Summary Statement Research Articles

A review of the use of simulation in dental education.

In line with the advances in technology and communication, medical simulations are being developed to support the acquisition of requisite psychomotor skills before real-life clinical applications. This review article aimed to give a general overview of simulation in a cognate field, clinical dental education. Simulations in dentistry are not a new phenomenon; however, recent developments in virtual-reality technology using computer-generated medical simulations of 3-dimensional images or environments are providing more optimal practice conditions to smooth the transition from the traditional model-based simulation laboratory to the clinic. Evidence as to the positive aspects of virtual reality include increased effectiveness in comparison with traditional simulation teaching techniques, more efficient learning, objective and reproducible feedback, unlimited training hours, and enhanced cost-effectiveness for teaching establishments. Negative aspects have been indicated as initial setup costs, faculty training, and the lack of a variety of content and current educational simulation programs.

Recommended implementation of arterial spin‐labeled perfusion MRI for clinical applications: A consensus of the ISMRM perfusion study group and the European consortium for ASL in dementia

This review provides a summary statement of recommended implementations of arterial spin labeling (ASL) for clinical applications. It is a consensus of the ISMRM Perfusion Study Group and the European ASL in Dementia consortium, both of whom met to reach this consensus in October 2012 in Amsterdam. Although ASL continues to undergo rapid technical development, we believe that current ASL methods are robust and ready to provide useful clinical information, and that a consensus statement on recommended implementations will help the clinical community to adopt a standardized approach. In this review, we describe the major considerations and trade‐offs in implementing an ASL protocol and provide specific recommendations for a standard approach. Our conclusion is that as an optimal default implementation, we recommend pseudo‐continuous labeling, background suppression, a segmented three‐dimensional readout without vascular crushing gradients, and calculation and presentation of both label/control difference images and cerebral blood flow in absolute units using a simplified model. Magn Reson Med 73:102–116, 2015. © 2014 Wiley Periodicals, Inc.

Pediatric and neonatal intubation training gap analysis: instruction, assessment, and technology.

Summary statement: Intubating adult patients presents numerous challenges for clinicians. Procedural complexities associated with performing pediatric and neonatal intubation, along with a lower frequency of a need for intubating pediatric and neonatal patients, further amplifies the difficulties associated with acquiring and maintaining relevant clinical skills. Clinicians must develop and maintain competency through training and continuing medical education. A systematic review was conducted through June 2012 to examine current instructional methods, assessment tools, and training models in pediatric and neonatal intubation training. Variability among the included literature on instruction, assessment, and models used to support training makes direct comparison problematic. The results of this review emphasize the need for improvement of current instructional methods to promote competency acquisition; development of valid, reliable assessment tools to evaluate clinician competency; and identification of a superior training model to promote acquisition and maintenance of skills associated with intubation of pediatric patients.

Establishing a safe container for learning in simulation: the role of the presimulation briefing.

Summary statement: In the absence of theoretical or empirical agreement on how to establish and maintain engagement in instructor-led health care simulation debriefings, we organize a set of promising practices we have identified in closely related fields and our own work. We argue that certain practices create a psychologically safe context for learning, a so-called safe container. Establishing a safe container, in turn, allows learners to engage actively in simulation plus debriefings despite possible disruptions to that engagement such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes. Establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a "fiction contract" with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety. As instructors collaborate with learners to perform these practices, consistency between what instructors say and do may also impact learners' engagement.

The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: evidentiary tables: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine.

A variety of technologies have been developed to assist decision-making during the management of patients with acute brain injury who require intensive care. A large body of research has been generated describing these various technologies. The Neurocritical Care Society (NCS) in collaboration with the European Society of Intensive Care Medicine (ESICM), the Society for Critical Care Medicine (SCCM), and the Latin America Brain Injury Consortium (LABIC) organized an international, multidisciplinary consensus conference to perform a systematic review of the published literature to help develop evidence-based practice recommendations on bedside physiologic monitoring. This supplement contains a Consensus Summary Statement with recommendations and individual topic reviews on physiologic processes important in the care of acute brain injury. In this article we provide the evidentiary tables for select topics including systemic hemodynamics, intracranial pressure, brain and systemic oxygenation, EEG, brain metabolism, biomarkers, processes of care and monitoring in emerging economies to provide the clinician ready access to evidence that supports recommendations about neuromonitoring.

The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a list of recommendations and additional conclusions: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine.

Careful patient monitoring using a variety of techniques including clinical and laboratory evaluation, bedside physiological monitoring with continuous or non-continuous techniques and imaging is fundamental to the care of patients who require neurocritical care. How best to perform and use bedside monitoring is still being elucidated. To create a basic platform for care and a foundation for further research the Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to develop recommendations about physiologic bedside monitoring. This supplement contains a Consensus Summary Statement with recommendations and individual topic reviews as a background to the recommendations. In this article, we highlight the recommendations and provide additional conclusions as an aid to the reader and to facilitate bedside care.

Is clinical trial registration for simulation-based research necessary?

Summary statement: The International Committee of Medical Journal Editors requires that all clinical trials be prospectively registered before being considered for publication in their member journals. Clinical trial registries are Web-based databases of clinical trials, providing researchers, journal editors, and reviewers detailed study information to help inform trial results. What is unclear is whether clinical trial registration is required for simulation-based studies, where typically health care providers are the subjects and where the outcomes may be provider based or patient based. In this article, we describe the background and reasoning behind clinical trial registration and discuss whether simulation-based studies should be registered as a prerequisite to publication.

“And It Happened Like This” : Summary and Unfolding in Biblical Hebrew Narrative Structure

In a number of passages in the Hebrew Bible, one finds what at first seem to be repetitions in the text. Not simply repetitions of events, but also at the beginning and end of the repetitions of the events, repetitions of actual wording. What is more, these seeming repetitions make it appear that the biblical author is confused about temporal sequence, since the same events are being repeated and in the repetition even earlier events are being related following later events (see Gen 10-11). But upon closer examination a distinctive structure appears: one of summary and unfolding. First will appear a summary statement, followed by a repetition of the contents of the summary in detailed form (the unfolding). Finally, a phrase repeated from the summary (an inclusio) closes the unfolding section and brings the reader back to the main narrative line. Eleven different examples of this will be documented, and a brief concluding comment made on the implications of this structure for translators of the Bible.

A patient safety approach to setting pass/fail standards for basic procedural skills checklists.

Checklists for basic procedural skills require an approach to standard setting in which patient safety concerns are paramount. We suggest that faculty members identify dimensions such as patient or clinician safety, procedure outcome, and patient comfort that are essential for a given procedure and demand for essential checklist items a high level of mastery that is not compensated by performance of nonessential items. This approach differs from traditional standard setting methods developed for written examinations, which allow examinees to miss a given percentage of items regardless of the specific items missed. Application of cut scores based on this patient safety standard resulted in requiring a substantial number of students to retrain and retest; these students would have passed if the traditional Angoff method had been used. Only by demanding a high level of mastery in the simulation laboratory can we promote patient safety in the messy and unpredictable real world.

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine.

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.

RETIRED: Managing Menopause Abstract and Summary Statement

Abstract Objective To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality. Outcomes Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Counselling and therapeutic strategies for sexuality concerns in the peri- and postmenopausal years are reviewed. Approaches to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are presented in the companion osteoporosis guideline. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library in August and September 2012 with the use of appropriate controlled vocabulary (e.g., hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e.g., hormone therapy, perimenopause, heart disease, and sexuality). Results were restricted to clinical practice guidelines, systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to publication dates of 2009 onwards and to material in English or French. Searches were updated on a regular basis and incorporated in the guideline until January 5, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, national and international medical specialty societies, and clinical practice guideline collections. Values The quality of the evidence in this document was rated using the criteria described by the Report of the Canadian Task Force on Preventive Health Care (Table 1).

New RHD variant alleles.

SUMMARY STATEMENT This report describes 22 new RHD variants whose identi-fication was prompted by discrepancies between theresults of targeted genotyping and serology. BACKGROUND The spread of targeted genotyping as a means to confirmserology data or to resolve hematologic discrepancies isaccelerating the discovery of new blood group variants.Listing of blood group variants in public databases inassociation with their phenotype, haplotype, and racialbackground may facilitate decision making by the trans-fusion specialist. BRIEF METHODS Targeted genotyping was performed on BloodChip Refer-encev4.0,anoligonucleotidemicroarraythatinterrogates69 polymorphic positions in the RHD gene (ProgenikaBiopharma, Derio, Spain). Phenotyping was performedby tube, microplate, gel column, solid-phase, andadsorption-elution methods using the following anti-Dreagents (see Table 1): Immuclone RUM-1 (R1), Series 4MS201/MS26 (R2), Gammaclone 401/F8D8 (R3), humanpolyclonal serum (R4), and Novaclone 175-2/D415 1E4(R5) from Immucor; Bioclone MAD2 (R6) and BiocloneD7B8/H1121G6/LORIFA (R7) from Ortho; TH-28 mono-clonal (R8) and ID-Card human polyclonal serum (R9)from Bio-Rad; ESD-1 monoclonal (R10) from DiagnosticsScotland; Albaclone Partial D panel (R11) and AlbacloneWeak D kit (R12) from Alba Bioscience; D-Screen9-monoclonal panel (R13) from Diagast; Albaclone6-monoclonal panel (R14), Albaclone 12-monoclonalpanel(R15),andhumanpolyclonalserum(R16)fromDia-Med. DNA sequencing of

SEPTEMBER 2014 PLACEMENT ADS

SEPTEMBER 2014 PLACEMENT ADS

From bricks to buildings: adapting the Medical Research Council framework to develop programs of research in simulation education and training for the health professions.

Presently, health care simulation research is largely conducted on a study-by-study basis. Although such "project-based" research generates a plethora of evidence, it can be chaotic and contradictory. A move toward sustained, thematic, theory-based programs of research is necessary to advance knowledge in the field. Recognizing that simulation is a complex intervention, we present a framework for developing research programs in simulation-based education adapted from the Medical Research Council (MRC) guidance. This framework calls for an iterative approach to developing, refining, evaluating, and implementing simulation interventions. The adapted framework guidance emphasizes: (1) identification of theory and existing evidence; (2) modeling and piloting interventions to clarify active ingredients and identify mechanisms linking the context, intervention, and outcomes; and (3) evaluation of intervention processes and outcomes in both the laboratory and real-world setting. The proposed framework will aid simulation researchers in developing more robust interventions that optimize simulation-based education and advance our understanding of simulation pedagogy.

The FMR1 gene, infertility, and reproductive decision-making: a review.

The strongest association between FMR1 and the ovary in humans is the increased risk of premature ovarian failure (POF) in women who carry the premutation level of CGG repeats (55–199 CGGs). Research on the FMR1 gene has extended to other endpoints of relevance in the OB/GYN setting for women, including infertility and ovarian hormones. After reviewing the nomenclature changes that have occurred in recent years, this article reviews the evidence linking the length of the FMR1 repeat length to fertility and ovarian hormones (follicle stimulating hormone and anti-mullerian hormone as the primary methods to assess ovarian reserve in clinical settings). The literature is inconsistent on the association between the FMR1 trinucleotide repeat length and infertility. Elevated levels of follicle stimulating hormone have been found in women who carry the premutation; however the literature on the relationship between anti-mullerian hormone and the CGG repeat length are too disparate in design to make a summary statement. This article considers the implications of two transgenic mouse models (FXPM 130R and YAC90R) for theories on pathogenesis related to ovarian endpoints. Given the current screening/testing recommendations for reproductive age females and the variability of screening protocols in clinics, future research is recommended on pretest and posttest genetic counseling needs. Future research is also needed on ovarian health measurements across a range of CGG repeat lengths in order to interpret FMR1 test results in reproductive age women; the inconsistencies in the literature make it quite challenging to advise women on their risks related to FMR1 repeat length.

Systematic use of the RAM nasal cannula in the Yale–New Haven Children’s Hospital Neonatal Intensive Care Unit: a quality improvement project

Objective: To evaluate the clinical efficacy of the RAM nasal cannula (NC) with different modes of non-invasive ventilation (NIV) in the neonatal intensive care unit (NICU).Methods: A single center prospective, observational study of infants placed on RAM NC. A small trial (Study 1) was completed in 16 infants on NIV via the RAM NC over a 48-h period to create Summary Statement recommendations. Next, over a 10-month period (Study 2), data were prospectively collected for the outcome of all infants receiving respiratory support with the RAM NC. Outcomes were compared between different modes of NIV and whether the recommendations were followed.Results: The Study 2 population consisted of 88 infants of whom 67 infants received nasal continuous positive airway pressure ventilation (NCPAP) and 21 received nasal intermittent positive pressure ventilation (NIPPV) via the RAM NC. The NIPPV group tended to be younger, smaller and stayed on the RAM NC longer. The overall success rate in weaning off the RAM NC, if our guidelines were followed, was 63%.Conclusion: RAM NC use with NIV was well tolerated in the neonatal population with the use of our guidelines. We speculate that use of our guidelines will lead to a more systematic use of the RAM NC in the NICU.

Update on pathology of antibody-mediated rejection in the lung allograft.

The determination of antibody-mediated rejection (AMR) in the pulmonary allograft remains a diagnostic challenge. Herein, we review the pathologic findings from recent studies, including the International Society of Heart and Lung Transplantation (ISHLT) summary statement on pulmonary AMR and preliminary data from the Banff allograft pathology study on AMR in lung transplant patients. Some pathologic findings, including acute lung injury and neutrophilic capillary infiltration, are likely to be associated with pulmonary AMR but do not appear to be specific pathologic markers. The ISHLT statement on pulmonary AMR lists numerous pathologic findings that may be associated with donor-specific antibodies (DSAs). Other recent studies, including the Banff study on pulmonary AMR, have found correlations between clinical AMR, defined in part by the presence of DSAs, and nonspecific acute lung injury and capillary neutrophils with or without C4d deposition. At this time, the diagnosis of lung transplant AMR requires multidisciplinary coordination and is ultimately determined by the managing clinician. In the full clinical context, including knowledge of serologic data for the presence or absence of DSAs, pathologic interpretation may provide valuable information that can guide therapy and support the clinical diagnosis.

Specialty Milestones and the Next Accreditation System

The Accreditation for Graduate Medical Education has developed a new process of accreditation, the Next Accreditation System (NAS), which focuses on outcomes. A key component of the NAS is specialty milestones-specific behavior, attributes, or outcomes within the general competency domains. Milestones will mark a level of proficiency of a resident within a competency domain. Each specialty has developed its own set of milestones, with semiannual reporting to begin July 2013, for 7 specialties, and the rest in July 2014.Milestone assessment must be based on objective data. Each specialty will determine optimal methods of measuring milestones, based on ease, cost, validity, and reliability. The simulation community has focused many graduate medical education efforts at training and formative assessment. Milestone assessment represents an opportunity for simulation modalities to offer summative assessment of milestone proficiencies, adding to the potential methods that residency programs will likely use or adapt. This article discusses the NAS, milestone assessment, and the opportunity to the simulation community to become involved in this next stage of graduate medical education assessment.

Asymmetry of lower limb joint loading in advanced knee osteoarthritis

Summary Statement This study provides preliminary evidence that people with knee osteoarthritis have greater asymmetry in joint loading than healthy controls. Altered loading of the contralateral limb may signify increased risk of injury to other lower limb joints in knee osteoarthritis. Introduction Compensatory overloading of other lower limb joints is a potential reason for the non-random evolution of osteoarthritis (OA). In individuals with knee OA altered joint loading exists of the contralateral cognate joints. However, previous studies have neglected the temporal features of asymmetry in joint loading. The study aimed to identify the amount and temporal features of asymmetry in lower limb joint loading in advanced knee OA. Patients and Methods Participants (n=15) were awaiting primary unilateral total knee replacement for OA (age 67.0 SD 8.9 years, height 1.66 SD 0.13 m, mass 84.2 SD 15.8 kg, BMI 30.7 SD 6.2 kg/m2, median KL grade 4). Data were compared to asymptomatic age and sex matched controls. Kinematic and kinetic data during walking was acquired with 12 cameras (VICON MX-F20) and two Kistler force platforms at 100 Hz and 400 Hz respectively. Data were analysed in Visual3D (C-Motion Inc., USA). Asymmetry was computed in MatLab using a recently published symmetry index (SI) and symmetry function (SF). Variables (computed using inverse dynamics) were the peak external moments (%BW∗Height) of the hip, knee and ankle. Differences between means of the SI variables in the OA and control groups were compared using Student's t-tests. Discrete variables were also compared between limbs (paired t-test) or between the affected limb and matched control limb. Effect sizes (Cohen's d ) for the differences were also computed. Results A significant between group difference (OA and control) for SI was observed for the transverse plane ankle joint moment (16.1 SD 8.0 vs. 10.4 SD 4.8 d = 0.8 p = 0.049). A large effect size for the sagittal plane knee joint moment (22.9 SD 12.1 vs. 12.7 SD 5.1 d = 1.1 p = 0.178) and a medium effect size for the transverse plane hip joint moment (26.4 SD 15.9 vs. 16.6 SD 9.0 d = 0.7 p = 0.098) were observed. The unaffected limb (OA group) had higher peak hip flexion (5.76 SD 1.49 vs.5.32 SD 1.51 p = 0.041) and internal rotation moments (−0.67 SD 0.34 vs. −0.41 SD 0.18 d = 0.004) and a lower ankle inversion moment (0.16 SD 0.14 vs. 0.34 SD 0.24 d = 0.9 p = 0.030) compared to the affected limb. Only the difference in the first peak knee adduction moment for the affected and matched control limb was statistically significant (−2.65 SD 1.38 vs. −2.16 SD 1.16 d = 0.7 p = 0.031). Discussion and Conclusion This study provides preliminary evidence of more asymmetry in joint moments of the lower limb in people with knee OA compared to controls. Further investigation with a larger sample is required to verify these findings. Altered loading of the contralateral cognate joints may signify increased risk of injury at the hip and ankle and highlights the need for monitoring of other lower limb joints in knee OA.

Condition assessment of two early Christian martyrs’, St. Christine's and St. Augustine's relics with paleoradiological methods in Hungary

Abstract Objectives Condition assessment of the relics of the Early Christian martyrs St. Christine and St. Augustine enshrined in the St. Gotthard Parish Church of Mosonmagyarovar, Hungary using radiological methods. The bodies are dressed up in ornate baroque style attires, the examination was conducted without opening the clothing. Our principle objective was to collect information on the general condition of the bodies, the internal characteristics of the skeletons and the attires with non-invasive methods. Methods Hundred and twenty-eight slice CT-scanner, conventional digital radiography. Results The preservation of the bones varies. The skeletons are incomplete, some elements were put together in non-anatomical position. Some kind of filling and reinforcement is proved in certain parts of the bodies. Conclusion The two bodies must have been assembled in the Baroque Era (17–18th c. AD). We got information on the condition and the attire of both bodies including skeletal preservation, the structure of the golden and silver embroidery and other decorations of the clothing. These radiographical images will provide crucial information in the course of the forthcoming conservation work conducted on the relics. Summary statement The scientific research of the holy relics are mainly connected Italian researchers and specialist from other countries, whom they cooperated with (Aufderheide, 2003; Fulchieri, 1996 [1] , [2] ). Perhaps the most well-known examination of the remains of St. Nicholas what Luigi Martino carried out in 1957 (Anatomical examination of the Bari relics, 2013 [3] ). In Central Europe, including Hungary, this was the first radiological examination and analysis of the entire relics (full human remains).