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Introduction Many patients receiving news of an unplanned pregnancy need not only a test result, but also the initiation of pregnancy options counseling. Thus, this online instructional module and objective structured clinical examination (OSCE) aim to provide foundational training for medical students in nondirective pregnancy options counseling. Methods To further the validity of a previously published OSCE, we reconsidered content, revised the checklist, and produced videos for rater training. We also developed a 30-minute preparatory module outlining a stepwise approach and providing a structured opportunity for values clarification. The 10-minute OSCE scenario involves a 24-year-old woman presenting to an urgent care center with persistent nausea who receives the diagnosis of an early, unplanned pregnancy. She responds to the news with shock and emotional silence, asking for guidance. We conducted the OSCE with 46 third-year medical students on the family medicine clerkship. Immediately after the OSCE, students completed a survey and self-assessment, followed by an individualized feedback session with a faculty member. Results In the self-assessment phase, students reflected on how successfully they utilized methods in the online module for handling emotional silence and presenting options. Student self-identified areas for improvement highlighted use of terminology and their response to difficult emotional encounters in the future. Discussion This online module and validated OSCE provide a valued opportunity for learners to practice nondirective pregnancy options counseling skills, including screening for intimate partner violence and reproductive coercion, engagement in self-assessment and receiving feedback, and engaging in personal values clarification.

Introduction Oral contraceptives are widely used for both contraceptive and noncontraceptive purposes. Of women ages 15–44 who have ever had sexual intercourse, 88% have used at least one hormonal contraceptive method. Health care providers caring for reproductive-age women need a strong base of knowledge in hormonal contraception. Those who provide contraceptive counseling must apply this knowledge to shared decision making, including effective quantitative communication. Methods Students and faculty at Florida International University Herbert Wertheim College of Medicine created a prerecorded lecture and in-class interactive case on contraceptive pharmacology and risk communication. The 20-minute lecture focused on mechanisms of action, bioavailability, drug-drug interaction, effectiveness, and major vascular risks of combined hormonal and progestin-only contraceptives. The 55-minute in-class session integrated knowledge of risks and effectiveness of contraception with risk communication surrounding contraceptive decision making and counseling. For the 2018 academic year, 122 first-year medical students participated in the session. Students anonymously answered three questions related to the session on their end-of-course evaluation. Student learning was assessed with five multiple-choice questions on the pharmacology final exam. Results Students rated the session very positively. They highly rated the lecture's utility and the sesssion's contribution to solidifying their basic science knowledge and understanding of its clinical applications. Class average performance on the relevant final exam questions was 88.4%. Discussion The lecture and case discussion successfully addressed gaps in the curriculum and provided students the opportunity to integrate multiple domains of learning. Students’ perception of the materials was positive, and they demonstrated adequate learning.

Objective Limitations on didactic time pose barriers to teaching non-directive pregnancy options counseling. This study set out to explore the use of an online module to support trainee performance in a pregnancy options counseling standardized-patient exercise implemented among third-year medical students, and to examine the effect of clinical experience on student performance. Study design An online module was developed. A convenience sample of forty-six student performances in a family medicine clerkship participated in a standardized patient exercise. Trained faculty rated performances. Students completed a self-assessment and provided feedback on the online module. Chi-square and Mann–Whitney-U tests were used to analyze data. Three coders qualitatively examined narrative student comments. Results Thirty-four students passed, 11 achieved a minimal pass, and one failed. The mean global rating from faculty was 2.8 (pass). Students with prior clinical experience significantly outperformed those without on the global rating scale with mean scores of 3.1 compared to 2.7, respectively (p = .044). All students agreed that the online module helped prepare them for the exercise. Qualitative analysis of students' feedback on the module revealed strengths in content and pedagogy. In their self-assessments, all but two students referred to content explicitly conveyed in the module. Conclusion All students agreed that an online module supported their performance of non-directive pregnancy options counseling skills. Prior clinical experience was associated with improved performance. This module, along with the simulated exercise, can be implemented as a blended learning exercise without additional faculty teaching effort in standardized patient resource centers. Implications Students agreed that an online module facilitates simulated performance of non-directive pregnancy options counseling skills. Future work should compare the impact of this approach to others, and explore the additional training needed to maintain and build on initial learning.

In 2014, the Association of American Medical Colleges identified 13 Core Entrustable Professional Activities for Entering Residency (Core EPAs), which are activities that entering residents might be expected to perform without direct supervision. This work included the creation of an interinstitutional concept group focused on faculty development efforts, as the processes and tools for teaching and assessing entrustability in undergraduate medical education (UME) are still evolving. In this article, the authors describe a conceptual framework for entrustment that they developed to better prepare all educators involved in entrustment decision making in UME. This framework applies to faculty with limited or longitudinal contact with medical students and to those who contribute to entrustment development or render summative entrustment decisions.The authors describe a shared mental model for entrustment that they developed, based on a critical synthesis of the EPA literature, to serve as a guide for UME faculty development efforts. This model includes four dimensions for Core EPA faculty development: (1) observation skills in authentic settings (workplace-based assessments), (2) coaching and feedback skills, (3) self-assessment and reflection skills, and (4) peer guidance skills developed through a community of practice. These dimensions form a conceptual foundation for meaningful faculty participation in entrustment decision making.The authors also differentiate between the UME learning environment and the graduate medical education learning environment to highlight distinct challenges and opportunities for faculty development in UME settings. They conclude with recommendations and research questions for future Core EPA faculty development efforts.

Background: Headache disorders are highly prevalent, and have a substantial and negative impact on health worldwide. They are largely treatable, but differences in structure, objectives, organization and delivery affect the quality of headache care. In order to recognize and remedy deficiencies in care, the Global Campaign against Headache, in collaboration with the European Headache Federation, recently developed a set of quality indicators for headache services. These require further assessment to demonstrate fitness for purpose. This is their first implementation to evaluate quality in headache care as a multicentre national study. Methods: Between September and December 2016, we applied the quality indicators in six Italian specialist headache centres (Bologna, Firenze, Modena, Padova, Roma Campus Bio-Medico and Roma Sapienza). We used five previously developed assessment instruments, translated into Italian according to Lifting The Burden’s translation protocol for hybrid documents. We took data from 360 consecutive patients (60 per centre) by questionnaire and from their medical records, and by different questionnaires from their health-care providers (HCPs), including physicians, nurses, psychologists and nursing assistants. Results: The findings, comparable between centres, confirmed the feasibility and practicability of using the quality indicators in Italian specialist headache centres. The questionnaires were easily understood by HCPs and patients, and were not unduly time-consuming. Diagnoses were almost all (> 97%) according to ICHD criteria, and routinely (100%) reviewed during follow-up. Diagnostic diaries were regularly used by 96% of physicians. Referral pathways from primary to specialist care existed in five of the six clinics, as did urgent referral pathways. Instruments to assess disability and quality of life were not used regularly, a deficiency that needs to be addressed. Conclusion: This Italy-wide survey confirmed in six specialist centres that the headache service quality indicators are fit for purpose. By establishing majority practice, identifying commonalities and detecting deficits as a guide to quality improvement, the quality indicators may be used to set benchmarks for quality assessment. The next step is extend use and evaluation of the indicators into non-specialist care. © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

OBJECTIVE To further the validity of a tool to assess nondirective pregnancy options counseling skills. METHODS Using a cross-sectional design, we explored four sources of construct validity evidence for an objective structured clinical examination for training and assessment of nondirective pregnancy options counseling: content, response process, internal structure, and relations to other variables. Content of the previously developed tool was enhanced through input from five family medicine educators. The objective structured clinical examination was implemented in a family medicine clerkship with third-year medical students from 2014 to 2015 using trained raters. Response process was addressed after a pilot round. Three new raters evaluated videotapes of 46 performances. Cronbach's alpha, intraclass correlation coefficients, and Spearman's rho were estimated with 95% confidence intervals. RESULTS The content validity was affirmed. Cronbach's alpha was 0.71. According to Landis and Koch's criteria, all but two items unique to the clinical situation of pregnancy options counseling generated substantial to perfect agreement (0.62-1.00). Relations to other variables within the checklist were strong, ranging from 0.66 to 0.87. DISCUSSION This tool for assessing pregnancy options counseling skills has excellent content and strong internal structure. Further work to improve the Global Rating Scale may be necessary for summative use.

Tuberculosis (TB) is one of the leading causes of death worldwide. Over the last decades, TB has also emerged in the pediatric population. Epidemiologic data of childhood TB are still limited and there is an urgent need of more data on very large cohorts. A multicenter study was conducted in 27 pediatric hospitals, pediatric wards, and public health centers in Italy using a standardized form, covering the period of time between 1 January 2010 and 31 December 2012. Children with active TB, latent TB, and those recently exposed to TB or recently adopted/immigrated from a high TB incidence country were enrolled. Overall, 4234 children were included; 554 (13.1%) children had active TB, 594 (14.0%) latent TB and 3086 (72.9%) were uninfected. Among children with active TB, 481 (86.8%) patients had pulmonary TB. The treatment of active TB cases was known for 96.4% (n = 534) of the cases. Overall, 210 (39.3%) out of these 534 children were treated with three and 216 (40.4%) with four first-line drugs. Second-line drugs where used in 87 (16.3%) children with active TB. Drug-resistant strains of Mycobacterium tuberculosis were reported in 39 (7%) children. Improving the surveillance of childhood TB is important for public health care workers and pediatricians. A non-negligible proportion of children had drug-resistant TB and was treated with second-line drugs, most of which are off-label in the pediatric age. Future efforts should concentrate on improving active surveillance, diagnostic tools, and the availability of antitubercular pediatric formulations, also in low-endemic countries.

11019Background: Although more than 23,000 oncologists are practicing in the United States, a markedly small number of these are Hispanic/Latino. Related perhaps are statistics reflecting the poor ...

Introduction This progressively disclosed case of a boy presenting with generalized edema was created as part of a case-based learning course for second- and third-year medical students and was designed to integrate with basic science and clinical learning. The case provides a strong opportunity for initial learning and/or targeted review of important pathophysiologic concepts. Methods This case is designed for the small-group format; we have used it with groups ranging from four to eight students. When possible, groups have been facilitated by one basic science and one clinical faculty member. Nonetheless, a clinician well versed in the case and familiar with basic renal physiology can run the session alone. Results We have used this case during our second-year organ system courses. Student ratings of this case have been uniformly high, with the common reaction that the case is critical in helping them integrate lecture and laboratory-based learning. They prefer to participate in these exercises toward the end of the organ system module, citing greater integrative value at this point. Discussion We have found that initial participation in this case is preparing students well for robust involvement in the more open-ended and complex problem-based learning cases of our third year. We have yet to conduct any systematic assessment of learning from participation in these cases.

Recognizing that all primary care doctors, as well as many specialty practitioners, deliver the news of unplanned pregnancy to their patients, the ninth edition of APGO Medical Student Educational Objectives specifies that third-year medical students should attain a “does” level of competency for pregnancy options counseling. Methods of evaluation include standardized patients (SPs), direct observation, and simulation. We could not identify any published SP for evaluation of options counseling skills, so we developed a resource with feedback from colleagues nationwide with extensive experience in family planning education of both medical students and residents. This resource consists of two fully written and developed SPs, the first being married woman in her early 20s and the second an unmarried woman in her late 30s, presenting to an urgent care center with vague gastrointestinal complaints. Both SPs are diagnosed with unexpected early intrauterine pregnancy. Students are tasked with delivering the news of pregnancy after receiving a sign-out with the medical history, physical, and test results, and dispositioning the patient. The patient challenges the student with silence, ambivalence, and the questions, “What should I do?” and “What would you do?” The resource was used to assess the skills of 104 third-year medical students in an obstetrics and gynecology clerkship at the University of Miami Miller School of Medicine. Student responses in a postworkshop survey included the following results related specifically to this resource. Of the 104 students in the clerkship, 98% felt the SP scenario “came across as realistic and believable.” Ninety-six percent thought the instructions they were given “were sufficient to complete the interaction, including disclosing pregnancy results and discussing options with the patient.” One hundred percent agreed that the medical information in the SP scenario instructions “was sufficient to handle the interaction with the assumed diagnosis of pregnancy.” Eighty-eight percent felt that participating in the SP scenario “increased comfort with my skills in nondirective options counseling,” while 80% believed it “increased my moral comfort with nondirective options counseling.”

Background: Brucellosis in humans is an infectious disease which may occur following contact with infected domestic animals or the ingestion of unpasteurized dairy products. It has rarely been described in pregnancy. The diagnosis, neuropsychiatric manifestations, and management of brucellosis in a 3rd-trimester pregnant woman are discussed. Case: A 24-year-old Mexican female, G3P2002, at 30 weeks gestation presented with fever, shaking chills, night sweats, a non-productive cough, weakness, nausea, vomiting, anorexia, and vague, dull, upper abdominal pain as well as neuropsychiatric findings. Extensive evaluation revealed serologic and culture evidence of Brucella infection. Her worsening neuropsychiatric condition necessitated preterm delivery with satisfactory neonatal and improved maternal outcomes. Conclusion: Bacteriologic infection of pregnant women with neuropsychiatric manifestations should prompt a careful investigation, and brucellosis should be considered if there is a travel history possibly compatible with contact with domestic animals or the ingestion of unpasteurized dairy products.

As the burden of unintended pregnancy and abortion in the United States now falls disproportionately to poor and uninsured women, appropriate contraceptive counseling requires strong limited health literacy communication skills. This standardized patient case was developed to assess patient-centered counseling skills for long acting reversible contraceptive (LARC) methods, low health literacy communication skills, and appropriate use of the Medical Eligibility Criteria for Contraceptive Use. The patient is a 27-year-old woman who underwent suction curettage for an incomplete abortion 2 weeks earlier in the emergency room and presents for a routine postoperative visit. The student assumes her care from an attending or resident who has already examined the patient and found her without complications, but has not yet determined possible contraceptive needs. All reviewers found the standardized patient realistic and appropriately detailed. Their recommended changes were for greater detail in risks, benefits, and efficacy for the methods and reassignment of some competencies to a higher trainee level.

Introduction This workshop contains tools to review basic medical encounter communications skills as applied to sexual history taking, and to introduce the advanced skills of both handling of emotional silence (“the potential empathic opportunity”) and communicating during intimate examination and procedures. The workshop consists of a series of five skits that serve as a springboard for facilitated discussion. The skits may either be acted by a faculty member serving as the physician and either a second faculty member or student acting as the patient, or shown in the provided video files. Methods The five skits depict sequential portions of a single office visit for “Ruby,” a patient known to this physician who presents with a “yeast infection” and a significant hidden agenda. The facilitator will show the scenes (or act them out) one at a time, following each scene with the questions: “What did the doctor do right/well? What did s/he do wrong/incorrectly?“ Built into each scene are examples of highly effective communications techniques and major communications errors. Other portions of the scenes provoke mixed reactions from observers/students. The facilitator guide contains instructions for leading the introduction of the workshop as well as scene-by-scene guides to facilitate discussion, and questions regarding the various communication skills depicted. Results This workshop has been used with every block of third-year students on the core obstetrics and gynecology clerkship at the University of Miami Miller School of Medicine for more than 4 years. Blocks number 10–27 students though the average number of students is around 20. Student ratings have been consistently “excellent” among 90% or more of respondents. It has also been presented to OB/GYN residents and family practice residents. Discussion Responses to specific skills depicted in the skits may vary, depending on how they are acted, providing a rich variety of discussion if the facilitator chooses to act in real time rather than use the videos. A student can be trained within 15 minutes to play the role of the patient. It is important to emphasize that she maintain the silence required in scene III to exploit the teaching points of the potential empathic opportunity, as novice actors have difficulty maintaining this silence.

High-purity nickel is mainly produced by electrowinning from sulphate and chloride solutions in the presence of high concentrations of boric acid as a buffer. The generally used pH is in the range 3–4 if Ni concentration in the electrolyte is higher than 10 g/l. Lower Ni concentration, as in the case of either industrial liquid effluents and in situ low grade Ni ore leaching, needs pH values ranging from 10 to 11 in order to hinder the evolution of hydrogen. Ni electrowinning from acidic and alkaline solutions is studied to determine in both cases the best operative conditions. Particularly Ni concentration, additive presence, pH values, temperatures, cathode material, current density and voltage, to be used in the case of low Ni concentration, have been considered to obtain low energy requirements together with pure nickel having a good morphology.

Objective This study evaluates an educational intervention focusing on the ethical reasoning and communication skills necessary in counseling patients about morally objectionable medical interventions. Study Design All students on the core clerkship in obstetrics and gynecology at the University of Miami Miller School of Medicine participated in a structured workshop. Students completed anonymous surveys before and after the workshop. Associations between the participants' change in comfort level in providing nondirective counseling and measured demographic variables were analyzed. Results Of 140 students, 37% (n = 52) positively changed their comfort level with nondirective options counseling; 10% (n = 14) negatively changed. Change in understanding of the physician's role was reported by 60% (n = 84). The exercise was rated as educationally valuable by 95% (n = 128), with 84% (n = 115) attesting that the workshop would help them “approach things differently.” Conclusion Evaluation of multiple parameters demonstrated that this workshop heightened student awareness of the ethical and communications skills challenges posed by this clinical situation.

The iron stripping from di(-2-ethylhexyl)phosphoric acid (D2EHPA) constitutes a problem in hydrometallurgical processes: whereas Fe(III) is easily extracted along with other elements such as zinc or cadmium, it is hard to strip it from the organic phase. It is well known that Fe(II) is readily stripped from D2EHPA, so a reduction of ferric to ferrous iron could be a way to solve this problem. In this work, the reductive stripping in vacuum of Fe(III) from D2EHPA has been studied by using SHG zinc powder as a reducing agent. The optimisation of operating conditions, such as degree of vacuum, acid concentration and quantity of added zinc, has been made. The experiments showed that a stripping yield greater than 89% in only one stage can be achieved, depending on A/O ratio, at 80 kPa of pressure. The iron reduction and stripping have been done simultaneously.