Critical Procedures Research Articles

Память как матрица истории в концепции П. Рикёра

The article discusses the problem of the relationship between history and memory as two independent forms of using the past within the framework of P. Ricoeur’s philosophy. The value of Ricoeur’s approach lies in the fact that he analyzes this problem at different levels, starting with the essence and mechanisms of work of both phenomena. The analysis of the interrelation and rivalry between history and memory allows us to take a fresh look at the problem of the referentiality of historical texts, namely, to shift the focus from the gap between the sign and the referent to their necessary connection. On the basis of the phenomenology of memory proposed by Ricoeur, it is possible to organize various forms of reference to the past. As forms of saving experience, history and memory carry a fundamental claim to truth, despite the fact that in both cases the image of the past is produced by the imagination. Imagination can be visualizing (allowing to see) or derealizing (cutting off from reality), therefore both memory and history need ways to verify this claim to truth. For memory, this way is recognizing, which is a subjectively experienced sensation, and for history it is the possibility of a permanent revision of its constructions in a process that Ricoeur calls standing for (représentance (Fr.)). These ways must remain autonomous, allowing both to realize its function. For memory, this is the keeping of the identity, the continuity of the subject, and for history, it is the implementation of a critical assessment and reorganization of experience, which is constantly enriched with new challenges and new data. Recognition of the memory independence restrains some actors usurping access to the past so far as they believe only they have the correct memory. History, on the other hand, through critical procedures, performs a corrective function and treats the past as the claim to truth, despite the subjectivity of memory.

Food safety and sanitation challenges of public university students in a developing country.

Inadequate catering facilities in Kenyan public universities compel students to handle and prepare their own food, in environments not designated for food preparation such as rooms in hostels. This study investigated the level of food safety and sanitation knowledge, attitude, and practice, among students in an effort to prevent food‐borne diseases. A cross‐sectional study was conducted among 535 students from two public universities in Kenya. Data were obtained through a piloted, structured questionnaire in line with Food and Agriculture Organization (FAO) guidelines, administered to students from seven different departments. Eighty percent of the students had adequate levels of food safety and hygiene knowledge, while 70% had a positive attitude toward food safety and sanitation. An average of 74% engaged in inadequate food safety and hygiene practices, with majority citing lack of equipment as a major contributor. ANOVA results revealed significant correlation between the gender and knowledge and practice of food safety and sanitation (F = 30.328, ρ = 0.000) and (F = 18.177,ρ = 0.000), respectively. Binary logistic regression showed that knowledge (β = 3.677, p < .000) fostered the practice of food safety and sanitation more in comparison with attitude (β = 2.244, p < .000). Kenyan universities should consider introducing food safety courses that emphasize Food Safety Management System (FSMS) and Hazard Analysis Critical Control Point (HACCP) practices and procedures especially to non‐science‐based courses, in addition to providing students with proper cooking and food handling facilities.

Critical parameters and procedures for anaerobic cultivation of yeasts in bioreactors and anaerobic chambers.

ABSTRACTAll known facultatively fermentative yeasts require molecular oxygen for growth. Only in a small number of yeast species, these requirements can be circumvented by supplementation of known anaerobic growth factors such as nicotinate, sterols and unsaturated fatty acids. Biosynthetic oxygen requirements of yeasts are typically small and, unless extensive precautions are taken to minimize inadvertent entry of trace amounts of oxygen, easily go unnoticed in small-scale laboratory cultivation systems. This paper discusses critical points in the design of anaerobic yeast cultivation experiments in anaerobic chambers and laboratory bioreactors. Serial transfer or continuous cultivation to dilute growth factors present in anaerobically pre-grown inocula, systematic inclusion of control strains and minimizing the impact of oxygen diffusion through tubing are identified as key elements in experimental design. Basic protocols are presented for anaerobic-chamber and bioreactor experiments.

Critical Assembly and Test Procedures Driven by Mechanical Constriction Principle for Advanced Performances of Solid‐State Batteries

The perspective aims to articulate the fundamental aspect of the unique mechanical constriction effect that is implied in some widely used experimental procedures in solid‐state battery assembly and test. The effect is important to battery performances in terms of the voltage stability with high voltage cathodes and Li metal anode, the fast‐charging ability using Li metal anode, and the cycling stability. The physical picture of the mechanical constriction effect under the constrained ensemble is first described. Theoretical and computational approaches to implement such a physical picture are then introduced to make concrete metastability and kinetic stability predictions that can be compared with experiments from various measurable aspects. Future directions are discussed in the end regarding a synergistic mechanical constriction design by simultaneously considering battery materials, assembly procedures, and device designs for advanced battery performances and the compatibility with practical considerations of interest to industries. It can be envisioned that fully unlocking the potential of the mechanical constriction design principle will greatly speed up the development of solid‐state batteries.

System of Psychological Support Based on Positive Suggestions to the Critically Ill Using ICU Doulas.

Background:Surviving critical illness often creates a lasting psychological impact, including depression, anxiety, and post-traumatic stress. Memories of frightening and delusional experiences are the largest potentially modifiable risk factor, but currently, there is no proven intervention to improve these inciting factors. Psychological support based on positive suggestion is a psychotherapeutic approach that can be provided even to patients in altered cognitive states and is therefore a viable psychotherapy intervention throughout the ICU stay. Traditional ICU care team members have limited time and training to provide such psychological support to patients. Doulas are trained supportive companions who have been effectively used to provide patient advocacy and emotional support in other clinical settings and may address this need. Our aim was to train and implement a psychological support based on positive suggestion program for the critically ill using doulas, and measure acceptance of this intervention through stakeholder feedback.Methods:Doula training included three objectives: an introduction to ICU practice structure and policies; education about fundamental aspects of critical care conditions and procedures; and didactic and hands-on learning experiences in effective use of psychological support based on positive suggestion in the critically ill. Doulas were evaluated at the end of their training and during subsequent clinical activities using competency-based assessments as well as through survey-based questions and interviews with key stakeholders.Results:The ICU doulas performed psychological support based on positive suggestion on 43 critically ill patients in the ICU setting. Stakeholder feedback from nurses, patients, and patient families was positive. The majority (28/32) of surveyed bedside ICU nurses reported that the doulas’ involvement was helpful for both patients and nurses alike. All interviewed family members offered positive comments about the ICU doula presence and of the 40 patients who recalled the intervention 37 found it comforting.Conclusions:Our program successfully trained two doulas to work effectively in the ICU setting performing patient-centered psychological support based on positive suggestion interventions. Their training improved their skill sets and was reported as beneficial by patients, families, and critical care nursing. This training program offers a proof of concept that could be applied in other medical centers, bringing doulas more commonly into the ICU practice to help humanize the experience for patients, families, and medical teams.

Use of Control Charts and Scientific Critical Thinking in Experimental Laboratory Courses: How They Help Students to Detect and Solve Systematic Errors

Systematic errors are unfortunately common in analyses performed by students in teaching laboratories. Quality control (QC) tools are required to detect and solve bias in laboratory analyses. However, although QC has become routine in real-world laboratories, it is still rarely applied in teaching laboratories. For this reason, systematic errors in students’ results remain unknown in many cases. In this study, the use of control charts and critical thinking methodologies are applied in laboratory lessons to show students how the control charts can be used to detect and correct systematic biases in analyses. Students practice how to evaluate out-of-control results by applying scientific critical thinking procedures based on knowledge acquired in previous subjects, aiming to find the source of the bias detected, solve it, and apply rectifying measures to improve the operational procedure. With the proposed methodology, students understand the importance of control charts in demonstrating the quality and validity of the data obtained. During the academic years applying this methodology, the most common source of bias was found to be related to an incorrect application of basic laboratory skills, which shows that these skills need to be learned and, most importantly, put into practice over the whole period of student training and cannot be taken for granted once they have been taught in the early stages of their curricula. The learning outcomes were assessed through an exercise that requires students to evaluate results obtained in the laboratory in previous years. It was found that the majority of students (97.6%) were able to detect a bias, find the source, and solve the error.

Effectiveness of Self-Directed Small-Group-Learning Against Self-Directed Individual-Learning Using Self-Instructional-Video in Performing Critical Emergency Procedures Among Medical Students in Malaysia: A Single-Blinded Randomized Controlled Study

BackgroundSelf-instructional-video is an effective self-directed learning method of clinical procedural skills. MethodA single-blinded randomized controlled study comparing small-group-learning and individual-learning was conducted to evaluate knowledge and skills retention of manual defibrillation and endotracheal intubation. Data were collected on knowledge, skill acquisition, and confidence, at pretest, post-test and retention at 6 months postintervention. ResultsSmall-group-learning demonstrated better outcomes on knowledge and skill acquisition of intubation compared to individual-learning. For defibrillation, both groups showed similar improvements in knowledge and skill acquisition. ConclusionSelf-directed small-group-learning is a better method for knowledge and skill acquisition, regardless of the procedure complexity.

The Relevance of Procurement in Public Administration: A South African Perspective

Public procurement is a big industry in public administration as taxpayers’ money spent by the government on goods, services and infrastructure accounts for the massive gross domestic product (GDP) of a country. This study upholds the idea that public procurement is relevant and activity of public administration. The public administration atmospheres focus on macro milieus and support the government to advance consciousness, dynamics convoluted purchases of government goods, services, works and infrastructure development. Such external environmental aspects moving public and private buyers in the same direction are that of reconnoitring those critical environmental inspirational procurement procedures. This calls for public administrators to design bid processes according to the above-mentioned influences, as they are cradles of government financial spending and economic progression. Public administration philosophies succor to offer dimensions and theoretical conceptual work on how procurement should proceed within the government. Such public administration theories are paramount to transcend the understanding of procurement in the public sector. Specifically, the generic administrative functions as they relate to public procurement are relevant in expounding this research. The paper is the exploratory one, seeking to expand the knowledge base and stimulate discourse on procurement practices in government. A qualitative research and content analysis was employed in this study. It can be deduced that there is the relevance of procurement in government, as government procures and spends billions and even trillions of rands financing goods, services, public works, massive infrastructure development-highways, bridges, dams, airports, seaports and other essential amenities. These massive kinds of procurement have to be accounted for against corrupt and state capture activities.

Development of postgraduate training in critical care medicine for nurse practitioners and physician assistants

Nurse practitioners (NPs) and physician assistants (PA) are increasingly providing care to the critically ill patients in the intensive care unit. We structured a 4-month training program for our existing NPs and PAs and assessed their knowledge and skill pre and post training. The program was composed of blended didactic in critical care medicine topics, critical care simulations in simulation laboratory, and supervised critical care procedures. Formal knowledge and skill assessments were performed before and after the program to assess success in meeting predefined learning objectives. The mean preintervention medical knowledge assessment score was 3.37 ± 0.56 SD, which significantly improved to 3.86 ± 0.46 SD (p < .00001). For clinical skills for critical care procedures, the mean preintervention score was 3.10 ± 0.86 SD, which improved to 3.61 ± 0.92 SD (p < .00001). The overall knowledge (including medical knowledge and clinical skills) improved from mean 3.30 ± 0.86 SD to 3.80 ± 0.42 SD. The improvement was seen regardless of the duration of experience in critical care medicine. We concluded that structured didactics with supervised procedural training along with dedicated training in simulation laboratories, even for a short period, improves the overall knowledge and clinical skills required to work in a critical care setting.

Frequency of Urgent or Emergent Vitreoretinal Surgical Procedures in the United States During the COVID-19 Pandemic

The American Academy of Ophthalmology (AAO) indicated that urgent or emergent vitreoretinal surgical procedures should continue during the coronavirus disease 2019 (COVID-19) pandemic. Although decreases in the frequency of critical procedures have been reported outside the field of ophthalmology, analyses are limited by volume, geography, and time. To evaluate whether the frequency of ophthalmic surgical procedures deemed urgent or emergent by the AAO changed across the United States during the COVID-19 pandemic. Vitreoretinal practices from 17 institutions throughout the US participated in this multicenter cross-sectional study. The frequency of 11 billed vitreoretinal Current Procedural Terminology (CPT) codes across respective weeks was obtained from each practice between January 1, 2019, and May 31, 2020. Data were clustered into intravitreal injections (code 67028), lasers and cryotherapy (codes 67141, 67145, and 67228), retinal detachment (RD) repairs (codes 67107, 67108, 67110, and 67113), and other vitrectomies (codes 67036, 67039, and 67040). Institutions were categorized by region (Northeast, Midwest, South, and West Coast), practice setting (academic [tax-exempt] or private [non-tax-exempt]), and date of respective statewide stay-at-home orders. Nationwide changes in the frequency of billing for urgent or emergent vitreoretinal surgical procedures during the COVID-19 pandemic. A total of 526 536 CPT codes were ascertained: 483 313 injections, 19 257 lasers or cryotherapy, 14 949 RD repairs, and 9017 other vitrectomies. Relative to 2019, a weekly institutional decrease in injections was observed from March 30 to May 2, 2020, with a maximal 38.6% decrease (from a mean [SD] of 437.8 [436.3] to 273.8 [269.0] injections) from April 6 to 12, 2020 (95% CI, -259 to -69 injections; P = .002). A weekly decrease was also identified that spanned a longer interval, at least until study conclusion (March 16 to May 31, 2020), for lasers and cryotherapy, with a maximal 79.6% decrease (from a mean [SD] of 6.6 [7.7] to 1.5 [2.0] procedures) from April 6 to 12, 2020 (95% CI, -6.8 to -3.3 procedures; P < .001), for RD repairs, with a maximal 59.4% decrease (from a mean [SD] of 3.5 [4.0] to 1.6 [2.2] repairs) from April 13 to 19, 2020 (95% CI, -2.7 to -1.4 repairs; P < .001), and for other vitrectomies, with a maximal 84.3% decrease (from a mean [SD] of 3.0 [3.1] to 0.4 [0.8] other vitrectomies) from April 6 to 12, 2020 (95% CI, -3.3 to -1.8 other vitrectomies; P < .001). No differences were identified by region, setting, or state-level stay-at-home order adjustment. Although the AAO endorsed the continued performance of urgent or emergent vitreoretinal surgical procedures, the frequency of such procedures throughout the country experienced a substantial decrease that may persist after the COVID-19 pandemic's initial exponential growth phase. This decrease appears independent of region, setting, and state-level stay-at-home orders. It is unknown to what extent vitreoretinal intervention would have decreased without AAO recommendations, and how the decrease is associated with outcomes. Although safety is paramount during the COVID-19 pandemic, practices should consider prioritizing availability for managing high-acuity conditions until underlying reasons for the reduction are fully appreciated.

Transmission of Severe Acute Respiratory Syndrome Coronavirus 1 and Severe Acute Respiratory Syndrome Coronavirus 2 During Aerosol-Generating Procedures in Critical Care: A Systematic Review and Meta-Analysis of Observational Studies.

To assess the risk of coronavirus transmission to healthcare workers performing aerosol-generating procedures and the potential benefits of personal protective equipment during these procedures. MEDLINE, EMBASE, and Cochrane CENTRAL were searched using a combination of related MeSH terms and keywords. Cohort studies and case controls investigating common anesthetic and critical care aerosol-generating procedures and transmission of severe acute respiratory syndrome coronavirus 1, Middle East respiratory syndrome coronavirus, and severe acute respiratory syndrome coronavirus 2 to healthcare workers were included for quantitative analysis. Qualitative and quantitative data on the transmission of severe acute respiratory syndrome coronavirus 1, severe acute respiratory syndrome coronavirus 2, and Middle East respiratory syndrome coronavirus to healthcare workers via aerosol-generating procedures in anesthesia and critical care were collected independently. The Risk Of Bias In Non-randomized Studies - of Interventions tool was used to assess the risk of bias of included studies. Seventeen studies out of 2,676 yielded records were included for meta-analyses. Endotracheal intubation (odds ratio, 6.69, 95% CI, 3.81-11.72; p < 0.001), noninvasive ventilation (odds ratio, 3.65; 95% CI, 1.86-7.19; p < 0.001), and administration of nebulized medications (odds ratio, 10.03; 95% CI, 1.98-50.69; p = 0.005) were found to increase the odds of healthcare workers contracting severe acute respiratory syndrome coronavirus 1 or severe acute respiratory syndrome coronavirus 2. The use of N95 masks (odds ratio, 0.11; 95% CI, 0.03-0.39; p < 0.001), gowns (odds ratio, 0.59; 95% CI, 0.48-0.73; p < 0.001), and gloves (odds ratio, 0.39; 95% CI, 0.29-0.53; p < 0.001) were found to be significantly protective of healthcare workers from contracting severe acute respiratory syndrome coronavirus 1 or severe acute respiratory syndrome coronavirus 2. Specific aerosol-generating procedures are high risk for the transmission of severe acute respiratory syndrome coronavirus 1 and severe acute respiratory syndrome coronavirus 2 from patients to healthcare workers. Personal protective equipment reduce the odds of contracting severe acute respiratory syndrome coronavirus 1 and severe acute respiratory syndrome coronavirus 2.

Novice nurses' readiness to practice in an ICU: A qualitative study.

Novice nurses (newly qualified within the first 3-year period of professional practice after registration) must first face the reality and complexity of caring for high-acuity patients in the critical care setting, which can be an unfamiliar and demanding environment. The successful transition from education to professional practice of novice nurses hired for intensive care must be supported. To explore Polish novice nurses' readiness to practice in an intensive care unit (ICU). Our study objectives included investigating pre-registration preparation for work in an ICU, identifying the most needed competencies to work in an ICU, and analysing organizational aspects of the professional orientation period. A qualitative phenomenology design was applied. We conducted qualitative content analysis based on individual semi-structured in-depth interviews. Study recruitment was performed using a purposeful and network sampling strategy. The final number of participants was 17 Polish novice nurses. The majority of responders replied that they were not prepared to work in an ICU after graduation. Professional orientation was planned-generally for a period of 3months; however, in most places it was shortened. The respondents identified the five competencies most needed to work in an ICU: communication, teamwork, professional self-confidence, and knowledge and its practical use. Their enhancement could be achieved through simulations during both pre-registration and professional training. Analysis of the novice nurses' orientation period revealed many difficulties that indicated a lack of readiness to practice in an ICU after graduation. Identifying novice nurses' strengths and weaknesses regarding clinical competence is important to guide the design of orientation programmes in ICU settings and nursing education programmes. Readiness for ICU work may be improved by enriching education with simulations that enable training in the practical use of knowledge and critical care procedures. A supportive work environment is crucial during professional orientation.

Day case angioplasty in a secondary care setting - initial experience.

Background: Peripheral artery disease presents an increasing healthcare burden worldwide. Day-case angioplasty in a secondary care setting can be a safe and effective means of meeting the growing demand for lower limb revascularisation. We evaluated the safety and efficacy of a day-case-based angioplasty service in a UK district general hospital. Patients and methods: Consecutive patients undergoing endovascular revascularisation between August 2018-February 2020 were analysed retrospectively. All patients were discussed at a multi-disciplinary (diabetic foot) team meeting following a day case algorithm. Patient and procedural characteristics, technical success, peri-procedural complications, and 30-day outcome of day-case angioplasties were compared with those requiring overnight stay or were hospitalized. Results: Fifty-seven percent of 138 patients were diabetic, mean age 75±12years, 95% had critical limb ischaemia (Fontaine III 12%, IV 83%), and baseline ankle brachial pressure index [ABPI] 0.40±0.30. Sixty-three patients (45%) were treated as planned day cases, 21 (15%) required overnight admission for social indications. Fifteen (11%) were planned admissions with the need for sequential debridement procedures, and 39 (28%) were already hospitalised at the time of referral to the vascular service. The overall technical success was 92% and not successful procedures mainly occurred in patients>80years. The ABPI increased at the initial follow-up to 0.84±0.18. Fifty-three percent required treatment of>1 level, 80% included recanalisations of chronic total occlusions, and average total lesion length was 133±90mm. Closure devices were employed in all cases. There were no major peri-procedural complications. A single minor access-site related bleeding episode (0.8%) occurred, requiring 24h observation in hospital. While significantly more wounds had closed in out-patients, the mortality, major amputation and target lesion revascularization did not differ between groups. Conclusions: Safe and effective day-case-based angioplasty can be provided in a secondary care setting for patients with critical limb ischaemia needing complex multi-level procedures.

Case Volume Analysis of Neurological Surgery Training Programs in the United States: 2017-2019

ABSTRACT BACKGROUND Neurological surgery resident applicants seek out certain aspects of training, including case volume. While graduating Accreditation Council for Graduate Medical Education (ACGME) summary data are available yearly, they are not program specific and drawing conclusions is difficult. OBJECTIVE To model general benchmarks for resident case volume across US programs to increase transparency and allow comparison of programs. METHODS ACGME neurosurgical resident national reports from 2017 to 2019 were downloaded. Averages, standard deviations, and medians were recorded from each of the 27 procedural categories. Monte Carlo simulations were performed. Each distribution was run independently 1 to 4 times to represent the number of residents in a given program per year. Cases were divided into different categories: endovascular, open vascular, tumor, spine, and pediatrics. RESULTS Average derived graduating case volumes were 1558 cases in 2017, 1599 cases in 2018, and 1618 cases in 2019. Programs with 3 residents per year averaged 4755 cases per year, with 90th percentile of 5401 cases per year. After removing endovascular cases, radiosurgery cases, and critical care procedures, the average was 3794 cases, with 90th percentile of 4197 cases per year. Categorically, the 90th percentile was 241 for open vascular, 373 for endovascular, 1600 for spine, 769 for tumor, and 352 for pediatrics. CONCLUSION Case volume is an important part of neurosurgical training and a major factor in determining applicant residency program ranking. Through Monte Carlo simulation, the average case volume for programs with 3 residents per year was determined. Metrics and benchmarking remain an important part of applicant and program growth.

Characteristics, management and outcome of prehospital pediatric emergencies by a Dutch HEMS

BackgroundIn prehospital care, the Helicopter Emergency Medical Service (HEMS) can be dispatched for critically injured or ill children. However, little detail is known about dispatches for children, in terms of the incidence of prehospital interventions and overall mortality. The primary objective of this study is to provide an overview of pediatric patient characteristics and incidence of interventions.MethodsA retrospective chart review of all patients ≤ 17 years who received medical care by Rotterdam HEMS from 2012 until 2017 was carried out.ResultsDuring the study period, 1905 pediatric patients were included. 59.1% of patients were male and mean age was 6.1 years with 53.2% of patients aged ≤ 3 years. 53.6% were traumatic patients and 49.7% were non-traumatic patients. 18.8% of patients were intubated. Surgical procedures were performed in 0.9%. Medication was administered in 58.1% of patients. Cardiopulmonary resuscitation (CPR) was necessary in 12.9% of patients, 19.9% were admitted to the intensive care unit and 14.0% needed mechanical ventilation. Overall mortality was 9.5%. Mortality in trauma patients was 5.5% and in non-trauma group 15.3%. 3.9% of patients died at the scene.ConclusionsPatients attended by HEMS are at high risk of prehospital interventions like CPR or intubation. EMS has little exposure to critically ill or injured children. Hence, HEMS expertise is required to perform critical procedures. Trauma patients had higher survival rates than non-traumatic patients. This may be explained by underlying illnesses in non-traumatic patients and CPR as reason for dispatch. Further research is needed to identify options for improving prehospital care in the non trauma pediatric patients.

Recommendation for Resuming Elective Surgery during the Normalising Period in COVID-19 Pandemic.

Recommendation for Resuming Elective Surgery during the Normalising Period in COVID-19 Pandemic.

Hot off the press: SGEM#308: Taking care of patients every day with physician assistants and nurse practitioners.

The role of advanced practice providers (APPs) in emergency medicine is evolving over time, with increased patient visits seen by physician assistants and nurse practitioners, as well as higher acuity patients. Little data exists regarding the impact of APPs on productivity, flow, and safety in the emergency department setting. We discuss a study by Pines et al in the December issue of Academic Emergency medicine, in which they evaluate the effect of APPs on productivity, safety, and flow of patients in a large, multicenter emergency medicine group. We provide critical evaluation and commentary, and highlight social media discussion.

Alternative cardiac intensive care unit locations during the COVID-19 pandemic at an academic medical center

Alternative cardiac intensive care unit locations during the COVID-19 pandemic at an academic medical center

Coronavirus-19 Multisystem Inflammatory Syndrome in Children (MIS-C): A Pediatric Simulation Case for Residents, Fellows, and Advanced Practice Providers.

IntroductionA rare but serious condition often requiring intensive care, multisystem inflammatory syndrome in children (MIS-C) is characterized by hyperinflammatory shock related to the SARS-CoV-2 pandemic. This resource teaches residents, pediatric emergency medicine fellows, and advanced practice providers who care for children to recognize and manage MIS-C and associated sequelae while applying the basic principles of pediatric resuscitation.MethodsThe simulation case was based on a real patient who presented to the emergency department with fever, rash, and cardiogenic shock. We designed the scenario to be used with a high-fidelity school-age mannequin in an emergency center resuscitation room or simulation lab. The case took 25 minutes to run, followed by a 15- to 20-minute debrief session. Personnel required for the case included a simulation technician, case instructor, emergency department nurse, parent, and consultant. Learners had to recognize the syndrome and treat the resultant shock and arrhythmia with a combination of vasopressors, antiarrhythmics, and defibrillation. Afterward, learners participated in a formal debriefing session and completed a written evaluation.ResultsTwenty-five learners (six pediatric emergency medicine fellows, 12 residents, and seven advanced practice providers) participated in the scenario over a 3-month period. The written evaluation was completed by 20 of the 25 participants; all 20 felt their confidence, comfort, and knowledge regarding the topic had increased, with an average score of 5 (strongly agree) on a 5-point Likert scale.DiscussionThis simulation case offers an effective experience for learners to become comfortable and confident in recognizing and managing MIS-C.

Driving excellence in credit risk management practices in commercial lending - an empirical analysis of Indian public sector banks

Credit decisions are investment decisions with uncertainty over future cash inflows. The credit/risk managers in banks have to make informed choices based on their risk perceptions about commercial borrowers and manage credit risk at operational, strategic and regulatory levels. This study has investigated the effectiveness of a wide array of credit risk management (CRM) practices of Indian public sector banks through statistical analysis of perceptions of their credit analysts. Based on a systematic and comprehensive review of CRM systems in these banks, the study concluded that the most functional CRM practices are - awareness about other banks' risk management systems, a strong loan appraisal and review mechanism, implementation of know your customer (KYC) norms, multi-tier credit approval process, risk-based appraisals, and controlling wilful defaults by all means. The study also observed that there are many statistically significant different managerial perceptions about several CRM practices and this might be affecting the decision-making and judgment process on loan appraisals, risk scoring, loan reviews and other critical CRM processes and procedures.