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SUMMARY STATEMENT As the field of healthcare simulation matures, formal accreditation for simulation fellowships and training programs has become increasingly available and touted as a solution to standardize the education of those specializing in healthcare simulation. Some simulation experts hold opposing views regarding the potential value of simulation fellowship program accreditation. We report on the proceedings of a spirited debate at the 20th International Meeting on Simulation in Healthcare in January 2020. Pro arguments view accreditation as the logical evolution of a maturing profession: improving training quality through standard setting, providing external validation for individual programs, and enhancing the program's return on investment. Con arguments view accreditation as an incompletely formulated construct; burdensome to the "financially strapped" fellowship director, misaligned with simulation fellows' needs and expectations, and confusing to administrators mistakenly equating accreditation with credentialing. In addition, opponents of accreditation postulate that incorporating curricular standards, practice guidelines, and strategies derived and implemented without rigor, supporting evidence and universal consensus is premature. This narrative review of our debate compares and contrasts contemporary perspectives on simulation fellowship program accreditation, concluding with formal recommendations for learners, administrators, sponsors, and accrediting bodies.

Background Low back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number. Methods A multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months. Results The percent of appropriately ordered radiographs increased from 5.8 to 53.9% and the monthly number of radiographs ordered decreased from 86 to 47 over the eight-month initiative. There were no compensatory increases in thoracic or lumbar computed tomography (CT) scans during this time frame. Conclusion A multi-component QI intervention led by a clinician champion is an effective way to reduce the overutilization of thoracic and lumbar radiographs in an urban public hospital emergency department.

Nowadays, digital images have a valuable role in our daily life, and can be used for various of applications like fingerprint recognition, video surveillance etc. Sometimes, images get infected with noise due to many reasons such as defects in camera sensors, transmission in noisy channel, faulty memory locations in the hardware etc. Processing a noisy image is not advisable because usually it yields erroneous outcomes. So, as to improve it for subsequence processing, the noise must be eliminated from the image in advance. Therefore, there is a need of an efficient image denoising technique that helps to deal with noisy image. Image de-noising is a process to realign the original image from the degraded image. In this paper, autoencoders based deep learning model is proposed for image denoising. The autoencoders learns noise from the training images and then try to eliminate the noise for novel image. The experimental outcomes prove that this proposed model for PSNR has achieved higher result compared to the conventional models.

The emotional and psychological toll of the COVID-19 pandemic has been characterized as a parallel pandemic, disproportionately affecting health care workers when compared to the general population. Recognizing the tragic effects that the pandemic was having on the psyche of our health care workers, a multidisciplinary peer-support program called Helping Healers Heal was augmented to address these complex needs in a large, urban, academic medical center in the Bronx, NY. A multimodal approach including wellness events, emotional support rounds, fast-tracked connections with therapeutic support, and coalition building was used to reach 80% of staff from May through August, 2020. The multidisciplinary team planned events and interventions to appeal to the myriad ways people cope and build resilience, and by utilizing existing resources, it proved extremely cost-effective. In a survey of the program's participants, 94% of respondents "agreed" or "strongly agreed" that their participation helped alleviate stress.

Noninvasive prenatal screening (NIPS) for fetal aneuploidy via cell-free DNA has been commercially available in the United States since 2011. In 2016, the American College of Medical Genetics and Genomics (ACMG) issued a position statement with specific recommendations for testing laboratories. We sought to evaluate adherence to these recommendations. We focused on commercial laboratories performing NIPS testing in the United States as of 1 January 2018. Sample laboratory reports and other materials were scored for compliance with ACMG recommendations. Variables scored for common and sex chromosome aneuploidy detection included detection rate, specificity, positive and negative predictive value, and fetal fraction. Labs that performed analysis of copy-number variants and results for aneuploidies other than those commonly reported were identified. Available patient education materials were similarly evaluated. Nine of 10 companies reported fetal fraction in their reports, and 8 of 10 did not offer screening for autosomal aneuploidies beyond trisomy 13, 18, and 21. There was inconsistency in the application and reporting of other measures recommended by ACMG. Laboratories varied in the degree to which they met ACMG position statement recommendations. No company adhered to all laboratory guidance.

Background: The people living in slums lack the basic civic amenities. Due to deprivation of socioeconomic resources and health care facilities these groups of people are more vulnerable to infectious diseases like HIV/AIDS. Aim& Objective: To assess the knowledge and awareness about HIV/AIDS and to identify related health education needs in urban slums of Jodhpur. Settings and Design: A cross sectional study was conducted during July – Nov 2018 in slums of Jodhpur city. Methods and Material: Two stage cluster sampling strategy was used to collect data from 1200 participants regarding HIV/ AIDS knowledge and awareness to identify health education needs in urban slums. Statistical analysis used: Descriptive statistics, chi-square test and multivariate logistics analysis were used. Results: A total of 1200 participants were surveyed, out of which 48.5 % were males. Among the study population 58% (n=697) has heard about HIV/AIDS and only 17.5% (n=211) have knowledge that the HIV and AIDS are different. Only 17.8% (n=214) have undergone HIV testing. Females were less likely aware about preventive measures of HIV than males (OR=0.09, 95%CI=0.05-0.14, P value45 years). Only 13.9% (n=110) of tobacco consumers and 11.5% (n=78) alcohol consumers have undergone HIV testing. Conclusions: The comprehensive health education program should be designed with focus on different education needs according to age and gender of urban slums.

INTRODUCTION The simulation fellowship training community has commenced efforts toward the development of core curricular elements for healthcare simulation fellowships but has not deployed the same effort to create evaluation strategies to monitor fellows' progress. The authors present a current view of simulation fellowship assessment strategies, their relative validity evidence using Kane's theoretical framework, and consider new approaches for defining expertise after training. METHODS Fellowship directors in North America were surveyed to identify what competencies are being used by the simulation fellowship community to monitor fellows' progress. A follow-up survey was sent to further clarify which tools with published validity evidence were being applied by current programs. RESULTS Of the 61 programs contacted, 44 (72.1%) responded and completed the first survey. Of the 44 programs, 32 (72.7%) reported using some formal assessment of their fellows. The most commonly assessed skill was debriefing. Twenty-three (37.7%) of the 61 programs contacted responded to the secondary survey. These reported that the most common published tool used was the Debriefing Assessment for Simulation in Healthcare, with only a few other tools mentioned. CONCLUSIONS There is a paucity of tools with published validity evidence being used to monitor a fellow's progression. The authors agree that further research needs to focus on creating validated assessment tools to assist in refining fellowship training.

Simulation has an established role in the education and training of healthcare professionals, but its function as a healthcare quality improvement (QI) tool is more emergent. In this edition of the journal, Ajmi and colleagues report on a simulation-based intervention that improved door-to-needle times and patient outcomes in acute ischaemic stroke.1 This prompts reflection on the positioning of simulation-based methods within QI programmes, the role of trained simulation experts as part of QI-focused teams and the directions for future scholarly enquiry that supports integration of these fields. The improvement report by Ajmi et al is a comprehensive and thoughtful example among many reports of simulation-based interventions to improve care processes and patient outcomes. Improved time-based targets in trauma,2 stroke and cardiac care are frequently cited in the literature, as are better resuscitation outcomes3 and compliance with practice guidelines.4 The identification of latent safety threats in clinical environments,5 6 including testing of new facilities prior to opening,7 is also well described. Such research is usually positioned as providing ‘proof’ that simulation ‘works’ for improving patient care. However, confounders and balancing measures may not be rigorously examined in this enthusiasm to demonstrate cause and effect. Team training using simulation can enable improvements in provider behaviours ,8 including those described by Ajmi et al ,1 where sequential tasks in time-critical patient journeys can be replaced by ‘parallel processing’. Location is also relevant, as ‘in situ simulation’—“taking place in the actual patient care setting/environment”9—affords a closer connexion to the physical environment for ‘real’, often ad hoc teams, to identify enablers or barriers for QI interventions.10 However, the effect could also lie in simulation shaping the culture and relationships 11 12 that underpin and support structural or process specific interventions. Most reported simulation-based improvement …

Healthcare organizations strive to deliver safe, high-quality, efficient care. These complex systems frequently harbor gaps, which if unmitigated, could result in harm. Systems-focused simulation (SFS) projects, which include systems-focused debriefing (SFD), if well designed and executed, can proactively and comprehensively identify gaps and test and improve systems, enabling institutions to improve safety and quality before patients and staff are placed at risk.The previously published systems-focused debriefing framework, Promoting Excellence and Reflective Learning in Simulation (PEARLS) for Systems Integration (PSI), describes a systematic approach to SFD. It includes an essential “pre-work” phase, encompassing evidence-informed steps that lead up to a SFD. Despite inclusion in the PSI framework, a detailed description of the pre-work phase, and how each component facilitates change management, was limited.The goal of this paper is to elucidate the PSI “Pre-work” phase, everything leading up to the systems-focused simulation and debriefing. It describes how the integration of project and change management principles ensures that a comprehensive collection of safety and quality issues are reliably identified and captured.

Safety science in healthcare has historically focused primarily on reducing risk and minimizing harm by learning everything possible from when things go wrong (Safety-I). Safety-II encourages the study of all events, including the routine and mundane, not only bad outcomes. While debriefing and learning from positive events is not uncommon or new to simulation, many common debriefing strategies are more focused on Safety-I. The lack of inclusion of Safety-II misses out on the powerful analysis of everyday work.A debriefing tool highlighting Safety-II concepts was developed through expert consensus and piloting and is offered as a guide to encourage and facilitate inclusion of Safety-II analysis into debriefings. It allows for debriefing expansion from the focus on error analysis and “what went wrong” or “could have gone better” to now also capture valuable discussion of high yield Safety-II concepts such as capacities, adjustments, variation, and adaptation for successful operations in a complex system. Additionally, debriefing inclusive of Safety-II fosters increased debriefing overall by encouraging debriefing when “things go right”, not historically what is most commonly debriefed.

Background: India contributes for one-third of the total burden of oral cancer worldwide. Lower socioeconomic groups are more affected with oral cancer as they are more attracted towards tobacco consumption and diagnosed in later stages due to lack of health-related awareness and diagnostic tools. Therefore, this study was conducted to assess the knowledge and awareness about oral cancer, its risk factors and to ascertain the distribution of risk factors in the urban slum population. Methods: A cross-sectional survey conducted in the urban-slum population of Jodhpur in 2019 using cluster sampling strategy to collect data from 1200 participants. The semi-structured questionnaire was used to obtain information on knowledge and awareness for oral cancer, its risk factors, signs, symptoms and distribution of different patterns of risk factors for oral cancer. Results: Out of surveyed 1200 participants, 48.5 % were males and 51.4 % were females. 46.6% males and 53.4% females of the study population heard about oral cancer Among study population, 28.9 % reported tobacco, 27.8% smoking, 29.8% alcohol and 27% betel-nut chewing as risk factor of oral cancer. Almost 53% considered oral cancer as a consequence of dental treatment and 49% believed that it can transmitted through close contact. The knowledge about signs or symptoms of oral cancer was quite low in urban-slums. Consumption of various risk factors like tobacco, alcohol, both alcohol and tobacco, arecanut were significantly associated with gender. Conclusion: This study highlights the lack of awareness regarding oral cancer and its risk factors in the urban-slum population. A significant number of the population in the study were tobacco or alcohol users which makes them more vulnerable to oral malignant diseases. This emphasized the need for health education interventions for raising oral cancer awareness in these high-risk groups. Keywords: Awareness, oral cancer, tobacco, urban slum

Diabetic neuropathy is an incapacitating chronic pathological condition that encompasses a large group of diseases and manifestations of nerve damage. It affects approximately 50% of patients with diabetes mellitus. Autonomic, sensory, and motor neurons are affected. Disabilities are severe, along with poor recovery and diverse pathophysiology. Physical exercise and herbal- based therapies have the potential to decrease the disabilities associated with diabetic neuropathy. Aerobic exercises like walking, weight lifting, the use of nutraceuticals and herbal extracts are found to be effective. Literature from the public domain was studied emphasizing various beneficial effects of different exercises, herbal and nutraceuticals for their therapeutic action in diabetic neuropathy. Routine exercises and administration of herbal and nutraceuticals, either the extract of plant material containing the active phytoconstituent or isolated phytoconstituent at safe concentration, have been shown to have promising positive action in the treatment of diabetic neuropathy. Exercise has shown promising effects on vascular and neuronal health. It has proven to be well effective in the treatment as well as prevention of diabetic neuropathy by various novel mechanisms, including Herbal and nutraceuticals therapy. They primarily show the anti-oxidant effect, secretagogue, anti-inflammatory, analgesic, and neuroprotective action. Severe adverse events are rare with these therapies. The current review investigates the benefits of exercise and nutraceutical therapies in the treatment of diabetic neuropathy.

Significant strides in advancing healthcare safety have been made. The improvements can be attributed, in part, to the proliferation of simulation-based medical education (SBME). The applications and benefits of simulation-based education have been demonstrated in: (a) teaching and emphasizing teamwork behaviors, particularly in high-risk fields like obstetrics; (b) simplifying, standardizing and practicing effective communication strategies; (c) implementing evidence based guidelines and recommendations; and (d) recognizing and practicing all these skills in interprofessional teams for high risk situations. Unique opportunities for simulation-based interprofessional education exist within obstetrics. A novel program for supporting simulation-based interprofessional education for Labor and Delivery staff by a professional liability insurer (PLI) will be described and lessons learned will be shared. A review of the utility of interprofessional simulation to introduce, improve and implement obstetric emergency checklists will also be presented.

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A variety of healthcare disciplines intersect during the care of a pregnant woman, especially during delivery. Simulation has been effectively utilized to train a wide range of health professionals on fundamental obstetric skills including cervical exams, assessment of fetal position, spontaneous vaginal delivery, and perineal laceration repair. Educators have used simulation equipment ranging from part-task trainers and full-body mannequins to organic materials such as different fruits or beef tongue, to train individuals or teams on core pregnancy-related procedures.

New York City became one of the epicentres of the COVID-19 pandemic in 2020. Simulation was used to establish the COVID-19 trained observer programme to mitigate healthcare workers’ infection risk during patient care. The members of the trained observer group consisted of 32 staff members. At the start of the training programme, they were provided donning and doffing guides with a step-by-step description of personal protective equipment (PPE) usage, followed by in-situ PPE simulation training. Later on, as PPE protocols evolved, additional educational modalities were used and included training videos, picture demonstrations of common PPE mistakes and repeated in-situ simulations. The early lessons which emerged from using simulation to train observers during the COVID-19 pandemic were the following: address PPE shortages during presimulation planning, prepare to perform updates for trained observers and use multiple educational modalities to train observers. Adequate amounts of PPE should be available to train observers. Repeated simulations are necessary to update observers on PPE protocols. Multiple learning modalities should educate the trained observers and equip them for their role in COVID-19 units.

Background: Socio-economic status can be an important determinant for patterns of tobacco consumption and its related health risks. Easy availability and affordable price may lead to the indulgence of smokeless tobacco; this deprived the section of society towards addiction of smokeless tobacco. Therefore, this study was conducted to ascertain smokeless tobacco use and its dependence in urban slum population of Jodhpur city.Methods: A cross-sectional survey was conducted in the urban-slum population of Jodhpur in 2019. A cluster sampling strategy was used to collect data from 1200 participants in different slums of Jodhpur city. The semi-structured questionnaire was used to obtain information on tobacco usage and willingness to quit.Results: Out of surveyed 1200 participants, 48.5% were males and 51.4% were females. 65.7% of the tobacco users reported in study population. Among tobacco user’s majority were using smokeless tobacco (75.4%), followed by 14.8% dual tobacco users and 9.8% were smoking tobacco. Out of female and male tobacco users, 95% females and 86.3% males were using smokeless forms of tobacco respectively. The frequency of daily tobacco use, time of tobacco chewing, duration of tobacco use was significantly associated with gender. No significant association was found between willingness to quit and gender.Conclusions: Smokeless tobacco was prevalent as compared to smoking form in urban-slums of Jodhpur city. Younger population and women were more attracted towards smokeless tobacco and willingness to quit tobacco was equally prevalent among males and females. An effective health education strategy for tobacco cessation should be designed according to age and gender of urban-slums.

This statement is designed primarily as an educational resource for clinicians to help them provide quality medical services. Adherence to this statement is completely voluntary and does not necessarily assure a successful medical outcome. This statement should not be considered inclusive of all proper procedures and tests or exclusive of other procedures and tests that are reasonably directed toward obtaining the same results. In determining the propriety of any specific procedure or test, the clinician should apply his or her own professional judgment to the specific clinical circumstances presented by the individual patient or specimen. Clinicians are encouraged to document the reasons for the use of a particular procedure or test, whether or not it is in conformance with this statement. Clinicians also are advised to take notice of the date this statement was adopted and to consider other medical and scientific information that becomes available after that date. It also would be prudent to consider whether intellectual property interests may restrict the performance of certain tests and other procedures.Noninvasive prenatal screening using cell-free DNA (NIPS) has been rapidly integrated into prenatal care since the initial American College of Medical Genetics and Genomics (ACMG) statement in 2013. New evidence strongly suggests that NIPS can replace conventional screening for Patau, Edwards, and Down syndromes across the maternal age spectrum, for a continuum of gestational age beginning at 9-10 weeks, and for patients who are not significantly obese. This statement sets forth a new framework for NIPS that is supported by information from validation and clinical utility studies. Pretest counseling for NIPS remains crucial; however, it needs to go beyond discussions of Patau, Edwards, and Down syndromes. The use of NIPS to include sex chromosome aneuploidy screening and screening for selected copy-number variants (CNVs) is becoming commonplace because there are no other screening options to identify these conditions. Providers should have a more thorough understanding of patient preferences and be able to educate about the current drawbacks of NIPS across the prenatal screening spectrum. Laboratories are encouraged to meet the needs of providers and their patients by delivering meaningful screening reports and to engage in education. With health-care-provider guidance, the patient should be able to make an educated decision about the current use of NIPS and the ramifications of a positive, negative, or no-call result.Genet Med 18 10, 1056-1065.

In situ simulation is the practice of simulation in the actual clinical environment and has demonstrated utility in the assessment of system processes, identification of latent safety threats, and improvement in teamwork and communication. Nonetheless, performing simulated events in a real patient care setting poses potential risks to patient and staff safety. One integral aspect of a comprehensive approach to ensure the safety of in situ simulation includes the identification and establishment of "no-go considerations," that is, key decision-making considerations under which in situ simulations should be canceled, postponed, moved to another area, or rescheduled. These considerations should be modified and adjusted to specific clinical units. This article provides a framework of key essentials in developing no-go considerations.

The Jewish community has traditionally taken ownership of its health, and has taken great strides to raise awareness about genetic issues that affect the community, such as Tay-Sachs disease and Hereditary Breast and Ovarian Cancer syndrome. Thanks in part to these heightened awareness efforts, many Orthodox Jewish individuals are now using genetics services as they begin to plan their families. Due to unique cultural and religious beliefs and perceptions, the Orthodox Jewish patients who seek genetic counseling face many barriers to a successful counseling session, and often seek the guidance of programs such as the Program for Jewish Genetic Health (PJGH). In this article, we present clinical vignettes from the PJGH's clinical affiliate, the Reproductive Genetics practice at the Montefiore Medical Center. These cases highlight unique features of contemporary premarital counseling and screening within the Orthodox Jewish Community, including concerns surrounding stigma, disclosure, "marriageability," the use of reproductive technologies, and the desire to include a third party in decision making. Our vignettes demonstrate the importance of culturally-sensitive counseling. We provide strategies and points to consider when addressing the challenges of pre- and post-test counseling as it relates to genetic testing in this population.

Advancements in molecular technology coupled with a greater awareness of the human genome and epigenome have broadened our understanding of the genetic contributions to the diabetic pregnancy. There are multiple genes and pathways that can result in a hyperglycemic environment for the fetus. Exposure to this environment in utero has an impact on the risk of adult-onset chronic diseases. How identification of an individual's genetic variants will impact clinical care and outcomes will continue to evolve as our understanding grows.

To date, preconceptual and prenatal patients have been offered gene-by-gene, disorder-by-disorder carrier screening. Newer techniques allow screening of many disorders at one time. The goal of this review is to provide an overview of the current practice and future direction of carrier screening within the preconceptual/prenatal setting.

We studied the clinical utility of chromosomal microarray analysis (CMA) in prenatal diagnosis in a clinical setting in New York City.Our center began offering CMA to pregnant women undergoing invasive diagnostic procedures for an abnormal structural finding on ultrasound, maternal age of 35 years or older, or elevated risk on aneuploidy screening, beginning March 2012. Our first six months experience is reported.Benign familial variants were the most common finding (16/22 fetuses). Variants of uncertain significance were frequent, especially when fathers were not available for testing (4/22 fetuses). Most patients undertook CMA as part of evaluation of an ultrasound anomaly (52%). One patient terminated a pregnancy based on an ultrasound finding in the setting of a benign familial variant on CMA, and a second terminated a pregnancy based on a copy number variant identified on CMA.For CMA to be maximally useful in prenatal diagnosis, parental DNA samples as well as robust datasets to provide predictive phenotypic information are required. The most common reason for undertaking CMA was to evaluate an ultrasound anomaly, and benign familial variants were a common finding. Genetic services are required to provide pre- and post-test genetic counseling and help families interpret results.

Noninvasive assessment of the fetal genome is now possible using next-generation sequencing technologies. The isolation of fetal DNA fragments from maternal circulation in sufficient quantity and sizes, together with proprietary bioinformatics tools, now allows patients the option of noninvasive fetal aneuploidy screening. However, obstetric care providers must become familiar with the advantages and disadvantages of the utilization of this approach as analysis of cell-free fetal DNA moves into clinical practice. Once informed, clinicians can provide efficient pretest and posttest counseling with the goal of avoiding patient harm. It is in the public’s best interest that test results contain key elements and that laboratories adhere to established quality control and proficiency testing standards. The analysis of cell-free fetal DNA in maternal circulation for fetal aneuploidy screening is likely the first of major steps toward the eventual application of whole fetal genome/whole fetal exome sequencing. Genet Med advance online publication 00 Month 2013

We describe a novel combination of medical simulation and Lean process improvement methodology applied to improve operating room (OR) turnover time (TOT). Excess OR TOT (time between one patient's exit and next patient's entry) negatively impacts throughput, patient care and revenue generation. Elimination of waste and improvement in efficiency are highly desirable. Lean methodology, applied to healthcare, seeks improvement by eliminating waste, revising processes and identifying/resolving problems at a root-cause level.1–4 Staff are engaged in change through weeklong rapid improvement events (RIE) to redesign, test and implement new work processes. An RIE includes critical assessment of the current state, mapping current processes, identification of the desired state, examination of process gaps, brainstorming improvements and experimentation to develop solutions and improve standard work.1 To address the issue of excess OR TOT, taking an OR out-of-service would be disruptive to patient care and cost-prohibitive. A simulated OR provided a potential opportunity to rapidly and repeatedly recreate the turnover process, develop and practice standard work, experiment without patient harm/disruption of care and engage staff members in designing and implementing improvements by encouraging experimentation with change. To capture this opportunity, the perioperative services, hospital-wide process improvement and simulation centre teams collaborated. ### Setting The Institute for Medical Simulation and Advanced Learning (IMSAL) and Jacobi Medical Center (JMC), a municipal hospital, Bronx, New York, …

Introduction Emergency medicine physicians must have the knowledge and skills to stabilize all life-and-limb-threatening conditions. These skills are especially important considering that the 1989 COBRA act clearly defines active labor as a condition unsuitable to transfer. Given this context, we thought it necessary to create a work that could be used to provide emergency physicians with the necessary skills to assist in deliveries both routine and complex. Methods The total time requirement for the workshop is 4 hours. Before the session begins, learners are asked to fill out a survey. Learners complete two 40-minute small-group sessions on the topics of normal vaginal delivery and shoulder dystocia with hands-on training with birthing manikins. After a short break learners complete a 65-minute small-group session for breech delivery with hands-on training. Each small-group session is preceded by a whole-group demonstration of required skills lasting 15 minutes as well a mini lecture on maternal hemorrhage and estimation of blood loss. Results Our workshop has been shown to successfully educate emergency physicians with a range of obstetric experience and improve their knowledge base and hands-on skills. One hundred percent of our learners felt this workshop was appropriate for them and met its stated goals. Discussion While this is not the first workshop to educate on obstetric deliveries and their possible complications, it is the first to be created with the emergency medicine provider as the intended audience and the first to create a curriculum around uncomplicated delivery, shoulder dystocia, breech delivery, and postpartum hemorrhage.

Background The World Health Organization's Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes.

Intimate partner violence (IPV) is a major health concern in the United States (ACOG 2013). The World Health Organization (WHO) describes IPV as any physical, sexual, psychological harm by a current or former intimate partner (WHO 2016). Due to the psychosocial depth and nature of discussions within genetic counseling sessions, patients may disclose and/or discuss IPV as it relates to sexual well-being, reproductive and overall health. This study aims to assess the role for IPV screening, counseling and intervention in genetic counseling practice by investigating the incidence, experiences and attitudes about IPV among genetic counseling patients. Patients receiving genetic counseling at an urban metropolitan hospital were anonymously surveyed about experiences and perspectives on IPV as a topic of discussion during genetic counseling sessions. Among 60 eligible patients, 50 completed the survey (49 females, 1 male, of which, 5 identified as LGBT) ages 20 to 66. The incidence of IPV in this group was 16.0 % (n = 8). Majority of participants had never been asked about IPV by a healthcare provider (n = 32; 64.0%), would have felt comfortable answering questions about IPV by their healthcare provider (n = 34; 68.0%), and would have felt comfortable answering questions about IPV by their genetic counselor (n = 39; 78.0%). Perspectives from all participants, notably those with IPV history, provided insights to the role of genetic counselors in areas for IPV screening and counseling training.

Background More than a decade ago, researchers described a survey of Maternal Fetal Medicine fellows that showed that chorionic villus sampling training was limited for Maternal Fetal Medicine fellows in the United States. Prenatal screening and diagnosis have rapidly evolved since then and include the introduction of noninvasive aneuploidy screening that uses cell-free fetal DNA. Yet, chorionic villus sampling remains the only method available for first-trimester genetic diagnosis. Objective This study evaluated the chorionic villus sampling training of Maternal Fetal Medicine fellows with respect to availability, competency standards, and education methods. Study Design In November 2015, an electronic survey was sent to Maternal Fetal Medicine fellows and fellowship directors of accredited Maternal Fetal Medicine fellowship programs in the United States. Results Fifty-eight percent of fellows (179/310) and 46% of program directors (35/76) responded. Ninety-five percent of Maternal Fetal Medicine fellows think that invasive diagnostic testing is essential to their training; 100% of fellows have amniocentesis training; and 65% have chorionic villus sampling training. The median number of chorionic villus sampling procedures that are expected during a fellowship in those who trained was 10. Eighty-eight percent of fellows and 89% of program directors state that chorionic villus sampling training could be better; 89% of fellows and 97% of directors would like access to simulated models. Barriers to training included lack of patients (71%) and lack of proficient attending supervisors (43%). Conclusion Since the last survey, >10 years ago, chorionic villus sampling training has declined further. A decrease in the number of procedures that are performed is the leading barrier to this training.

To evaluate the prefrontal space (PFS) ratio of fetuses of African descent without Down syndrome and compare it to the PFS ratio previously established in a homogeneous Caucasian population to determine whether there is a difference in the ratio in these two groups. The PFS ratio was calculated retrospectively from stored 2D images of 100 African, African-American and African-Caribbean fetuses in the second and third trimester performed at the authors’ center. Other data including the maternal age, gestational age, and ethnicity were collected. An unpaired T test was used to compare the previously published Caucasian mean, 0.97 (SD 0.29) with the mean established for the black population 1.37 (SD 0.44). The difference between these two PFS ratios was found to be significant (p < 0.0001). This pilot study suggests a significant difference in the PFS in the non-Caucasian population. In order to use the PFS as a sonographic screening tool for Down syndrome, it will be important to determine normal values in different ethnic populations.

Background: As various dental procedures can transmit HIV, rapid HIV oral testing facilities in dental settings could play a major role in prevention of HIV infection. Being most popular HIV testing methods worldwide, the rapid HIV oral test is not available in India and its level of acceptance in Indian dental settings is unexplored. This study conducted with the objective to assess patient’s knowledge about HIV and their willingness toward rapid HIV oral testing in dental settings.Methods: This cross-sectional study was conducted in two dental clinics selected from two different largest mixed socioeconomic housing societies of Jodhpur respectively. A semi structured questionnaire consisting of demographics, respondent’s general knowledge towards AIDS/HIV infection, willingness towards HIV rapid oral test was developed for data collection. Standard descriptive statistics were calculated and comparisons between demographic data and willingness to get tested in dental setting, awareness for HIV etc. were analyzed.Results: Total of 473 age-eligible patients were surveyed out of which 214 were males. The difference about the knowledge of HIV/AIDS between two groups of education levels (p

A 26-year-old healthy gravida 3 woman (with history of two spontaneous pregnancy losses) delivers at term a 2,730-g female infant by normal spontaneous vaginal delivery. The second trimester maternal serum alpha-fetoprotein was elevated, and amniocentesis revealed normal female karyotype. The pregnancy was complicated by oligohydramnios (diagnosed at 20 weeks' gestation) that progressed to anhydramnios by 29 weeks' gestation. Fetal ultrasonography showed bilaterally enlarged echogenic kidneys (Fig. 1) and signs suggestive of a Dandy-Walker variant. Figure 1. Fetal ultrasonography at 20 weeks' gestation showing increased renal echogenicity. At delivery, the Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. The baby develops tachypnea and is transferred to the neonatal intensive care unit on nasal continuous positive airway pressure. Initial physical examination reveals asymmetry of the head and face (right ear pinna “crumpled” and left ear pinna flattened), multiple positional contractures that are predominantly in the upper extremities, and clenched fists. Abdominal ultrasonography shows bilateral echogenic kidneys with small cysts predominantly at the periphery (Fig. 2). Figure 2. Renal ultrasonography showing mildly enlarged, echogenic kidneys with multiple small cysts, predominantly at the periphery. Neurosonography shows bilateral subependymal hemorrhages with small intraventricular hemorrhage and signs suggestive of lissencephaly. Magnetic resonance imaging of the brain confirms these findings. A 4-week-old male neonate presents to the clinic with a history of “noisy breathing since birth.” His mother reports that the noise is unaffected by crying, feeding, agitation, or position. She denies any history of fever, cyanosis, vomiting, choking, diaphoresis, murmur, or seizures. The infant was born at term, weighing 3,600 g, to a primigravida mother via normal vaginal delivery, and there were no perinatal complications. There are no findings of note on family history. The child is gaining weight satisfactorily on formula feedings. On physical examination, the well-nourished infant appears in no apparent distress. His …

This analysis explores how to optimise knowledge transfer in healthcare simulation by applying cognitive load theory to curriculum design and delivery for both novice and expert learners. This is particularly relevant for interprofessional learning which is team-based, as each participant comes to the simulation experience with different levels of expertise. Healthcare simulation can offer opportunities to create complex and dynamic experiences that replicate real clinical situations. Understanding Cognitive Load Theory can foster the acquisition of complex knowledge, skills and abilities required to deliver excellence in patient care without overwhelming a learner's ability to handle new materials due to working memory limitations. The 2 aspects of working memory that will be explored in this paper are intrinsic load and extrinsic load. These will be addressed in terms of the learner's level of expertise and how to consider these elements to enhance the learning environment in simulation scenario development and delivery. By applying the concepts of Cognitive Load Theory, this paper offers educators a method to tailor their curricula to navigate working memory and optimise the opportunity for knowledge transfer.

Since its introduction four years ago, noninvasive prenatal screening for fetal aneuploidy (NIPS) has been widely adopted as a screening tool for women at a high risk for fetal aneuploidy. As use expands into the general population, questions arise concerning the integration of NIPS into preexisting screening paradigms. This study aims to examine the use of NIPS in current practice among prenatal counselors, predominantly in the United States, in order to inform strategies for the optimal use of both new and existing screening techniques. We electronically surveyed 208 members of the National Society of Genetic Counselors to ascertain how NIPS is currently being used. Genetic counselors were also queried as to the advantages and disadvantages of offering NIPS to all patients regardless of a priori risk. Results indicate substantial variation in practice regarding which patients are offered NIPS and how counselors have incorporated this technology into existing screening routines. The majority of participants report offering NIPS in conjunction with another method of screening for fetal aneuploidy, indicating that NIPS is being used as an addition rather than as a replacement. These screening methods primarily include nuchal translucency (NT) (45.1 %, n = 78) and first trimester serum screening, with or without an NT (19.7 %, n = 34). Furthermore, the majority report that they would be concerned about losing the clinical value of an NT in a complete transition to NIPS (85.4 %, n = 164). Counselors are evenly split on the merits of expanding the use of NIPS to the general population (con: 55.3 %, n = 105; pro: 44.7 %, n = 85). The lack of consensus suggests that updated practice guidelines might benefit counselors. In addition, respondents emphasized the need to better educate patients and providers about the risks, benefits, and limitations of the test.

Self-checkout is the emergent/emerging retail technology wherein users (shoppers) check out their own items using an interactive kiosk. A dramatic growth is anticipated in the prevalence of self-checkout systems in retail environments. A study was conducted to develop and evaluate a redesign of a self-checkout system with a focus on issues related to physical accessibility for wheelchair users. Two checkout station prototypes were built: a full-scale model of an existing system and a full-scale model of a system with design modifications (e.g., inclusion of appropriate wheelchair clearance under the workstation, reduced vertical position of the credit card reader, etc.). Five wheelchair users and 10 non-wheelchair users performed simulated self-checkout activities using both workstations. The principal independent variable was workstation type (standard design vs. modified design). The dependent measures were productivity (time to complete a transaction), shoulder flexion angle, torso flexion angle, and the user's subjective assessment of the experience. The results of this study indicate that workstation type did not influence productivity levels in either participant group (wheelchair users or non-wheelchair users). Posture, on the other hand, was significantly improved: the peak shoulder angle was reduced by 64% in wheelchair users and by 69% in the non-wheelchair user group. Peak flexion angle of the torso was also reduced by 67% for wheelchair users. Subjective feedback from the wheelchair user group supported the postural data by showing an overall preference for the redesigned workstation, whereas the non-wheelchair group showed no preference between the two. These results indicate that design for populations with specific limitations does not need to come at a cost of reduced accessibility for persons without these limitations; universal design is achievable.

This study was undertaken to determine whether the benefits of a single course of antenatal steroid treatment for neonatal respiratory morbidity diminish beyond 7 days.A retrospective chart review was performed of all deliveries less than 34 weeks' gestation where delivery occurred after completing a single course of antenatal steroids (dexamethasone or betamethasone). Maternal and neonatal charts were reviewed, treatment course was confirmed, and neonatal morbidities were collected.Of 197 neonates whose mothers received a full course of antenatal steroids, 98 delivered within 7 days and 99 delivered more than 7 days after the initial dose. The 2 groups were similar in gestational age at delivery (30 weeks 0 days vs 30 weeks 4 days). The groups were also similar in maternal age, race, payor status, type of steroid given, route of delivery, gender, and birth weight. Overall, infants delivering within 7 days had a lower incidence of receiving respiratory support for more than 24 hours (62% vs 81%, P.01), but there were no significant differences between the groups in surfactant treatment (39% vs 47%), use of mechanical ventilation (49% vs 59%), necrotizing enterocolitis (6% vs 4%), intraventricular hemorrhage (15% vs 20%), oxygen dependence at 28 days (24% vs 23%) or at 36 weeks estimated gestational age (13% vs 12%), length of stay (34 days vs 38 days), or mortality (2 vs 0). These results were no different when evaluating only infants delivered before 30 weeks.Among infants exposed to a single course of antenatal steroids, delivering more than 7 days after initiation of treatment was associated with an increased need for short-term respiratory support, but not other measures of neonatal morbidity. These data challenge the concept of diminishing efficacy of steroids after 7 days, and question the need for considering a rescue course.

A study was conducted to explore the use of universal design principles in the redesign of a grocery store self-checkout system – focusing on the accessibility for wheelchair users. Two checkout stations were built: one was a dimensionally accurate model of an existing system and the other was a redesign of this system, using universal design principles. Five wheelchair users and ten non-wheelchair users performed simulated self-checkout activities, using both checkout stations. The dependent variables were productivity, shoulder and torso posture, and users' subjective assessment. Results indicated that productivity was not significantly affected by checkout station type and posture was significantly improved – peak shoulder angle was reduced by 64% in wheelchair users and by 69% in the non-wheelchair group, and peak sagittal angle (forward lean) of the torso was reduced by 66.5% for wheelchair-users. Subjective feedback from both user groups showed a preference for the redesigned checkout station

Noninvasive prenatal screening for fetal aneuploidy analyzes cell-free fetal DNA circulating in the maternal plasma. Because cell-free fetal DNA is mainly of placental trophoblast origin, false-positive and false-negative findings may result from placental mosaicism. The aim of this study was to calculate the potential contribution of placental mosaicism in discordant results of noninvasive prenatal screening.We performed a retrospective audit of 52,673 chorionic villus samples in which cytogenetic analysis of the cytotrophoblast (direct) and villus mesenchyme (culture) was performed, which was followed by confirmatory amniocentesis in chorionic villi mosaic cases. Using cases in which cytogenetic discordance between cytotrophoblast and amniotic fluid samples was identified, we calculated the potential contribution of cell line-specific mosaicism to false-positive and false-negative results of noninvasive prenatal screening.The false-positive rate, secondary to the presence of abnormal cell line with common trisomies in cytotrophoblast and normal amniotic fluid, ranged from 1/1,065 to 1/3,931 at 10% and 100% mosaicism, respectively; the false-negative rate was calculated from cases of true fetal mosaicism, in which a mosaic cell line was absent in cytotrophoblast and present in the fetus; this occurred in 1/107 cases.Despite exciting advances, underlying biologic mechanisms will never allow 100% sensitivity or specificity.