Fifty to sixty per cent of drug addicts are seropositive for HIV. At the AIDS stage, hepatic lesions are extremely frequent (90 per cent), but they have low activity and are seldom responsible for death.

[Segmental tuberculosis of the colon manifested by rectal stenosis]

Colonic tuberculosis is currently exceptionally rare in western countries. This interesting report reminds of its existence and emphasizes the diagnostic problems with Crohn's disease in the past. The barium enema enables to show the main aspects of colonic tuberculosis, i.e. variable forms of stenosis. The contribution of colonoscopy is essential in defining the lesions and allowing multiple biopsies. These biopsies may show the presence of granulomas with caseous necrosis, and possibly the Koch Bacillus on direct examination or in culture. The conditions of prescription of the medical treatment are similar to that of other tuberculous locations. Surgery is indicated in the presence of complications, when there is a doubt the malignant nature of the lesion, finally at the stage of cicatricial stenosis.

[High prevalence of infection by hepatitis B virus and HIV in incarcerated French drug addicts]

This clinical and biological study was undertaken to assess the prevalence of infection by HIV, HBV and HDV in male drug abusers entering a prison. One hundred and thirteen drug users accepted to be tested: 14 (12 p. 100) were homosexual; 12 (11 p. 100) consumed more than 80 g per day of alcohol. The mean duration of drug addiction was 5 +/- 2.9 years; 50 (44 p. 100) declared having used a personal syringe while 63 (56 p. 100) usually shared their syringe. Serum activity of transaminases higher than twice the normal value was noted in 36 cases (32 p. 100). One hundred and two (90 p. 100) drug abusers had a HBV marker, 17 (15 p. 100) were HBs Ag carriers, 9 had anti-HBc antibody alone. The prevalence of antibodies to the HDV was 23 p. 100 and was higher among the HBs Ag carriers (65 p. 100). There were no cases of AIDS. Clinical examination showed lymphadenopathy in 49 cases (43 p. 100), a weight loss of more than 10 p. 100 in 47 cases (42 p. 100), and in 69 cases (61 p. 100), HIV positive serology, confirmed by Western blot. The duration of drug addiction was longer in the 102 drug users with HBV markers. Long duration of drug abuse and the use of a shared syringe increased the risk of HIV infection. No relation was noted between the presence of HBV markers and HIV positive serology. In this population the prevalence of HIV, HDV markers and HIV infection was high, but no relation with the duration of previous incarceration or homosexuality was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Interobserver agreement in the physical diagnosis of alcoholic liver disease

Agreement among six physicians for 18 clinical signs in 50 alcoholic patients was prospectively studied. Twenty patients had alcoholic cirrhosis, 14 noncirrhotic alcoholic liver disease, and 16 alcoholics had no clinical or biochemical abnormalities. Agreement was assessed by kappa index for categorical variables and by intraclass correlation coefficient for the others. A good agreement was observed for ascites (r = 0.75) and splenomegaly (r = 0.75). It was fair for jaundice (r = 0.65), Dupuytren's contracture (r = 0.65), and vascular spiders (r = 0.64). However, it was poor for white nails (r = 0.27) and hepatic consistency (r = 0.11). Agreement was better among senior physician's than junior physicians. In order to assess which signs contributed to differentiate the three groups of patients, a stepwise discriminant analysis was realized; it identified three variables: vascular spiders (P less than 0.001), splenomegaly (P less than 0.001), and abdominal wall collateral veins (P less than 0.01). These results suggest that studies based on physical findings must be cautiously considered.

[Value of echotomography for the diagnosis of lithiasis of the common bile duct]

The accuracy of ultrasonography (US) for the diagnosis of cholelithiasis and for dilatation of the intra- and extra-hepatic biliary tree is well known. However, the value of US for the diagnosis of common bile duct stones remains poorly defined. We performed a prospective study in 100 patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP); all the examinations were carried out by the same sonographist in the 24 h preceding the ERCP. Fifty patients had choledocholithiasis, 20 patients had obstruction of the bile ducts without lithiasis and the common bile duct (CBD) was free in 30 patients. The sensitivity of US for the diagnosis of choledocholithiasis was 40 p. 100, the specificity 90 p. 100. The positive and negative predictive values of the "CBD stone" sign was 80 p. 100 and 60 p. 100 respectively. In a total of 30 false negatives, the CBD could not be explored in 4 cases, dilatation of the CBD was missed in one case, and obstruction of the CBD by an other disease was diagnosed in 2; in all the other cases, US was able to appreciate the CBD size as well as the ERCP. In the 20 patients with an obstructed CBD but without choledocholithiasis, US diagnosed a stone in 5 cases. Age, serum bilirubin, existence of a previous cholecystectomy, technical difficulties, stone size were comparable in patients with true positive tests and in patients with false negative tests. However the diagnosis of choledocholithiasis was more frequently achieved in patients with dilated CBD over 10 mm (p less than 0.05) and in patients with multiple stones.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary kallikrein and plasma renin activity in normal human pregnancy

Urinary kallikrein excretion (UK), plasma renin activity (PRA), and 24-hour urine volume, sodium, and potassium excretion rates were determined sequentially in 16 normal pregnant women. Throughout gestation, UK was significantly elevated as compared to values obtained in 13 control women (1466 +/- 152 vs 375 +/- 90 U/g creatinine). The highest level was observed in Period 2 of gestation, corresponding to Weeks 17 to 24. PRA was also significantly elevated during pregnancy (11.97 +/- 1,35 vs 1.06 +/- 0.90 ng/ml/hr), with the highest level in Period 2. Mean 24-hour urine volume, sodium, and potassium excretion rates were significantly higher during pregnancy. Nor correlation was found between UK and: PRA, urine volume, and sodium and potassium excretions. These findings indicate a consistent activation of the renal-kallikrein-kinin system during pregnancy. We postulate that this vasodilator system might play a role in the maintenance of normotension in pregnancy, counteracting tha effect of the renin-angiotensin-aldosterone system.