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Introduction: Competence committees (CCs) centre their work around documentation of trainees' performance; undocumented contributions (i.e. informal, unrecorded material like personal judgements, experiential anecdotes and contextual information) evoke suspicion even though they may play a role in decision making. This qualitative multiple case study incorporates insights from a social practice perspective on writing to examine the use of undocumented contributions by the CCs of two large post‐graduate training programmes, one in a more procedural (MP) speciality and the other in a less procedural (LP) one. Methods: Data were collected via observations of meetings and semi‐structured interviews with CC members. In the analysis, conversations were organised into triptychs of lead‐up, undocumented contribution(s), and follow‐up. We then created thick descriptions around the undocumented contributions, drawing on conversational context and interview data to assign possible motivations and significance. Results: We found no instances in which undocumented contributions superseded the contents of a trainee's file or stood in for missing documentation. The number of undocumented contributions varied between the MP CC (six instances over two meetings) and the LP CC (22 instances over three meetings). MP CC discussions emphasised Entrustable Professional Activity (EPA) observations, whereas LP CC members paid more attention to narrative data. The divergent orientations of the CCs—adding an 'advis[ing]/guid[ing]' role versus focusing simply on evaluation—offers the most compelling explanation. In lead‐ups, undocumented contributions were prompted by missing and flawed documentation, conflicting evidence and documentation at odds with members' perceptions. Recognising other 'red flags' in documentation often required professional experience. In follow‐ups, purposes served by undocumented contributions varied with context and were difficult to generalise; we, therefore, provide deeper analysis of two vignettes to illustrate. Conclusions: Our data suggest undocumented contributions often serve best efforts to ground decisions in documentation. We would encourage CC practices and policies be rooted in more nuanced approaches to documentation. van Enk and colleagues show that undocumented contributions in competency committees often work in service of best efforts to ground decisions in documentation. [ABSTRACT FROM AUTHOR]

• The Mobile Skills and Simulation Cart is a valuable way to support novice nurses in their practice. • Nurses felt more confident and competent after participating in the Mobile Skills and Simulation Cart sessions. • Clinical leadership saw an improvement in nursing morale on units that Mobile Skills and Simulation Cart frequented. • The Mobile Skills and Simulation Cart likely contributed to safe patient care by focusing on high yield topics. The COVID-19 pandemic disrupted nursing students' clinical training, resulting in under preparedness of novice nurses in acute care hospitals due to gaps in knowledge and skills. Portable simulation-based education programs could be used to meet nurses' learning needs. The Mobile Skills and Simulation Cart (MSSC) program was developed based on needs assessment, followed by implementation and a mixed methods program evaluation. A total of 688 session evaluations were completed by nurses who participated in the MSSC program indicating they were extremely satisfied with the program and reported increased knowledge. It improved nurses' confidence and skills. Additionally, during the program evaluation phase, 32 nurses who participated in MSSC sessions, along with sixteen clinical leaders, reported integration of learning into clinical practice. Patient safety incident reports showed fewer chest tube issues, and increased safety surrounding heparin infusion practices. Overall, nursing turnover remained stable with early signs of potential improvement and increased morale. The MSSC has proven effective in enhancing nurses' knowledge, confidence, and comfort with skills. Simulation may positively impact patient care and safety, with early indications of potential benefits on nursing turnover. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The utility of routine therapeutic drug monitoring (TDM) in children living with HIV has not been extensively studied. The purpose of this study was to assess this strategy. METHODS: This was a single-center, prospective observational study of routine TDM for protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and integrase strand transfer inhibitors (INSTIs) in children living with HIV who were receiving antiretroviral therapy (ART) between February and December 2014. Outcome measures included the proportion of serum antiretroviral (ARV) medication concentrations in the therapeutic range (target values extrapolated from adult data) and the effect of serum concentrations on virologic control, medication adherence, and toxicity. RESULTS: Forty-eight children with a median age of 13 years (interquartile range, 3-18) were included. Median viral load (VL) and CD4% were <40 copies/mL (range, <40-124) and 37.4% (range, 8.4-47.9), respectively. Adherence was considered excellent in 95.8% of patients. Of the 50 serum trough concentrations (PI n = 19 [38%]; NNRTI n = 27 [54%]; INSTI n = 4 [8%]), 66% (n = 33) were in the therapeutic range, 12% (n = 6) were subtherapeutic, and 22% (n = 11) were supratherapeutic. There was no statistically significant correlation between serum ARV concentrations and patient demographics, VL, CD4%, or adherence. No clinically significant adverse events were noted. One dose adjustment was made for a subtherapeutic serum raltegravir concentration, likely attributable to interaction with ritonavir. CONCLUSIONS: This study does not support routine TDM in healthy children living with HIV who are well controlled on antiretroviral medication regimens. A more targeted strategy, such as when adherence is questioned or when there are suspected drug interactions, may be more appropriate. [ABSTRACT FROM AUTHOR]

Traditional in-person delivery of nursing orientation programs at a large academic hospital could not occur because of the COVID-19 pandemic, with the need to limit group sizes and adhere to physical distancing guidelines. A nurse educator team pivoted the orientation program to a virtual model combined with the review of select clinical skills and buddy shifts. Thismodel effectivelymet the nurses' needs required to practice safely on an inpatient environment. [ABSTRACT FROM AUTHOR]

In case 1, we hypothesise that the cephalohaematoma developed into subgaleal abscess with bacterial seeding from the antecedent urinary tract infection. The blood culture was also negative, white cell count (WCC) was 5.7 × 10 SP 9 sp /L and C-reactive protein (CRP) was 77.4 mg/L. Cranial ultrasound showed a lentiform 8.9 × 6.9 cm collection consistent with a large uncomplicated cephalohaematoma. If the cephalohaematoma does show signs of localised infection with possible extension, appropriate imaging with high diagnostic yield for osteomyelitis (CT or magnetic resonance imaging) is warranted with consideration given to debridement. [Extracted from the article]

• We analyzed encephalopathy/encephalitis cases following immunization. • 57 acute and 4 chronic cases were reported via active surveillance over 21 years. • 69% of cases had an alternate cause for encephalopathy/encephalitis than vaccination. • Encephalopathy/encephalitis following vaccination is most often non-vaccine related. Neurological adverse events following immunization (AEFI) remain poorly characterized. Our objective was to describe pediatric acute and chronic encephalopathy and encephalitis cases following immunization reported via active sentinel surveillance from 1992 to 2012. This case series provides a descriptive analysis of encephalopathy/encephalitis admissions reported to the Canadian Immunization Monitoring Program ACTive (IMPACT). Acute cases were reported if symptom onset (seizures, decreased level of consciousness, change in mental status) occurred 0–7 days after tetanus or pertussis-containing vaccines, 0–15 days after other inactivated vaccines, or 5–30 days after live vaccines. Chronic cases of subacute sclerosing panencephalitis or subacute progressive rubella encephalitis were reported at any interval after vaccination. Clinical data were examined to identify possible causes for encephalopathy/encephalitis other than vaccination. Sixty-one cases of encephalopathy/encephalitis following immunization were reported to IMPACT over 21 years; 57 (93.4%) were classified as acute and 4 (6.6%) were chronic cases of subacute sclerosing panencephalitis. Most patients (73.8%) were previously healthy and immunocompetent. The vaccines most frequently administered prior to presentation were diphtheria-tetanus-pertussis, measles-mumps-rubella, and influenza. At discharge, 38 patients (62.3%) had normal neurological status or were expected to recover. Forty patients (70.2%) with acute encephalopathy/encephalitis had a more likely alternate etiology besides vaccination based on neuroimaging, symptoms suggestive of infection, laboratory-confirmed non-vaccine-related infection, or clinical diagnosis. No cases of encephalitis were causally associated with pertussis or influenza vaccines. Two patients (50%) with subacute sclerosing panencephalitis had known wild-type measles infection prior to immunization. Three deaths were reported during hospitalization (4.9%); all were acute encephalitis/encephalopathy cases and none were confirmed to be vaccine-related. Encephalopathy/encephalitis following immunization remains a rare but serious adverse event. Most cases had another more likely etiology than vaccination. Continued monitoring and analysis of AEFI is paramount to ensure the safety of immunization programs. [ABSTRACT FROM AUTHOR]

BACKGROUND There is an increasing demand for reduced‐sugar products due to the worldwide prevalence of obesity, diabetes, and cardiovascular diseases. The aim of this study was to evaluate the effects of sugar (sucrose) reductions on the acceptability, preference, and quality of strawberry‐flavored yogurts. A consumer rejection threshold test and an acceptability test (N = 53) were conducted using six yogurt samples with decreasing concentrations of sugar (12–5/100 g). Additional physicochemical tests (pH, °Brix, water‐holding‐capacity, viscosity, and color) were conducted to examine the quality and shelf‐life of strawberry‐flavored yogurts with reductions of sucrose during 28 days of storage at 4 °C. RESULTS: Reduction of sucrose affected the acceptability and physicochemical characteristics of yogurts. The consumer rejection threshold showed that sucrose in strawberry‐flavored yogurts could be reduced to 5.25/100 g from an initial concentration of 12/100 g without affecting the preferences of consumers. The 71%‐sucrose (8.50/100 g of yogurt) was perceived as the most liked (6.27 using a nine‐point hedonic scale) and the most preferred (rank sum = 127.50) yogurt sample. For the physicochemical properties of yogurts, the viscosity (3263–5473 cP) decreased, and the color lightness (80.98–85.44) increased during 28 days of storage at 4 °C. CONCLUSION: Physicochemical properties and preferences were affected by the reduction of sugar. The consumer rejection threshold analysis showed that sucrose can be reduced to less than half of the initial concentration. These findings are useful to understand consumers' acceptability and shelf‐life of yogurts with reduced‐sugar formulations in the developing of new products. © 2020 Society of Chemical Industry [ABSTRACT FROM AUTHOR]

Background Respiratory syncytial virus (RSV) is a major cause of pneumonia and bronchiolitis in children. Mortality rates in previously healthy children hospitalized with RSV are <0.5%, but up to 37% in patients with underlying medical conditions. The objective of this study was to characterize factors associated with deaths among children hospitalized with RSV infection in Canadian pediatric centers. Methods This was a retrospective case series of children aged ≤18 years with RSV-associated deaths at centers affiliated with the Pediatric Investigators Collaborative Network on Infections in Canada from 2003–2013, inclusive, was performed. Cases were identified using RSV-specific International Classification of Diseases codes to capture deaths where a diagnosis of RSV infection was present. Results Eleven centers reported 79 RSV-associated deaths. RSV was regarded as primarily responsible for death in 32 cases (40.5%). Median age at death was 11 months (range, <1 month to 16 years). Thirty-nine patients (49.4%) were male. Fourteen patients (17.7%) had no known risk factors for severe RSV infection. Healthcare-associated RSV infections (HAIs) accounted for 29 deaths (36.7%), with RSV judged to be the primary cause of death in 9 of these cases. Conclusions RSV-associated deaths were predominantly associated with chronic medical conditions and immunocompromised states among infants; however, 1 in 5 deaths occurred among patients with no known risk factors for severe RSV. Mortality associated with HAI accounted for over a third of cases. These findings highlight patient groups that should be targeted for RSV prevention strategies such as infection control practices, immunoprophylaxis, and future vaccination programs. [ABSTRACT FROM AUTHOR]

Background. There is a misconception that elderly cancer patients cannot tolerate standard doses of chemotherapy because of the frequency and severity of myelosuppressive complications. The reactive use of colony-stimulating factors (i.e., in response to severe neutropenia) commonly observed in this setting contributes to the frequency and severity of these complications. This study evaluated the incidence of febrile neutropenia and related events in elderly cancer patients receiving pegfilgrastim beginning with cycle 1 (proactive) in comparison with pegfilgrastim initiated after cycle 1 at the physician's discretion (reactive). Methods. Patients (≥65 years of age) with either solid tumors or non-Hodgkin's lymphoma (NHL) were randomly assigned to receive pegfilgrastim either proactively or reactively. The primary endpoint was the proportion of patients experiencing febrile neutropenia. Results. There were 852 patients enrolled (median age, 72 years). Proactive pegfilgrastim use resulted in a significantly lower incidence of febrile neutropenia for both solid tumor and NHL patients compared with reactive use. Proactive pegfilgrastim use also led to fewer hospitalizations resulting from neutropenia and febrile neutropenia by approximately 50%. Antibiotic use was lower for solid tumor patients receiving proactive pegfilgrastim and equivalent in the two NHL groups. Conclusions. This is the largest, randomized, prospective trial evaluating growth factor support in typical elderly cancer patients. Proactive pegfilgrastim use effectively produced a lower incidence of febrile neutropenia and related events in elderly patients with either solid tumors or NHL receiving an array of mild to moderately neutropenic chemotherapy regimens. Pegfilgrastim should be used proactively in elderly cancer patients to support the optimal delivery of standard chemotherapy. [ABSTRACT FROM AUTHOR]

Objective: To sample dietary supplements (DS) labeled as ephedra-free to evaluate whether products met their labeling claim. Methods: One control DS product containing ephedra alkaloids and 29 DS labeled as ephedra-free were purchased from various retail locations in San Francisco. All products were sent to the California Department of Health Services (CDHS), Food and Drug Laboratory for content and quantity analysis. All laboratory personnel were blinded to product names and labeled contents. All DS products were screened for the presence of undeclared drugs, ephedra alkaloids, and heavy metals including lead, arsenic, cadmium and mercury. All products were also evaluated for compliance with the labeling requirements of the Dietary Supplement Health and Education Act (DSHEA) of 1994. Results: None of the DS labeled as ephedra-free tested positive for the presence of ephedra alkaloids; as expected, the control product did test positive. Heavy metals were detected in three ephedra-free labeled DS products. All 24 products that tested positive for caffeine listed caffeine or a botanical source of caffeine on the DS label. All but two products were in compliance with DS labeling as required by DSHEA. Conclusions: This study demonstrates that manufacturers met their labeling claims for ephedra-free products. Special attention should be given to the presence of heavy metals and other drugs like caffeine, synephrine, and botanical sources of caffeine as these ingredients have replaced ephedra. [ABSTRACT FROM AUTHOR]

Abstract: Locus control regions (LCRs) are defined by their ability to confer reproducible physiological levels of transgene expression in mice and therefore thought to possess the ability to generate dominantly a transcriptionally active chromatin structure. We report the first characterization of a muscle-cell-specific LCR, which is linked to the human desmin gene (DES). The DES LCR consists of five regions of muscle-specific DNase I hypersensitivity (HS) localized between −9 and −18 kb 5′ of DES and reproducibly drives full physiological levels of expression in all muscle cell types. The DES LCR DNase I HS regions are highly conserved between humans and other mammals and can potentially bind a broad range of muscle-specific and ubiquitous transcription factors. Bioinformatics and direct molecular analysis show that the DES locus consists of three muscle-specific (DES) or muscle preferentially expressed genes (APEG1 and SPEG, the human orthologue of murine striated-muscle-specific serine/threonine protein kinase, Speg). The DES LCR may therefore regulate expression of SPEG and APEG1 as well as DES. [Copyright &y& Elsevier]

Sugar not only provides the desirable sweetness but its reduction can also alter the physico-chemical properties of foods. The objective of this study was to evaluate the effects of tagatose as a sugar substitute on selected physico-chemical properties and sensory acceptability of strawberry-flavored yogurts. Six yogurt samples with decreasing concentrations of sucrose (8.50 to 1.70 g/100 g) and increasing concentrations of tagatose (0.00 to 9.24 g/100 g) were evaluated. Physico-chemical tests (pH, lactic acid (%), °Brix, water-holding capacity (WHC), viscosity, and color) were conducted to examine the quality and shelf-life of yogurts during 28 days of storage at 4 °C. An acceptability test (n = 55) was conducted to evaluate the sensory characteristics of yogurts. Sucrose reductions by the replacement of up to 80% tagatose showed marginal effects on the selected physico-chemical properties; however, the loss of red color (a*) and increase in yellowness (b*) of the tagatose-substituted samples were significant. Strawberry yogurts with tagatose replacements had similar acceptability scores for all attributes. Sucrose reduction showed a positive effect on the purchase intent of the strawberry yogurts (an increase of 3–30%). These findings can be used to understand the effects of tagatose/sucrose formulations on the acceptability and physico-chemical properties of yogurts. [ABSTRACT FROM AUTHOR]

Summary: Electrical synapses are neuronal gap junctions that mediate fast transmission in many neural circuits . The structural proteins of gap junctions are the products of two multigene families. Connexins are unique to chordates ; innexins/pannexins encode gap-junction proteins in prechordates and chordates . A concentric array of six protein subunits constitutes a hemichannel; electrical synapses result from the docking of hemichannels in pre- and postsynaptic neurons. Some electrical synapses are bidirectional; others are rectifying junctions that preferentially transmit depolarizing current anterogradely . The phenomenon of rectification was first described five decades ago , but the molecular mechanism has not been elucidated. Here, we demonstrate that putative rectifying electrical synapses in the Drosophila Giant Fiber System are assembled from two products of the innexin gene shaking-B. Shaking-B(Neural+16) is required presynaptically in the Giant Fiber to couple this cell to its postsynaptic targets that express Shaking-B(Lethal) . When expressed in vitro in neighboring cells, Shaking-B(Neural+16) and Shaking-B(Lethal) form heterotypic channels that are asymmetrically gated by voltage and exhibit classical rectification. These data provide the most definitive evidence to date that rectification is achieved by differential regulation of the pre- and postsynaptic elements of structurally asymmetric junctions. [Copyright &y& Elsevier]

Invertebrate gap junctions are composed of proteins called innexins and eight innexin encoding loci have been identified in the now complete genome sequence of Drosophila melanogaster. The intercellular channels formed by these proteins are multimeric and previous studies have shown that, in a heterologous expression system, homo- and hetero-oligomeric channels can form, each combination possessing different gating characteristics. Here we demonstrate that the innexins exhibit complex overlapping expression patterns during oogenesis, embryogenesis, imaginal wing disc development and central nervous system development and show that only certain combinations of innexin oligomerization are possible in vivo. This work forms an essential basis for future studies of innexin interactions in Drosophila and outlines the potential extent of gap-junction involvement in development. [Copyright &y& Elsevier]

Competing Interests: Competing interests: None declared.

Introduction The simulation of patient death remains controversial in simulation-based education. We investigated the effect of simulated patient death on learners' skill retention, stress levels, and emotions. Methods After ethics approval, we recruited residents at two Canadian universities. Participants were randomized to manage a simulated cardiac arrest ending with either the unexpected death (intervention group) or survival (control group) of the simulated patient (i.e., manikin). Three months later, all participants performed the same scenario but with the opposite outcome. Blinded video raters assessed participants' non-technical and technical crisis resource management (CRM) skills at both time points. Stress levels (represented by anxiety level, salivary cortisol concentration, and cognitive appraisal) and emotional valence were measured. Outcomes were analyzed using analysis of covariance (ANCOVA) or generalized estimating equations as appropriate. Results The analysis included 46 participants (intervention: n=24; control: n=22). Simulated death neither affected retention of non-technical CRM skills (mean retention Ottawa Global Rating Scale score in the death group [29.4, 95% CI: 27.0, 31.8] versus control group [29.4, 95% CI: 26.8, 32.0; p = 0.87]) nor technical CRM skills (mean retention task-specific checklist score in the manikin death group [11.8, 95% CI: 10.5, 13.0] versus the control group [12.5, 95% CI: 11.3, 13.7; p=0.69]). The simulated death had negative effects on participants' anxiety levels, cognitive appraisal, and emotions. Conclusion Simulated patient death did not affect the retention of non-technical or technical CRM skills but led to greater levels of short-term anxiety, stress, and negative emotions among learners., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Khanduja et al.)

This article was migrated. The article was marked as recommended. Preparations for the COVID-19 pandemic required healthcare teams to practice known skills, such as intubation, with renewed consideration for safety, as well as develop new Standard Operating Procedures (SOPs) for health care delivery. In these conditions, translational simulation based-education (SBE) is a well-known tool that supports health care teams to improve the system using design thinking methods such as walkthroughs and team-based simulation. However, the pandemic has introduced two stressors on translational SBE simultaneously. Firstly, the need for rapid upskilling of front-line staff and rapid change to SOPs. Secondly, the need for social or physical distancing at work, such that it quickly became inappropriate for large groups of individuals to practice in-situ SBE and debrief together in close proximity. An educational approach that brings the best of translational SBE while minimizing contact and maximizing experiential learning is needed. Digital learning has been rapidly adopted by much of medical education during the pandemic. Focusing on a strong alignment between learning goals with intended clinical performance change outcomes we sought to leverage a digital education format that allowed for low barriers to adoption, yet supported the experiential, dynamic reality of translational SBE. In the absence of the ability to quickly train large numbers of people due to the need for social distancing, an immersive experience that can only be provided by virtual reality (VR) videos was the next best thing. VR, using 360-degree video, supported the creation of instructional videos from SBE events in the hospital which allow the learner to immerse and explore multiple points within the scenario. We describe how the very act of recording a video assisted in the rapid development of SOPs through translational simulation. We then describe the use of VR to stay true to the spirit of simulation for experiential learning and nearly hands-on training., (Copyright: © 2020 Posner G et al.)

In-situ simulation occurs in the clinical environment. This allows healthcare providers greater access to the educational session while providing the opportunity to test systems or protocols in place. Anaphylaxis is a rare and life-threatening event. As such, many healthcare providers are uncomfortable managing it. The use of simulation as an educational methodology allows the learners to practice rare, high-risk scenarios in a low-risk environment. There is no negative impact to an actual patient when an in-situ simulation education session is provided. Usually there are positive results due to increased staff awareness and improved process. In the spring of 2015, stakeholders at the outpatient antibiotic therapy program (OPAT) at The Ottawa Hospital (TOH) approached the nurse educator team to develop an education session around anaphylaxis management. The nurse educators chose to design and implement an in-situ simulation scenario involving the inter-professional clinic team. Through the use of inter-professional in-situ simulation the team was able to clarify roles, identify equipment issues and rectify those issues as this technical report describes., Competing Interests: The authors have declared that no competing interests exist.