Three-day Course Research Articles

Is Remote Learning as Effective as In-Person Learning for Contouring Education? A Comparison of Face-to-Face vs. Online Delivery of the Anatomy and Radiology Contouring Bootcamp

<h3>Purpose/Objective(s)</h3> The Anatomy and Radiology Contouring (ARC) Bootcamp was a three-day in-person course providing integrated radiology, anatomy, and contouring education for radiation oncology (RO) residents and medical physicists. The course consisted of didactic radiology and contouring lectures, small group anatomy sessions using cadaveric prosections, and real-time contouring using commercial software. Acknowledging the importance of increasing access to the Bootcamp, we launched an online (ONL) version of the ARC Bootcamp in November 2019. We evaluated the ONL course's impact on participants' knowledge acquisition, contouring skills, and self-confidence by comparing it to the face-to-face (F2F) course. <h3>Materials/Methods</h3> The F2F Bootcamp was adapted into an ONL version using the Teachable platform (teachable.com). The ONL course was structured in a linear progression of locked modules to offer similar content to the F2F comparator. Participants from the 2019 F2F and the 2019–2020 ONL Bootcamp provided consent for the study and completed pre-and post-intervention evaluations, which assessed anatomy/radiology knowledge, contouring skills, anatomy/radiology knowledge and contouring self-confidence, and course satisfaction. <h3>Results</h3> Fifty-seven (F2F: n = 30; ONL: n = 27) participants completed both evaluations. The ONL course had a substantially wider geographic participation, with participants from 19 countries (vs. 4 countries in the F2F course) completing the pre-evaluation. F2F had primarily RO resident participation (80%) compared to ONL (41%). In the ONL course, most were from a different field (52%), including medical physics residents or medical students. Compared to baseline self-assessments, both cohorts demonstrated similar self-confidence improvements with their anatomy knowledge, contouring skills, and in interpreting radiology images (all <i>P</i> < 0.001). In the anatomy/radiology knowledge testing, the ONL group showed improvement (mean improvement ± SD: 4.6 ± 6.3 on a 40-point scale; <i>P</i> < 0.001) but the F2F group did not (1.6 ± 5.6; <i>P</i> = 0.159). The F2F group demonstrated improvement with the contouring assessment (mean ± SD: 0.10 ± 0.17 on a 1-point Dice scale; <i>P</i> = 0.004), whereas only a trend was found for the ONL group (0.07 ± 0.16; <i>P</i> = 0.076). Both cohorts perceived the course as a positive learning experience (F2F: 4.8 ± 0.4 on a 5-point scale; ONL: 4.5 ± 0.6) and stated it will improve their professional practice (F2F: 4.6 ± 0.5 on a 5-point scale; ONL: 4.2 ± 0.8). Both groups would recommend the course to others (F2F: 4.8 ± 0.4 on a 5-point scale; ONL: 4.4 ± 0.6). <h3>Conclusion</h3> The ONL ARC Bootcamp achieved similar results as the F2F version, with improved self-confidence, knowledge scores, and high satisfaction levels among participants. The ONL course is more accessible to diverse geographic regions and disciplines, allows for ongoing education during the COVID-19 pandemic, and can be used as a framework to develop other online educational interventions in radiation oncology.

Effect of Different Corticosteroid Regimens on the Outcome of Severe COVID-19-Related Acute Respiratory Failure. A Retrospective Analysis.

Background: Systemic corticosteroids are associated with reduced mortality in COVID-19-related acute respiratory failure; however, the type and dose has not yet been established. Objectives: To compare the outcomes of dexamethasone vs. methylprednisolone, along with the effects of rescue, short-term, high-dose boluses of corticosteroids. Methods: Before/after and case/control retrospective analysis of consecutive critically ill COVID-19 subjects. Subjects were initially given dexamethasone; however, after review of the local protocol, methylprednisolone was suggested. A three-day course of 1000 mg/day of methylprednisolone was administered in the case of refractory hypoxemia within the first 10 days of treatment. Propensity score-adjusted comparisons were performed. Results: A total of 81 consecutive subjects were included (85% males, 60 ± 10 years, SAPS II 27 ± 7, SOFA 4 [IQR 3, 6] points) and 51 of these subjects (62.9%) received dexamethasone and 29 (35.8%) had methylprednisolone. The groups were well matched for age, comorbidities, and severity at admission. No differences were found in the duration of ICU stay, hospital mortality, or infectious complications between the groups. A total of 22 subjects (27.2%) received a rescue bolus; these subjects had a significantly lower oxygenation, a higher driving pressure, and an increased ventilatory ratio during the first ten days. Short-term/high-dose boluses were associated with higher hospital mortality, longer mechanical ventilation and ICU and hospital stay, and more infectious complications. A subgroup of subjects who received the boluses had significantly improved oxygenation and lower hospital mortality. Conclusions: We were unable to find any difference between dexamethasone or methylprednisolone on the explored outcomes; high-dose boluses of corticosteroids were associated with a worse outcome. However, a subgroup of subjects was identified in whom the high-dose boluses seemed beneficial.

Virtual non-technical skills assessment training is an effective, scalable approach for novice raters

OBJECTIVESThe COVID-19 pandemic has forced a creative transition to virtual platforms due to physical distancing and travel restrictions. We designed and tested a highly scalable virtual training curriculum for novice raters using the Oxford NOTECHS non-technical skills rating system.DESIGNA three-day training course comprising virtual didactics, virtually facilitated simulations, and independent live observations was implemented. NOTECHS scores were submitted for eleven standardized video simulations and four live operations. Intraclass correlation coefficients (ICCs) were calculated for total NOTECHS scores and subcomponent scores. Raters previously trained in-person with the same standardized videos served as a comparator group for equivalence testing.SETTINGAll study activities were conducted in a large academic tertiary referral center in Singapore as part of an ongoing surgical safety initiative.PARTICIPANTSSeven staff members underwent training (three virtually and four in-person). None had prior surgical experience or non-technical skills assessment training.RESULTSICCs for total NOTECHS scores were 0.85 (95% CI, 0.73-0.98) for virtually trained raters and 0.83 for those trained in-person (95% CI, 0.68-0.99). Scores were equivalent between groups within a 10% margin.CONCLUSIONSNon-technical skills assessment can be reliably taught in a highly scalable virtual format. Virtual NOTECHS training is a valuable tool for educational and quality improvement initiatives during the COVID-19 pandemic and for centers that lack ready access to onsite non-technical skills training expertise.

Engaging Occupational Safety and Health Professionals in Bridging Research and Practice: Evaluation of a Participatory Workshop Program in the Danish Construction Industry.

Engaging occupational safety and health (OSH) professionals has scarcely been evaluated as a means for transferring knowledge to practice about physical workload in the construction industry. The aim of this work was to examine how participants used and incorporate research-based knowledge from a three-day training course into practice. Twenty OSH professionals from the Danish construction industry participated in a workshop-training course. Researchers presented new knowledge and results about physically demanding work. The participants selected which themes they wanted to work with and developed an action plan. Evaluation was done using surveys and phone interviews. Analysis was based on how the OSH-professionals describe themselves, organizations, and the construction industry. Participant’s average scores on the level of implementation of their chosen action plans were 3 (on a response scale from 1–5, where 1 is ‘to a very low degree’ and 5 is ‘to a very high degree’) immediately after the workshop program and 2.5 at follow-up. Qualitative evaluations showed that actions had been initiated, and some progress had been made. The participants were satisfied with the workshop course and the possibility to increase their knowledge through inputs from researchers and colleges and strongly believe that they would succeed with implementing their action plans in the future.

P–464 What is the optimal ovarian stimulation (OS) protocol for women who undergo planned oocyte cryopreservation (POC)?

Abstract Study question When repeated cycles of OS for planned oocyte cryopreservation using a standard GnRH antagonist protocol are required, can OS protocol modifications improve oocyte yield? Summary answer Compared to repeating a standard GnRH antagonist protocol, switching to a long GnRH agonist protocol for POC results in a higher number of cryopreserved oocytes. What is known already The total number of cryopreserved oocytes is a key parameter of POC programs because of its association with livebirth. A substantial proportion of women embarking on POC will undergo repeated cycles of OS to reach their desired target number of vitrified oocytes. According to recent guidelines, the GnRH antagonist protocol with GnRH agonist triggering is considered the first choice protocol for POC, because of its safety profile and convenience. However, in women with normal ovarian reserve, the long GnRH agonist protocol results in a higher number of oocytes retrieved. Evidence regarding the optimal protocol for POC is limited. Study design, size, duration This is a single-centre, retrospective cohort study including 283 women who had a first cycle for POC using a standard GnRH antagonist protocol and who requested a second OS cycle to increase their total number of vitrified oocytes for later use. The choice of protocol for the second cycle was left at the discretion of the reproductive medicine specialist. All OS cycles took place between January 2009 and December 2019 in a tertiary referral hospital. Participants/materials, setting, methods After ovarian reserve testing, the first cycle OS was performed using rFSH or HPhMG in a GnRH antagonist protocol. For the second cycle, a GnRH antagonist protocol with or without antagonist pretreatment, or a long GnRH agonist protocol was prescribed. The primary outcome was the number of mature oocytes (MII) vitrified per cycle. Cycle characteristics were compared. Data were assessed by generalized estimating equation (GEE) regression analysis adjusting for covariates. Main results and the role of chance In total, 226 (79.9%) women had a GnRH antagonist protocol and 57 (20.1%) had a long GnRH agonist protocol in their second OS cycle for POC. Overall, mean age was 36.6±2.4 years. The median (CI) number of mature oocytes vitrified after the second OS cycle was significantly higher than that after the first cycle [8 (5–11) vs. 7 (4–10), p &amp;lt; 0.001]. According to GEE multivariate regression, adjusting for relevant confounders, switching from a GnRH antagonist protocol in the first cycle to a long GnRH agonist protocol in the second cycle was the only significant predictor of the number of vitrified oocytes after the subsequent cycle (coefficient 1.59, CI 0.29–2.89, p-value = 0.017). Age, AFC, initial dose and type of gonadotropins did not predict the number of vitrified oocytes. None of the women developed moderate or severe OHSS. Similarly, of 174 women who underwent their first OS cycle with a standard GnRH antagonist protocol, 133 women (76.4%) had the same protocol for their second cycle and 41 women (23.6%) an additional three-day course of GnRH antagonist pretreatment. According to GEE multivariate regression, this protocol modification did not result in more mature oocytes available for vitrification (coefficient –0.25, CI –1.86–1.36, p-value = 0.76). Limitations, reasons for caution These data should be interpreted with caution because of the retrospective design and limited sample. Although more oocytes were obtained with a long GnRH agonist protocol we have no data on livebirth in women returning to use their oocytes to support the choice for a specific OS protocol for POC. Wider implications of the findings: Although oocyte yield in the context of POC is an important parameter that may be modulated by the choice of OS protocol, the ultimate outcome measure of a successful POC program is livebirth after oocyte vitrification. Future research of oocyte parameters reflecting oocyte quality is paramount. Trial registration number Not applicable

A Nurse Training Program for Robotic Skills Acquisition and Career Advancement

Objective: Robotic surgery presents the state of the art surgical techniques in the era of minimally invasive surgery. A nurse’s role in surgery has been altered with the development of robotics. Our unique program at Polk State College in Florida was a robotic nursing program in which we certified nurses after a great deal of training. In this study our goal was to assess the survey outcomes of this program and to see if there was room for any improvements.&#x0D; Materials and Methods: We have successfully completed 4 three-day courses. During these courses we trained a total of 30 nurses and technicians. This special three-day course involved learning through online modules, didactic education, hands on training, and live surgery. We asked for their response to various questions about the course through an online survey. The trainees were asked to rank the questions about the program.&#x0D; Results: We obtained 20 out of 30 responses from our certified trainees. Seventy-five percent of the certified trainees agree that this robotics nursing program has helped them advance in a career. Overall, 85% of the certified trainees stated that this program was beneficial to them, and 95% agree that they would recommend this robotic nursing program to others.&#x0D; Conclusion: This survey demonstrated a well-designed robotics nurse-training program might help trainees to gain robotic skills. Also, they declared that their certification helped them make some kind of advance in their career.

Effects on staff outcomes and process evaluation of the educating nursing staff effectively (TENSE) program for managing challenging behavior in nursing home residents with dementia: A cluster-randomized controlled trial

BackgroundChallenging behavior is prevalent in people with dementia residing in nursing homes and places a high burden on the nursing staff of dementia special care units. This study evaluates an educational program for nursing staff for managing challenging behavior: The Educating Nursing Staff Effectively (TENSE) program. This program can be tailored to care organizations’ wishes and needs and combines various learning styles. ObjectiveThe aim of this cluster-randomized controlled trial was to examine the short-term (3 months) and long-term (9 months) effects of the TENSE training program on experienced stress, work contentment, and stress reactions at work in nursing staff working in dementia special care units. DesignCluster-randomized controlled trial. MethodsNursing staff members of 18 dementia special care units within nine nursing homes from different Netherlands regions were randomized into an intervention (n = 168) or control (n = 129) group. The TENSE program consisted of a three-day training course and two follow-up sessions after three and six months, respectively. The primary outcome was stress experienced by nursing staff measured with the Utrecht Burnout Scale - C. Secondary outcomes were work contentment and stress reactions at work. Furthermore, process evaluation data on the reach of and compliance with the program and the program's feasibility and relevance were collected. Data were collected between November 2012 and November 2014. ResultsIn general, the participants appreciated the quality and relevance of the TENSE training and evaluated the content of the training as beneficial. The TENSE training had no effect on the components of experienced stress, i.e., emotional exhaustion (p = 0.751), depersonalization (p = 0.701), and personal accomplishment (p = 0.182). Furthermore, no statistically significant effects of the intervention on work contentment and stress reactions at work were found. ConclusionsThe TENSE training program did not have an effect on experienced stress, work contentment, nor stress reactions at work of nursing staff working in dementia special care units. In future studies, more focus on practicing new skills seems needed.Trial registration: NTR (Dutch Trial Registration) number NTR3620

A Delayed Case of Pericarditis Following Recovery From COVID-19 Infection

Pericarditis is a rare cardiac complication of coronavirus 19 (COVID-19) infection. Recent case reports describe severe sequelae of pericarditis, including cardiac tamponade, developing within days of initial COVID-19 symptoms. We present a case of pericarditis with slower onset and milder symptoms, developing over a period of a few weeks in an immunocompetent male who recovered from COVID-19 several months earlier.A 65-year-old male presented to an emergency department several times for one week of worsening chest and neck symptoms, along with fever. He had been symptom-free after a three-day course of cough, myalgias, and fever with positive COVID-19 testing, approximately 70 days earlier. He was ultimately admitted for fever and pericarditis with an associated pericardial effusion and positive PCR testing for COVID-19.Pericarditis should be considered in the differential diagnosis for patients with COVID-19 and unexplained persistent chest symptoms. The possibility of recurrent or atypical latent infection should additionally be considered in the months following the initial COVID-19 infection. Bedside ultrasound may facilitate early diagnosis and management of COVID-19 associated pericarditis.

Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO-defined non-severe pneumonia and wheeze.

Worldwide, pneumonia is the leading cause of death amongst children under five years of age, and accounts for approximately two million deaths annually. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, and the severity of the disease. Treatment is then tailored according to the classification. For non-severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non-severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. The WHO recommends treating non-severe pneumonia with oral antibiotics. Pneumonia is more commonly caused by viruses that do not require antibiotic treatment, but pneumonia caused by bacteria needs management with antibiotics to avoid complications. There is no clear way to quickly distinguish between viral and bacterial pneumonia. It is considered safe to give antibiotics, however, this may lead to the development of antibiotic resistance, and thus, limit their use in future infections. Therefore, it is essential to explore the efficacy of antibiotics for children with WHO-defined non-severe pneumonia and wheeze. To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO-defined non-severe pneumonia and wheeze. We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers (December 2020). We included randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children, aged 2 to 59 months, with non-severe pneumonia and wheeze. We defined non-severe pneumonia as 'a cough or difficulty in breathing, with rapid breathing (a respiratory rate of 50 breaths per minute or more for children aged 2 to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months), chest indrawing and wheeze'. We excluded trials involving children with severe or very severe pneumonia, and non-RCTs. Our primary outcomes were clinical cure and treatment failure; secondary outcomes were relapse, mortality, and treatment harms. We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Two review authors independently assessed the search results, extracted data, assessed risk of bias and the certainty of the evidence. We contacted the authors of two included trials and the author of the trial awaiting classification to obtain missing numerical outcome data. We included three trials involving 3256 children aged between 2 to 59 months, who exhibited features of non-severe pneumonia with wheeze. The included trials were multi-centre, double-blind, randomised, placebo-controlled trials carried out in Malawi, Pakistan, and India. The children were treated with a three-day course of amoxicillin or placebo, and were followed up for a total of two weeks. We assessed the included trials at overall low risk of bias for random sequence generation, allocation concealment, blinding, attrition bias, and selective reporting. Only one trial was assessed to be at high risk for blinding of outcome assessors. One trial is awaiting classification Antibiotic therapy may result in a reduction of treatment failure by 20% (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.68 to 0.94; three trials; 3222 participants; low-certainty evidence). Antibiotic therapy probably results in little or no difference toclinical cure (RR 1.02, 95% CI 0.96 to 1.08; one trial; 456 participants; moderate-certainty evidence), and in little or no difference to relapse (RR 1.00, 95% CI 0.74 to 1.34; three trials; 2795 participants; low-certainty evidence), and treatment harms (RR 0.81, 95% CI 0.60 to 1.09; three trials, 3253 participants; low-certainty evidence). Two trials (2112 participants ) reported on mortality; no deaths occurred in either group. One trial reported cases of hospitalisation, diarrhoea (with and without dehydration), rash (without itch), tremors, mild nausea and vomiting. We do not currently have enough evidence to support or challenge the continued use of antibiotics for the treatment of non-severe pneumonia. There is a clear need for RCTs to address this question in children aged 2 to 59 months with 2014 WHO-defined non-severe pneumonia and wheeze.

Lako rešivo kada se prepozna - prikaz slučaja - kutana larva migransa

Introduction: Cutaneous larva migrans (CLM) is a syndrome, defined by clinical appearance of slowly migrating cutaneous eruption caused by inoculation with animal hookworms larvae in the skin. Despite the typical clinical presentation, CLM is frequently misdiagnosed due to its rarity in temperate climate urban communities. Case Report: We report a case of a 42-year old female, admitted to an outpatient clinic with eruption of multiple intense pruritic, erythematous, exudative papules and oval plaques, located predominately on the back. The patient claimed that skin lesions started three weeks before the examination, during her vacation in Thailand, and at first, was taught to be caused by a contact with jelly fish. Lesions were treated unsuccessfully with oral antihistamines and various topical corticosteroids, which lead to more questions regarding the differential diagnosis. Dermoscopical and histopathological findings were indicative of parasitic infection, most likely CLM. A three-day course of oral albendazole, 400 mg daily, resulted in complete cure of the disease. Conclusions: Careful clinical examination and detailed history taken from the patient are fundamentals for creating a set of differential diagnoses, that can be further clarified by the use of laboratory findings, imaging methods (including dermoscopy) and biopsy with histopathology. Although CLM has a benign self-limiting course, intense itch may substantially impact the quality of life, and possible visceral involvement or concomitant parasitic infection may lead to serious health deterioration in unrecognized cases.

Broadening Understandings of the Cultural Value of Aloha in a Teacher Educator Program

This study examined how pre-service teachers’ in a mainstream teacher education program expanded their understandings of the Hawaiian cultural value of aloha to reflect the integrity of the translation of aloha as originating in Hawaiian ancestral text. Data were collected from 10 elementary and 11 secondary pre-service teachers’ personal written reflections at the end of each of day of a three-day course. A post-course questionnaire was collected 10 months post-course completion, after pre-service teachers’ student teaching experience. As a result of qualitatively analyzing their written reflections and post-course questionnaire three patterns emerged to reflect the shifts in their understanding of the word aloha: 1) Common Understandings of Aloha; 2) Methods for Activating Aloha; and 3) Sustainable Practices. 16 out of 21 or 76% of the pre-service teachers confirmed that they experienced a shift in their understanding of aloha. The remaining five responded that their understandings of aloha did not “shift,” but rather used the following words to indicate that their understanding of aloha: “expanded,” “strengthened,” “influenced,” “renewed,” and “broadened.” In order for pre-service teachers to be comfortable with the language and meanings associated with a cultural value laden concept like aloha they personally connected with the meaning of the word, expanded understanding through academic learning, and reflected upon new understandings. While tensions and discomfort about using language and cultural concepts from “outside” one’s own ethnic and racial background may still exist, we are encouraged by the idea that pre-service teachers can commit to broadening and embracing understandings of aloha as a meaningful part of their daily classroom practices and lives.

S1691 Colitis in a Rheumatologic Patient

INTRODUCTION: Although a known of cause diarrhea, the pyrimidine synthesis inhibitor leflunomide is a rare cause of overt pancolitis that presents a formidable diagnostic challenge. CASE DESCRIPTION/METHODS: A 46-year-old female with a medical history of psoriatic arthritis was admitted with a two-week history of progressive right upper-quadrant pain, frequent non-bloody diarrhea, tenesmus, and non-bloody emesis. Her immunosuppressant therapy included certolizumab for the past five years and leflunomide for the past 17 months. She denied use of other medications. Initial laboratory evaluation was significant for a mild leukocytosis, lipase of 476 U/L (normal: 12–61 U/L) and C-reactive protein of 50.8 mg/L (normal ≤8.0 mg/L). A stool pathogen panel including Clostridioides difficile was negative. RUQ ultrasound revealed cholelithiasis without cholecystitis. Computed-tomography imaging with contrast revealed no evidence of pancreatitis and mild wall thickening with mucosal hyperenhancement, consistent with ileocolitis (Figure A). A subsequent colonoscopy was notable for circumferential, contiguous inflammation throughout the colon but a normal terminal ileum. Sigmoidal inflammation was mild with a decreased vascular pattern, erythema, and mild friability (Figure B). Biopsy of the descending colon (Figure C) demonstrated surface erosion, crypt abscess (arrowhead) and destruction, and increased lamina propria inflammation without the chronic inflammation classically seen in inflammatory bowel disease. Cytomegalovirus immunostaining was negative. Symptoms persisted despite a three-day course of high-dose intravenous steroids. The decision was made to stop leflunomide, the disease-modifying anti-rheumatologic drug, due to select case reports documenting rare leflunomide-induced colitis. Symptoms improved within two weeks of drug cessation, with a reduction of stool frequency to two formed bowel movements daily, resolution of abdominal pain, and improvement of erythema on repeat flexible sigmoidoscopy. DISCUSSION: This case demonstrates the value of a comprehensive medication history and the diagnostic challenge of leflunomide-induced colitis. Patients with rheumatologic diseases are often on medications with adverse gastrointestinal effects, including biologics, steroids, NSAIDs and other immunomodulators. The lack of randomized studies, vague radiologic, endoscopic and histologic findings, as well as the variable onset after medication initiation makes leflunomide-induced colitis a challenging and rare diagnosis.Figure 1.: Abdominal CT with contrast revealing ileocolitis, mild wall thickening, and mucosal hyperenhancement of the entire colon, consistent with colitis.Figure 2.: Colonoscopy of sigmoid colon revealing mild inflammation with erythema, decreased vascular pattern, and mild friability.Figure 3.: Descending colon; biopsies show surface erosion, crypt abscesses and crypt destruction. There is also increased laminar propria inflammation (100x).

A 61-year-old Female with Right Upper Abdominal Pain.

Case PresentationA 61-year-old female presented to the emergency department with right upper quadrant abdominal pain following a cholecystectomy 18 days prior. Computed tomography (CT) of her abdomen demonstrated a large abscess in her post-hepatic fossa. She was admitted to the general surgery service and received an image-guided percutaneous drain placement with interventional radiology with immediate return of purulent material. She was discharged home after a three-day hospital course with outpatient antibiotics and follow-up.DiscussionPatients may have multiple complications following cholecystectomy, including infection, bleeding, biliary injury, bowel injury, or dropped stone. The emergency clinician must consider cholecystectomy complications including gallbladder fossa abscess in patients presenting with abdominal pain in the days to weeks following cholecystectomy, especially if they present with signs of sepsis. Critical actions include obtaining CT and/or ultrasonography, initiating broad spectrum antibiotics, and obtaining definitive source control by either surgery or interventional radiology.

The impact of the Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia training course in Ethiopia: A mixed methods longitudinal cohort study.

SummaryReducing maternal mortality remains a global priority, particularly in low- and middle-income countries (LMICs). The Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia (OB) course is a three-day refresher course for trained anaesthesia providers addressing common causes of maternal mortality in LMICs. This aim of this study was to investigate the impact of SAFE training for a cohort of anaesthesia providers in Ethiopia.We conducted a mixed methods longitudinal cohort study incorporating a behavioural questionnaire, multiple-choice questionnaires (MCQs), structured observational skills tests and structured interviews for anaesthesia providers who attended one of four SAFE-OB courses conducted in two regions of Ethiopia from October 2017 to May 2018.Some 149 participants from 60 facilities attended training. Behavioural questionnaires were completed at baseline (n = 101, 69% response rate). Pre- and post-course MCQs (n = 121, n = 123 respectively) and pre- and post-course skills tests (n = 123, n = 105 respectively) were completed, with repeat MCQ and skills tests, and semi-structured interviews completed at follow-up (n = 88, n = 76, n = 49 respectively). The mean MCQ scores for all participants improved from 80.3% prior to training to 85.4% following training (P < 0.0001) and skills test scores improved from 56.5% to 83.2% (P < 0.0001). Improvements in MCQs and skills were maintained at follow-up 3-11 months post-training compared to baseline (P = 0.0006, < 0.0001 respectively). Participants reported improved confidence, teamwork and communication at follow-up.This study suggests that the SAFE-OB course can have a sustained impact on knowledge and skills and can improve the confidence of anaesthesia providers and communication within surgical teams.

Prevention of severe infectious complications after colorectal surgery using oral non-absorbable antimicrobial prophylaxis: results of a multicenter randomized placebo-controlled clinical trial

BackgroundSurgical site infections (SSIs) are common complications after colorectal surgery. Oral non-absorbable antibiotic prophylaxis (OAP) can be administered preoperatively to reduce the risk of SSIs. Its efficacy without simultaneous mechanical cleaning is unknown.MethodsThe Precaution trial was a double-blind, placebo-controlled randomized clinical trial conducted in six Dutch hospitals. Adult patients who underwent elective colorectal surgery were randomized to receive either a three-day course of preoperative OAP with tobramycin and colistin or placebo. The primary composite endpoint was the incidence of deep SSI or mortality within 30 days after surgery. Secondary endpoints included both infectious and non-infectious complications at 30 days and six months after surgery.ResultsThe study was prematurely ended due to the loss of clinical equipoise. At that time, 39 patients had been randomized to active OAP and 39 to placebo, which reflected 8.1% of the initially pursued sample size. Nine (11.5%) patients developed the primary outcome, of whom four had been randomized to OAP (4/39; 10.3%) and five to placebo (5/39; 12.8%). This corresponds to a risk ratio in the intention-to-treat analysis of 0.80 (95% confidence interval (CI) 0.23–2.78). In the per-protocol analysis, the relative risk was 0.64 (95% CI 0.12–3.46).ConclusionsObservational data emerging during the study provided new evidence for the effectiveness of OAP that changed both the clinical and medical ethical landscape for infection prevention in colorectal surgery. We therefore consider it unethical to continue randomizing patients to placebo. We recommend the implementation of OAP in clinical practice and continuing monitoring of infection rates and antibiotic susceptibilities.Trial registrationThe PreCaution trial is registered in the Netherlands Trial Register under NL5932 (previously: NTR6113) as well as in the EudraCT register under 2015–005736-17.

Influence of Clinical Expertise Between Clinician-Instructors Versus Student-Instructors on the Effectiveness of Ultrasound Courses

To investigate how the extent of an ultrasound instructor's clinical expertise influences the level of hands-on ultrasound competency achieved by clinicians after three-day ultrasound courses in abdominal and emergency ultrasound. The second goal was to determine how physicians in residency rate the sonographic and didactic skills of student instructors compared to medical staff instructors. A total of N = 100 residents participating in a 3-day ultrasound workshop were randomly trained either by 15 student instructors or by clinical staff physicians, both with > 2years of teaching experience. Both instructor groups had previously completed 120 hours of didactic instructor training. Ultrasound competencies were assessed by a standardized objective structured clinical examination (OSCE) of healthy individuals. The sonographic and didactic skills of both instructor groups were rated by questionnaires with six-step Likert items (1 = excellent, 6 = poor). The cohort, trained by student instructors, achieved the same scoring level as the second cohort, trained by physician instructors (mean score 76.4, versus 73.7 of max.100points, p = 0.28) in the final OSCE. The sonographic qualification was rated for student educators as 1.44 (mean) [1.1-1.62], versus residents 1.46 [1.26-1.61], versus attendings 1.29 [1.05-1.61]. Didactic skill levels were rated without significant differences with means of 1.53, 1.57 and 1.53, respectively. The didactic competence of student instructors does not differ statistically from the competency levels of experienced physicians. In terms of the acquired ultrasound skills of trainees, our data indicate that student instructors can be as efficient as staff instructors. Therefore, student instructors can be employed as resource-saving ultrasound educators without decreasing the skills level achieved by course participants, provided that they previously underwent a comprehensive didactic and sonographic training program.

Mass drug administrations with dihydroartemisinin-piperaquine and single low dose primaquine to eliminate Plasmodium falciparumhave only a transient impact on Plasmodium vivax: Findings from randomised controlled trials.

BackgroundMass administrations of antimalarial drugs (MDA) have reduced the incidence and prevalence of P. falciparum infections in a trial in the Greater Mekong Subregion. Here we assess the impact of the MDA on P. vivax infections.MethodsBetween May 2013 and July 2017, four villages in each Myanmar, Vietnam, Cambodia and Lao PDR were selected based on high prevalence of P. falciparum infections. Eight of the 16 villages were randomly assigned to receive MDA consisting of three-monthly rounds of three-day courses of dihydroartemisinin-piperaquine and, except in Cambodia, a single low-dose of primaquine. Cross-sectional surveys were conducted at quarterly intervals to detect Plasmodium infections using ultrasensitive qPCR. The difference in the cumulative incidence between the groups was assessed through a discrete time survival approach, the difference in prevalence through a difference-in-difference analysis, and the difference in the number of participants with a recurrence of P. vivax infection through a mixed-effect logistic regression.Results3,790 (86%) residents in the intervention villages participated in at least one MDA round, of whom 2,520 (57%) participated in three rounds. The prevalence of P. vivax infections fell from 9.31% to 0.89% at month 3 but rebounded by six months to 5.81%. There was no evidence that the intervention reduced the cumulative incidence of P.vivax infections (95% confidence interval [CI] Odds ratio (OR): 0.29 to 1.36). Similarly, there was no evidence of MDA related reduction in the number of participants with at least one recurrent infection (OR: 0.34; 95% CI: 0.08 to 1.42).ConclusionMDA with schizontocidal drugs had a lasting effect on P. falciparum infections but only a transient effect on the prevalence of P. vivax infections. Radical cure with an 8-aminoquinoline will be needed for the rapid elimination of vivax malaria.

Parecoxib as an adjunct therapy for the treatment of refractory non-surgical cancer pain

Evidence for the use of short-term daily parenteral parecoxib for refractory or uncontrolled non-surgical cancer pain is limited. This study aimed to characterise the real-world off-label use and report on clinical experiences in an Australian cancer cohort. Eligible patients received at least one dose of parecoxib of an intended three-day course between October 2015 and December 2018. Data were collected to characterise the parecoxib treatment cohort (cancer diagnosis, metastases, sites and types of pain and prior analgesia). Parecoxib-related adverse events, pain scores (worst and median), and concurrent opioid use were assessed at 24 h pre (T0) and 24 (T1), 48 (T2), 72 (T3) and 96 h (T4) post first parecoxib dose. Sixty-five patients (39 males and 26 females) and 68 courses of parecoxib (three patients treated twice) were included in analyses: metastatic disease (86%), bone pain (54%) and taking ≥3 classes of analgesic medications (69%). Pain types varied (46% non-specific, 22% neuropathic and 32% other). Most (94%) received parecoxib by subcutaneous administration. Following parecoxib, median 24-h pain scores and worst pain scores improved for 59% (40/68) and 50% (34/68) of patients, respectively. In the first 24 h (T0 to T1), median (4 vs. 2, p < 0.01) and worst (6 vs. 5, p < 0.01) pain scores were reduced and sustained to T4 (4 vs. 2.5, p = 0.01). Breakthrough analgesia requirements reduced for 63% (43/68) of patients, while total concurrent opioid use remained constant. Mean/median oral morphine equivalence for T0 vs. T1 was 111 mg/75 mg vs. 162 mg/90 mg, (p > 0.8). Two patients ceased parecoxib due to renal/liver function abnormalities and two experienced mild injection-site reactions. In this real-world study, parecoxib was utilised as adjunctive therapy in a select patient cohort to contribute to reduced pain scores with no new safety signals. Prospective randomised studies in larger cohorts would improve understanding of the effects of parecoxib.

Pain relief by Ketorol Express after oral surgery procedures

The aim of the study was providing rationale for using a new form of Ketorol Express for pain relief in outpatient dental practice. The study comprised 85 patients with an average age of 43.2 years, who were prescribed a three-day course of Ketorol Express therapy after a complex traumatic tooth extraction. Three different visual-analog scales were used to assess the severity of pain, the patient's General well-being, and the doctor's General well-being. After treatment with dispersed Ketorol Express tablets, the severity of the pain syndrome decreased from 4 to 1.8 points within three days. Anesthesia occurred on average in 10 minutes. This therapy was safe and well tolerated. There were no one serious adverse events, and no one patient stopped therapy due to side effects.

Train-the-Trainers in hand hygiene: a standardized approach to guide education in infection prevention and control

BackgroundHarmonization in hand hygiene training for infection prevention and control (IPC) professionals is lacking. We describe a standardized approach to training, using a “Train-the-Trainers” (TTT) concept for IPC professionals and assess its impact on hand hygiene knowledge in six countries.MethodsWe developed a three-day simulation-based TTT course based on the World Health Organization (WHO) Multimodal Hand Hygiene Improvement Strategy. To evaluate its impact, we have performed a pre-and post-course knowledge questionnaire. The Wilcoxon signed-rank test was used to compare the results before and after training.ResultsBetween June 2016 and January 2018 we conducted seven TTT courses in six countries: Iran, Malaysia, Mexico, South Africa, Spain and Thailand. A total of 305 IPC professionals completed the programme. Participants included nurses (n = 196; 64.2%), physicians (n = 53; 17.3%) and other health professionals (n = 56; 18.3%). In total, participants from more than 20 countries were trained. A significant (p < 0.05) improvement in knowledge between the pre- and post-TTT training phases was observed in all countries. Puebla (Mexico) had the highest improvement (22.3%; p < 0.001), followed by Malaysia (21.2%; p < 0.001), Jalisco (Mexico; 20.2%; p < 0.001), Thailand (18.8%; p < 0.001), South Africa (18.3%; p < 0.001), Iran (17.5%; p < 0.001) and Spain (9.7%; p = 0.047). Spain had the highest overall test scores, while Thailand had the lowest pre- and post-scores. Positive aspects reported included: unique learning environment, sharing experiences, hands-on practices on a secure environment and networking among IPC professionals. Sustainability was assessed through follow-up evaluations conducted in three original TTT course sites in Mexico (Jalisco and Puebla) and in Spain: improvement was sustained in the last follow-up phase when assessed 5 months, 1 year and 2 years after the first TTT course, respectively.ConclusionsThe TTT in hand hygiene model proved to be effective in enhancing participant’s knowledge, sharing experiences and networking. IPC professionals can use this reference training method worldwide to further disseminate knowledge to other health care workers.