Clinical Simulation Research Articles

Enhancing Clinical Education Training with Immersive Reality (XR)

A core element of clinical education is the observed structured clinical examination (OSCE) that simulates real-life clinical practice. These OSCEs can be enhanced through combining the best elements of emerging technologies in the design of enhanced simulation environments to prepare healthcare graduates for changing clinical practice as it integrates new and emerging technologies. New and emerging immersive reality (XR) headsets that allow digital enhancement of practice with real tools and procedures can be combined with haptic feedback such as a high-fidelity manikin within an interactive immersive room that can replicate a wide variety of real-world scenarios at the touch of a button. In this way XR can enhance authentic learning in clinical and first responder practice by enabling exposure to critical elements of clinical simulation in a safe, contextual learning environment that is cost effective and scalable compared to the expense of simulations involving actors and physical real-life sets. In response this concise paper introduces the development of a framework for enhanced simulation practice using the Blended Learning Simulation Suite (BLISS).

PROJECT-BASED LEARNING AS A MEANS OF DEVELOPING SPEAKING SKILLS OF MEDICAL STUDENTS

This article explores the effectiveness of project-based learning (PBL) as a pedagogical approach to enhance speaking skills of medical students, emphasizing the practical application of language within professional field. In the context of evolving medical education, the need for proficient English language skills among healthcare professionals has become increasingly topical. By integrating constructivist, experiential, communicative, and task-based learning theories, PBL fosters critical thinking, collaboration, and creativity. Through active engagement in projects such as clinical simulations, case studies, and health campaigns, students not only acquire linguistic competence but also bridge knowledge across disciplines such as biology, pharmacology, ethics, etc. This study aims to analyze the methodologies, impacts, and potential obstacles of PBL in medical English education. The findings are intended to inform English language instructors in medical educational establishments, ultimately enhancing the quality of training for future healthcare professionals in a globalized surroundings. By promoting effective communication skills, PBL serves as a vital tool in preparing a new generation of adaptable and skilled practitioners.

Cloud based adaptive learning system: virtual reality and augmented reality assisted educational pedagogy development on clinical simulation

An adaptive learning system provides support for student’s academic progress by varying learning routes and pedagogical contents to satisfy various students’ unique academic needs. The primary goal of this research work is to enhance and expand occupational efficiency through the use of technological pedagogical content knowledge (TPCK) frameworks in nursing education. The authors developed an adaptive federated cloud computing learning system in order to better prepare students for the demands of real-world professional practice. The article examined the use of virtual reality(VR) and augmented (AR) technologies in nursing education and developed an instrument that skillfully combines knowledge from the reputable literature on clinical competencies with the peculiarities and ingenuousness particular to virtual simulations. Designated for the remote sharing and utilization of combined educational resources, cloud computing is a distributed information communication technology (ICT) infrastructure built on the Internet of Things (IoT) framework. To increase the occupational efficiency among the nurses and midwives, an educational simulation applied in a way that gamifies the curriculum component for interactive educational pedagogy will be necessary. As a completely integrated part of the curriculum, simulation has proven to be beneficial for nursing students at all levels of instruction. Nursing educators have a plethora of options at their disposal to introduce simulation-based learning approaches into their curricula in the modern era. A three-dimensional (3D) interactive environment that provides users with a sense of spatial presence is created through computer technology, which is an immersive digital ecosystem of VR and AR utilized to improve teaching and learning in nursing education. In this study, the authors offered a cost- effective clinical simulation laboratory for clinical students, nurses, midwives, and practicing healthcare professionals in a manner that ensures constant learning and occupational efficiency by adopting the TPCK model in its central discussion and implementation. The TPCK model has demonstrated how to recognize the boundaries between technological components and pedagogical structures as well as how they are connected when creating facts in nursing education.

Simulation-Based Training in Clinical Event Debriefing Improves Leadership Performance.

Clinical event debriefing (CED) improves healthcare team performance and patient outcomes. Most pediatric emergency medicine (PEM) physicians do not receive formal training in leading CED. Our objectives were to develop a CED curriculum and evaluate its effect on performance, knowledge, comfort, and clinical practice. This was a single group pre-post-retention study. We developed a hybrid curriculum with simulation, an interactive module, and individual feedback. We invited faculty and fellows from the PEM division of our hospital to participate. During an in-person training day, participants led standardized clinical simulation scenarios followed by simulated CED with immediate feedback on their leadership performance. They watched an interactive module between scenarios. Participants returned for a retention assessment 2-6 months later with a third simulation and debrief. Participants completed surveys measuring attitudes, experiences, and knowledge. Participants also evaluated the curriculum.The primary outcome was CED leadership performance using a novel 21-item tool that we developed, the Debrief Leadership Tool for Assessment (DELTA). A blinded, trained rater measured performance with DELTA. Secondary outcomes included changes in knowledge and comfort and changes in clinical practice. Twenty-seven participants enrolled and completed all parts of the curriculum and assessments. Debrief leadership performance improved by a mean of 3.7 points on DELTA pre-training to post-training (95% confidence interval = 2.7, 4.6, P < 0.01) and by 1.4 points from pre-training to retention (95% confidence interval = 0.1, 2.8, P = 0.03). Knowledge and comfort also significantly improved from pre-training to post-training and were sustained at retention. Most (67%) participants changed their clinical practice of CED after completing the curriculum. All participants would recommend the training to other PEM physicians. A hybrid simulation-based curriculum in leading CED for PEM physicians was associated with improvement in CED leadership performance, knowledge, and comfort. PEM physicians incorporated training into their clinical practice.

Contributions of Clinical Simulation with Standardized Patients in the Subject of OT intervention in Mental Health

The paper discusses the contributions of clinical simulation with standardized patients in the teaching of occupational therapy at the Universidad Andrés Bello, highlighting its importance in the formation of practical skills, the improvement in the understanding of the empathic aspects of care, and its relevance of its use in mental health. The study was carried out using a quantitative methodology with a cross-sectional analytical design of local validation. The universe was made up of 60 students of the VIII semester of the Occupational Therapy career of the Andrés Bello University, Viña del Mar campus. Among the main results, it is inferred that clinical simulation offers a safe learning environment that allows students to practice skills before interacting with real users; facilitates the development of empathy and effective communication in a therapeutic context; contributes to a better understanding of emerging dynamics and challenges in mental health; It improves students' competencies to apply theories in practical situations. In conclusion, it promotes critical reflection on behavior and decisions in the context of the intervention, helping to evaluate performance in real attention situations, encouraging active and collaborative learning among students.

Academic nursing administrators perceptions of replacing clinical hours with simulation

BackgroundNursing education has seen a shift towards simulation-based education (SBE) to meet the demands of a rapidly evolving healthcare landscape. Maryland's Clinical Simulation Resource Consortium (MCSRC) aimed to enhance SBE utilization; however, noted a decline in SBE usage post pandemic prompting an investigation into nurse administrators' perspectives on replacing clinical hours with SBE. MethodsThis descriptive quality improvement study was informed by Rogers' Diffusion of Innovation (DOI) Theory. Semi-structured interviews were conducted with four academic nurse administrators from various pre-licensure nursing programs in Maryland. The data collected were analyzed using thematic analysis. ResultsNurse administrators who value SBE as a safe learning space are integral when building and maintaining infrastructure to support simulation usage. Identified barriers related to faculty buy-in, workload, and inadequate human resources to deliver high-quality simulations can hinder sustained adoption of clinical simulation. ConclusionsThis study highlights the necessity of continuous faculty training in SBE and dedicated resources to support simulation infrastructure. Recommendations include sustained investment in faculty development, creating specialized roles for simulation champions, and fostering collaborations to strengthen simulation integration. The findings emphasize the pivotal role of nurse administrators in navigating challenges and maximizing SBE's potential to replace clinical hours in nursing education, urging ongoing support and strategic planning for successful integration.

Evaluation of ComBat Harmonization for Reducing Across-Tracer Differences in Regional Amyloid PET Analyses.

Differences in amyloid positron emission tomography (PET) radiotracer pharmacokinetics and binding properties lead to discrepancies in amyloid-β uptake estimates. Harmonization of tracer-specific biases is crucial for optimal performance of downstream tasks. Here, we investigated the efficacy of ComBat, a data-driven harmonization model, for reducing tracer-specific biases in regional amyloid PET measurements from [18F]-florbetapir (FBP) and [11C]-Pittsburgh compound-B (PiB). One hundred thirteen head-to-head FBP-PiB scan pairs, scanned from the same subject within 90 days, were selected from the Open Access Series of Imaging Studies 3 (OASIS-3) dataset. The Centiloid scale, ComBat with no covariates, ComBat with biological covariates, and GAM-ComBat with biological covariates were used to harmonize both global and regional amyloid standardized uptake value ratios (SUVR). Variants of ComBat, including longitudinal ComBat and PEACE, were also tested. Intraclass correlation coefficient (ICC) and mean absolute error (MAE) were computed to measure the absolute agreement between tracers. Additionally, longitudinal amyloid SUVRs from an anti-amyloid drug trial were simulated using linear mixed effects modeling. Differences in rates-of-change between simulated treatment and placebo groups were tested, and change in statistical power/Type-I error after harmonization was quantified. In the head-to-head tracer comparison, ComBat with no covariates was the best at increasing ICC and decreasing MAE of both global summary and regional amyloid PET SUVRs between scan pairs of the same group of subjects. In the clinical trial simulation, harmonization with both Centiloid and ComBat increased statistical power of detecting true rate-of-change differences between groups and decreased false discovery rate in the absence of a treatment effect. The greatest benefit of harmonization was observed when groups exhibited differing FBP-to-PiB proportions. ComBat outperformed the Centiloid scale in harmonizing both global and regional amyloid estimates. Additionally, ComBat improved the detection of rate-of-change differences between clinical trial groups. Our findings suggest that ComBat is a viable alternative to Centiloid for harmonizing regional amyloid PET analyses.

The Clinical Judgment Debriefing Structure: Integrating the Clinical Judgement Measurement Model into debriefing

The transformation of nursing education in the United States, driven by the Next Generation NCLEX (NGN), demands a focus on clinical judgment. However, a gap exists in the literature regarding debriefing structures that center on clinical judgment and integrate the Clinical Judgment Measurement Model (CJMM). This paper introduces the Clinical Judgment Debriefing Structure (CJDS) that was designed to incorporate the CJMM into debriefing to support the development of clinical judgment and enhance NGN preparedness. The CJDS provides clinical judgment practice using reflective questions and tasks by emphasizing each element in Layer 3 of the CJMM. Implementation involves faculty inputting simulation content into the CJDS by preparing answers to the standardized reflection questions and tasks. The CJDS streamlines faculty preparation and ensures standardization of each debriefing session. Presented at the 2023 International Nursing Association for Clinical Simulation and Learning (INACSL) conference, the CJDS received positive feedback, indicating its practicality and applicability in simulation practices. Findings from initial testing of the CJDS using a qualitative/quantitative design, demonstrated increased knowledge and confidence in clinical judgment. While measuring clinical judgment remains challenging, the CJDS stands as a unique tool for centering debriefing on clinical judgment and guiding students through Layer 3 of the CJMM, ultimately contributing to safer nursing practice.

Assessment of the impact of Long COVID on labour market participation and potential economic effects in the EU

Abstract This paper estimates the economic cost of long COVID through its direct impacts on the labour market. The direct implications of long COVID for affected individuals concern their capacity to work, and their productivity at work. Some individuals might continue to work, but at a lower productivity level, some might reduce their hours worked, including as a result of temporary absences, and some might stop working at all. To the best of our knowledge, so far, no study has explicitly addressed the impact of long COVID on the EU labour market. The present paper provides a tentative assessment using available estimates from surveys, clinical follow-up studies and model simulations of the prevalence of long COVID. This tentative approach yields an estimated negative impact on labour supply of 0.2-0.3% in 2021 and 0.3-0.5% in 2022. In person-equivalents, this means long COVID would have reduced labour supply by 364,000-663,000 in 2021 and by 621,000-1,112,000 in 2022, combining the effect of lower productivity, higher sick leaves, lower hours, and increased unemployment or inactivity. The lower bound of this range is close to a recent estimate put forward for the US (Abraham &amp; Rendell, 2023). Available labour market data suggest a mixed picture when it comes to the impact of long COVID. Overall, the possible role of long COVID in the rising trend in sick leave, disability and activity-limiting health factors, warrants careful monitoring going forward, due to its potential impact on labour supply and labour productivity, and on public finances through increased social benefits, pensions, health care and long-term care expenditure.

Nursing Students’ Satisfaction with Clinical Simulation: A Cross-Sectional Observational Study

Clinical Simulation improves results in the students’ learning tests and allows for preserving acquired knowledge for longer periods of time, promoting more significant learning. This study was conducted to analyze Nursing students’ satisfaction with Clinical Simulation in three centres attached to a university from southern Spain. Methods: A quantitative, non-experimental and cross-sectional descriptive study was carried out. The students included were attending their third year of the Nursing undergraduate course and had already taken part in training sessions by means of Clinical Simulation. The Satisfaction Scale with High-Fidelity Clinical Simulation in Students (SSHF) was used for data collection. This scale has been validated and has 33 items grouped into eight factors. The SPSS software (version 28), was used for data analysis, establishing p-values &lt; 0.05 for the statistically significant differences. Results: The participants were 180 students, with a mean age of 22.17 years old. Of them, 90.56% belonged to the female gender. A mean score of 3.82 out of 5 was obtained in the SSHF items. The items that obtained the highest scores were the following: benefits of Clinical Simulation as it relates theory with practise; possibility of learning based on the mistakes made; and comfort and respect while the sessions were developed. The item that obtained the lowest score was “timing for each simulation case”. We found significant differences in the results obtained according to each attached centre. Conclusions: The students showed high satisfaction levels regarding High-Fidelity Clinical Simulation in each of the three attached centres included in the study. Nevertheless, they stated the need to invest more time in Clinical Simulation sessions.

Quantification of training in educational methodology among teachers on the degree course in medicine: a pilot study

BackgroundMedical education has undergone significant changes over the last decades. Scientific and technological progress alongside contemporary society’s changing requirements have driven demand for highly trained, competent doctors. In response to this need, university faculties of medicine have sought innovative forms of teaching and evaluating the students on their degree courses. The aim of this study was to quantify the characteristics and extent of academic training in teaching methods, of participation in innovative teaching initiatives, and training in simulation and debriefing among the teaching personnel on the degree course in medicine at the University of Granada (Spain).MethodsThis transversal descriptive study was conducted among a population of 121 educators teaching on the medical degree course at the University of Granada, Spain. All responded to a specially designed CoRe-Content Representation questionnaire. This consisted of various parts: (a) demographic data; (b) teaching experience and qualifications; (c) specific information about training in teaching skills received. The Fisher test was applied whenever the dependent variable had two values (dichotomous) and the Chi-square test when it had more than two values (polytomic). Statistical significance was established with an alpha error of 5%.ResultsThe results showed that 87.60% of the educators had received no training in debriefing. There was a notable gender gap, whereby women held fewer management posts, fewer were engaged in clinical activity, and fewer had undergone training in clinical simulation. Teachers with degrees in medicine had undergone less regulated training than educators with other degree qualifications.ConclusionThe main areas of medical training that require improvement (and so present challenges to be met in the years to come) are as follows: a definitive solution to the existing gender gap, general implementation of new educational models and methods (especially learning based on clinical problem-solving and simulation), closing generation gaps, and improved training processes for educators with clinical attachment.

Impact of teaching modality on soft skill development: Oral health literacy awareness skills assessed using standardized patient experiences.

Health literacy awareness is a crucial skill for health professionals, yet training may be lacking. Didactic lectures may improve health literacy awareness in future health professionals, however, compressed curricula may lead educators to consider the incorporation of eLearning into the delivery of health literacy education. E-modules have been shown to engage learners, yet little is known about their effectiveness in instilling behavioral change in learners' clinical communication skills. This study aimed to shed light on the impact of learning modality on dental students' ability to learn and translate soft skills into clinical settings. An e-module on health literacy awareness was created by the researchers with an equivalent lecture developed. Fifty-six dental students were randomly assigned to a control or intervention cohort (lecture or e-module) and all cohorts participated in standardized patient experiences to be assessed in a simulated but authentic patient care scenario. Pre- and post-intervention scores, simulation scores, and learner reflections were compared. Fifty-six students participated in the study. Post-intervention health literacy awareness knowledge increased for both intervention cohorts. In clinical simulation, intervention cohorts scored significantly higher on nearly all variables, with the lecture cohort scoring consistently better than e-learners. Both lecture and e-learning are effective learning modalities for promoting health literacy awareness, but dental students learning the subject via lecture may translate certain newly acquired soft skills more effectively in clinical scenarios.

Clinical Simulation Program for the Training of Health Profession Residents in Confidentiality and the Use of Social Networks.

In the transition to a professional learning environment, healthcare professionals in their first year of specialized postgraduate clinical training (known as residents in Spain) are suddenly required to handle confidential information with little or no prior training in the safe and appropriate use of digital media with respect to confidentiality issues. The aims of this study were: (1) to explore the usefulness of an advanced clinical simulation program for educating residents from different healthcare disciplines about confidentiality and the dissemination of clinical data or patient images; (2) to explore the use of social networks in healthcare settings; and (3) to explore participants' knowledge and attitudes on current regulations regarding confidentiality, image dissemination, and the use of social networks; Methods: This was a cross-sectional study. Data were collected from all 49 first-year residents of different health professions at a Spanish hospital between June and August 2022. High-fidelity clinical simulation sessions designed to address confidentiality and health information dissemination issues in hospital settings, including the use of social networks, were developed and implemented. Data were assessed using a 12-item ad hoc questionnaire on confidentiality and the use of social media in the healthcare setting. Descriptive of general data and chi-square test or Fisher's exact test were performed using the SPSS 25.0 software; Results: All the participants reported using the messaging application WhatsApp regularly during their working day. A total of 20.4% of the participants stated that they had taken photos of clinical data (radiographs, analyses, etc.) without permission, with 40.8% claiming that they were unaware of the legal consequences of improper access to clinical records. After the course, the participants reported intending to modify their behavior when sharing patient data without their consent and with respect to how patients are informed; Conclusions: The use of advanced simulation in the training of interprofessional teams of residents is as an effective tool for initiating attitudinal change and increasing knowledge related to patient privacy and confidentiality. Further follow-up studies are needed to see how these attitudes are incorporated into clinical practice.

Characteristics, Impact, and Trends of Healthcare Simulation in Latin America and the Caribbean: A Bibliometric Analysis.

This study highlights the growing significance of healthcare simulation in enhancing the quality and safety of patient care across Latin America and the Caribbean, by analyzing bibliometric trends and the impact of publications on simulation-based clinical training between 2012 and 2022. Leveraging the Scopus database and VOSviewer software for thesaurus interaction analysis, the research identified 610 documents, accumulating 4681 citations, thereby indicating a burgeoning interest in this field with notable publication spikes in 2017 and 2020. Brazil and the United States emerged as leading contributors, with a primary focus on "simulation training," "clinical competence," "medical education," and "education." The study observed an uptick in international collaboration, mirroring the increase in document count and citations. This bibliometric review underscores the emphasis on evaluating technical skills and clinical practices as prevailing areas of interest, highlighting Brazil's significant academic contributions, and suggesting a promising future for the implementation of clinical simulation in the region. The study advocates for continued scholarly output to align with global advancements in medical simulation, aiming to optimize patient outcomes.

Transitioning from specialisation to collaboration: interprofessional clinical simulation, metacognition and the phenomenon of convergence

ABSTRACT Research into metacognitive processes within interprofessional clinical simulation has been largely overlooked in the literature. This study explores how interprofessional simulation may influence cognitive and metacognitive processes across several professional programmes; medicine, nursing, pharmacy, and occupational therapy. This study focused on changes in performance pre- and post-simulation, with undergraduate students from each profession answering a set of questions related to the simulation case, requiring specialized knowledge from each profession. Question scores, item confidence judgment ratings, and calibration values were collected and analyzed. The data revealed a pattern of convergence in post-simulation assessments, where professions initially with lower performance in the pre-simulation phase improved, and those initially performing well demonstrating a decline in performance. Calibration values indicated that medical students developed metacognitive errors from their interactions in the simulation, which were not present pre-simulation, and that occupational therapy students suffered a loss of confidence and calibration in questions within their own field resulting from their experience (being more accurate pre-simulation). The authors anticipate that the phenomenon of convergence may have longer-term consequences, potentially fostering distrust among professions for those with declining performance. The authors propose that expanding awareness of convergence phenomena and conducting repeated simulations (thus facilitating further team development) could mitigate this issue.

Perception of University Nursing Students and Faculty Members Regarding Simulated Practices: A Mixed Methods Study.

Clinical simulation has been used as a teaching strategy for students in health programmes, fostering greater preparedness and confidence in performing procedures. This study aimed to analyse the perception of fourth-semester nursing students and teachers regarding the simulated practice methodology implemented in a private university in Cali, Colombia. A robust mixed-methods approach was used, incorporating quantitative surveys and qualitative interviews with 41 students and 5 teaching nursing faculty members. Data triangulation was applied to ensure the robustness of the results. Both students and teachers reported a positive perception of simulated practice, which contributes to knowledge acquisition and contextual learning. Students emphasised that simulation improved their prior knowledge and motivated them to explore new topics. Lecturers emphasised the importance of well-trained instructors in simulation environments. However, participants identified challenges affecting performance, including simulation duration, group size, realism, and resource constraints. Students and teachers recommend strategic changes to the curriculum to optimise simulation practices.

The effectiveness of enhanced reality simulation on postmastectomy patient care management provided by nursing students: a quasi-experimental study

AimThe aim of this study was to evaluate the effect of enhanced reality simulation on nursing students' learning satisfaction and self-confidence and patient care management knowledge and skills regarding postmastectomy care. BackgroundBreast cancer is a common disease with increasing incidence and mastectomy is the treatment of choice. Postmastectomy patient care is a multidimensional and complex process. For various reasons, nursing students today graduate with inadequate clinical skills and do not have experience with many cases. DesignThis quasi-experimental study was conducted using a pretest–posttest design with a nonequivalent control group. MethodsThis study was conducted with fourth-year nursing students (78 students). Students were allocated to each group through a simple random allocation using IBM SPSS Statistics version 24. Research data were collected at the Clinical Simulation Training Center of the university in 2020–2021 academic year. The study group (n=39) learned using a scenario-based learning approach with moulage in a real clinical setting using enhanced reality simulation, while the control group (n=39) learned using the same scenario-based approach with the routine practice adult standard patient care model. The data were collected through the “Student Sociodemographic and Descriptive Characteristics Data Collection Form”, the “Student Satisfaction and Self-Confidence in Learning Scale”, the “Postmastectomy Patient Care Skills Checklist” and the “Pre–Post Knowledge Test on Postmastectomy Patient Care Management”. ResultsAll 78 participants completed the training course. The training significantly increased the Student Satisfaction and Self-Confidence in Learning Scale subdimension scores of both groups (p<0.05). The Postmastectomy Patient Care Management scores of the study group students who received enhanced reality simulation training significantly increased (p<0.05), while there was no significant effect on the scores of the control group students (p>0.05). While most the students in the study group increased their rates of correct answers to Postmastectomy Patient Care Management questions significantly (p<0.05) after the enhanced reality simulation training, the students in the control group showed no significant improvement (p>0.05). The training significantly (p<0.001) increased the mean postmastectomy patient care skills control scores. This increase had a high effect size on the study group. ConclusionEnhanced reality simulation is a learning method that increases nursing students' learning satisfaction and self-confidence and patient care management knowledge and skills regarding postmastectomy care. Learning with enhanced reality simulation is an effective approach for nursing education that improves nursing students' learning satisfaction and self-confidence and patient care management knowledge and skills regarding postmastectomy care.

Evaluation of the effect of CYP2D6 and OCT1 polymorphisms on the pharmacokinetics of tramadol: Implications for clinical safety and dose rationale in paediatric chronic pain.

Our investigation aimed to assess the dose rationale of tramadol in paediatric patients considering the effect of CYP2D6/OCT1 polymorphisms on systemic exposure. Recommendations were made for the oral dose of tramadol to be used in a prospective study in children (3months to < 18 years old) with chronic pain. Intravenous pharmacokinetic and genotype data from neonatal patients (n = 46) were available for this analysis. The time course of tramadol and O-desmethyltramadol (M1) concentrations was characterized using a nonlinear mixed effects approach in conjunction with extrapolation principles. Clinical trial simulations were then implemented to explore the effects of polymorphism, maturation and developmental growth on the disposition of tramadol and M1. Reported efficacious exposure range in adult subjects were used as reference. The pharmacokinetics of tramadol and M1 was characterized by a two-compartment model. The total clearance of tramadol (CLPP) comprised CYP2D6-mediated metabolism (CLPM) and other pathways (CLPO). Age-related changes in CLPM, CLPO and M1 clearance (CLMO) were described by a sigmoid function, with CYP2D6 as a covariate on CLPP and CLPM, and OCT1 on CLMO. Simulation scenarios includingdifferent CYP2D6/OCT1 combinations revealed that steady-state concentrations are above the putative ranges for analgesia in >15% and >70% of subjects after doses of 3 and 8mg/kg, respectively. In the absence of genotyping, reference exposure ranges can be used to define the dose rationale for tramadol in paediatric chronic pain. However, a starting dose of 0.5mg/kg/day should be considered, followed by stepwise titration to the desired analgesic response.

Designing and testing clinical simulations of an early warning system for implementation in acute care settings.

Conducting simulation testing with end-users is essential for facilitating successful implementation of new health information technologies. This study designed a standardized simulation testing process with a system prototype prior to implementation to help study teams identify the system's interpretability and feasibility from the end-user perspective and to effectively integrate new innovations into real-world clinical settings and workflows. A clinical simulation model was developed to test a new Clinical Decision Support (CDS) system outside of the clinical environment while maintaining high fidelity. A web-based CDS prototype, the "CONCERN Smart Application," which leverages clinical data to measure and express a patient's risk of deterioration on a 3-level scale ("low," "moderate," or "high"), and audiovisual-integrated materials, were used to lead simulation sessions. A total of 6 simulation sessions with 17 nurses were held to investigate how nurses interact with the CONCERN Smart application and how it influences their critical thinking, and clinical responses. Four themes were extracted from the simulation debriefing sessions and used to inform implementation strategies. The strategies include how the CDS should be improved for practical real-world use. Standardized simulation testing procedures identified and informed the necessary CDS improvements, the enhancements needed for real-world use, and the training requirements to effectively prepare end-users for system go-live.

Evaluation of ComBat harmonization for reducing across-tracer differences in regional amyloid PET analyses.

Introduction Differences in amyloid positron emission tomography (PET) radiotracer pharmacokinetics and binding properties lead to discrepancies in amyloid-β uptake estimates. Harmonization of tracer-specific biases is crucial for optimal performance of downstream tasks. Here, we investigated the efficacy of ComBat, a data-driven harmonization model, for reducing tracer-specific biases in regional amyloid PET measurements from [18F]-florbetapir (FBP) and [11C]-Pittsburgh Compound-B (PiB). Methods One-hundred-thirteen head-to-head FBP-PiB scan pairs, scanned from the same subject within ninety days, were selected from the Open Access Series of Imaging Studies 3 (OASIS-3) dataset. The Centiloid scale, ComBat with no covariates, ComBat with biological covariates, and GAM-ComBat with biological covariates were used to harmonize both global and regional amyloid standardized uptake value ratios (SUVR). Variants of ComBat, including longitudinal ComBat and PEACE, were also tested. Intraclass correlation coefficient (ICC) and mean absolute error (MAE) were computed to measure the absolute agreement between tracers. Additionally, longitudinal amyloid SUVRs from an anti-amyloid drug trial were simulated using linear mixed effects modeling. Differences in rates-of-change between simulated treatment and placebo groups were tested, and change in statistical power/Type-I error after harmonization was quantified. Results In the head-to-head tracer comparison, ComBat with no covariates was the best at increasing ICC and decreasing MAE of both global summary and regional amyloid PET SUVRs between scan pairs of the same group of subjects. In the clinical trial simulation, harmonization with both Centiloid and ComBat increased statistical power of detecting true rate-of-change differences between groups and decreased false discovery rate in the absence of a treatment effect. The greatest benefit of harmonization was observed when groups exhibited differing FBP-to-PiB proportions. Conclusion ComBat outperformed the Centiloid scale in harmonizing both global and regional amyloid estimates. Additionally, ComBat improved the detection of rate-of-change differences between clinical trial groups. Our findings suggest that ComBat is a viable alternative to Centiloid for harmonizing regional amyloid PET analyses.