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Abstract Over the past decade technological advances in the realm of ultrasound have allowed what was once a cumbersome and large machine to become essentially hand-held. This coupled with a greater understanding of lung sonography has revolutionized our bedside assessment of patients. Using ultrasound not as a diagnostic test, but instead as a component of the physical exam, may allow it to become the stethoscope of the 21st century.

Abstract Background Ultrasound guidance during central line insertion has significantly reduced complications associated with this procedure and has led to it being incorporated as standard of care in many institutions. However, inadvertent arterial penetration and dilation remains a problem despite ultrasound guidance and can result in significant morbidity and even mortality. Dynamic ultrasound confirmation of guidewire position within the vein prior to dilation may help to prevent and even eliminate this feared complication. Methods A prospectively collected database of central line insertions for one author utilizing this novel technique was retrospectively reviewed for all incidents of arterial dilation over a period from September 2008 to January 2010. Results During the study period 53 central lines were inserted with no incidents of arterial dilation. Conclusions Ultrasound confirmation of guidewire position has the potential to reduce or eliminate the morbidity and mortality of arterial dilation during central line placement.

Abstract Background Traumatic injury is a leading cause of morbidity and mortality in developed countries worldwide. Recent studies suggest that many deaths are preventable if injuries are recognized and treated in an expeditious manner – the so called 'golden hour' of trauma. Ultrasound revolutionized the care of the trauma patient with the introduction of the FAST (Focused Assessment with Sonography for Trauma) examination; a rapid assessment of the hemodynamically unstable patient to identify the presence of peritoneal and/or pericardial fluid. Since that time the use of ultrasound has expanded to include a rapid assessment of almost every facet of the trauma patient. As a result, ultrasound is not only viewed as a diagnostic test, but actually as an extension of the physical exam. Methods A review of the medical literature was performed and articles pertaining to ultrasound-assisted assessment of the trauma patient were obtained. The literature selected was based on the preference and clinical expertise of authors. Discussion In this review we explore the benefits and pitfalls of applying resuscitative ultrasound to every aspect of the initial assessment of the critically injured trauma patient.

Introduction: Congenital Long QT Syndrome (LQTS) is common in a First Nations community in Northern British Columbia due to the founder variant KCNQ1 p.V205M. Although well characterized molecularly and clinically in adults, no data have been previously reported on the pediatric population. The phenotype in adults has been shown to be modified by a splice site variant in KCNQ1 (p.L353L). The CPT1A p.P479L metabolic variant, also common in Northern Indigenous populations, is associated with hypoglycemia and infant death. Since hypoglycemia can affect the corrected QT interval (QTc) and may confer risk for seizures (also associated with LQTS), we sought to determine the effect of all three variants on the LQTS phenotype in children within our First Nations cohort., Methods: As part of a larger study assessing those with LQTS and their relatives in a Northern BC First Nation, we assessed those entering the study from birth to age 18 years. We compared the corrected peak QTc and potential cardiac events (syncope/seizures) of 186 children from birth to 18 years, with and without the KCNQ1 (p.V205M and p.L353L) and CPT1A variants, alone and in combination. Linear and logistic regression and student t -tests were applied as appropriate., Results: Only the KCNQ1 p.V205M variant conferred a significant increase in peak QTc 23.8 ms ( p  < 0.001) above baseline, with females increased by 30.1 ms ( p  < 0.001) and males by 18.9 ms ( p  < 0.01). There was no evidence of interaction effects with the other two variants studied. Although the p.V205M variant was not significantly associated with syncope/seizures, the odds of having a seizure/syncope were significantly increased for those homozygous for CPT1A p.P479L compared to homozygous wild type (Odds Ratio [OR]3.0 [95% confidence interval (CI) 1.2-7.7]; p  = 0.019)., Conclusion: While the KCNQ1 p.V205M variant prolongs the peak QTc, especially in females, the CPT1A p.P479L variant is more strongly associated with loss of consciousness events. These findings suggest that effect of the KCNQ1 p.V205M variant is mild in this cohort, which may have implications for standard management. Our findings also suggest the CPT1A p.P479L variant is a risk factor for seizures and possibly syncope, which may mimic a long QT phenotype., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Bene Watts, Gauthier, Erickson, Morrison, Sebastian, Gillman, McIntosh, Ens, Sherwin, McCormick, Sanatani and Arbour.)

Background: Indigenous women have higher rates of chronic disease than Indigenous men and non-Indigenous women. Long QT syndrome (LQTS) can be inherited or acquired; the latter may occur with chronic disease. A prolonged corrected QT value (QTc) is an independent risk factor for ventricular arrhythmias and sudden death, but few studies have quantified the impact of chronic disease on the QTc. We assessed the association between chronic disease and QTc prolongation in a population of First Nations women previously ascertained to study a high rate of inherited LQTS due to a unique genetic (founder) variant in their community., Methods: This substudy focusing on women expands on the original research where patients with clinical features of LQTS and their relatives were assessed for genetic variants discovered to affect the QTc. Medical records were retrospectively reviewed and chronic diseases documented. Using multivariate linear regression, adjusting for the effect of genetic variants, age, and QTc-prolonging medications, we evaluated the association between chronic disease and the QTc., Results: In total, 275 women were included. After adjustments, a prolonged QTc was associated with coronary artery disease (26.5 ms, 95% confidence interval [CI] 9.0-44.1 ms; P = 0.003), conduction system disease (26.8 ms, 95% CI 2.2-51.4 ms; P = 0.033), rheumatoid arthritis (28.9 ms, 95% CI 12.7-45.1 ms; P = 0.001), and type 2 diabetes mellitus (17.9 ms, 95% CI 3.6-32.3 ms; P = 0.015)., Conclusions: This quantification of the association between chronic disease and QTc prolongation in an Indigenous cohort provides insight into the nongenetic determinants of QTc prolongation. Corroboration in other populations will provide evidence for generalisability of these results., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Both urban and rural environments around the globe have become dominated by alien plant species to the extent that plantscapes from one region or country have become difficult to distinguish from many others. This process of plant community homogenisation comes at a cost to cultural identity and undermines people's sense of place. Although invasive alien plant species have received considerable attention in recent decades, issues with non-invasive alien plant species have largely been ignored, and yet they contribute significantly to biotic homogeneity and impose an ever accumulating invasion debt: a debt that increases in proportion with their population sizes. By contrast, an abundance of native species in the places where people live is important for strengthening commitment to biodiversity conservation. Is there therefore sufficient evidence of harm from increasing numbers of non-invasive alien plants to justify local and central governments introducing measures to substantially reduce the proportion of non-invasive aliens in both urban and rural environments?, (© 2023 John Wiley & Sons Ltd.)

Background: As simulation education continues to grow, more consideration has been given to creating and maintaining a psychologically safe simulation learning environment. It is known that failing to provide psychological safety can lead to feelings of incompetence and a lack of confidence with students. However, it is essential to understand what makes and maintains psychological safety in simulation from both student and facilitator's perspectives. In further understanding psychological safety, nursing educators can challenge students to think beyond that of task attainment and into the deeper realm of critical thinking and critical reflection., Objectives: The aim of this study was to understand students' and facilitators perspectives of psychological safety in simulation., Methods: Participants in this qualitative interpretive description study were seven students and four faculty that were chosen using convenience sampling. The data was collected over a 2-week period where semi-structured interviews were used to collect the participants perspectives. Data analysis was continuous and iterative and used inductive analysis., Results: There were two student themes which focused on the student-facilitator interaction: 1) dynamic interaction, 2) student self-efficacy. The facilitators results showed two themes which focused on 1) simulation design and 2) trust., Conclusion: Diverging thoughts are present between faculty and students in what constitutes psychological safety. In describing both the similarities and differences, we have a better understanding on how to create and maintain psychological safety thereby, providing students with the best learning experience possible., Competing Interests: Declaration of competing interest There are no conflicts of interest to declare., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Understanding the physiological effects of responding to crises is a critical component in understanding how to manage and prepare medical professionals to be crisis responders. Heart rate variability (HRV) is the variation in rate between a succession of R-R intervals. This variation is not only affected by physiological processes such as respiration or metabolic rate but is also directly controlled by the autonomic nervous system. As such, heart rate variability has been proposed as a noninvasive tool to measure the physiological stress response. The aim of this systematic review is to consolidate heart rate variability literature in the context of medical emergencies to determine if heart rate variability changes predictably from baseline when responding to medical crises. This may demonstrate utility as an objective, noninvasive measure of stress response. A systematic literature review of six databases yielded 413 articles, 17 of which met our inclusion criteria of being written in English, measuring HRV in healthcare providers, and measuring HRV in real or simulated medical resuscitations or procedures. Articles were then analyzed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) scoring system. Out of the 17 articles reviewed, 11 demonstrated statistically significant results showing heart rate variability responding in a predictable manner to stress. Three articles utilized a medical simulation as the stressor, six used medical procedures, and eight used medical emergencies encountered during clinical work. Overall, a predictable trend in heart rate variability metrics of standard deviation from the mean value of normal-to-normal (N-N) intervals (SDNN), root mean square of the successive differences (RMSSD), mean number of times per time interval in which the change in successive normal sinus (N-N) intervals exceeds 50 ms (PNN50), low frequency % (LF%), and low-frequency-to-high-frequency ratio (LF/HF) was observed when responding to stress. This systematic literature review showed that heart rate variability among healthcare providers responding to stressful scenarios follows a predictable pattern of change and expands our understanding of the physiology of stress in healthcare providers. This review supports the use of HRV to monitor stress during high-fidelity simulation to ensure that appropriate physiological arousal is achieved during the training of medical personnel., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Peabody et al.)

This study investigated the effectiveness of high-fidelity immersive simulation education to support inter-professional hospital clinical staff in recognizing and responding to aggression, violence, and clinical deterioration of patients admitted with mental health issues. Increased incidents of aggression and violence have been reported in many clinical hospital settings, especially in mental health wards. Patients experiencing severe psychological distress/agitation can result in the escalation of physiological symptoms such as chest pain, difficulty breathing, traumatic injury, etc. Mental health staff do receive aggression prevention training and medical emergency team training. However, there is added complexity when dealing with a mental health patient who is exhibiting aggressive, violent behaviour while also experiencing a medical or psychological emergency. Therefore, mental health staff needed a combined training programme that enhanced their delivery of recovery focussed care, de-escalation, and medical emergency crisis resource management skills. This study used a prospective quasi experimental research design with repeated measures. Hospital clinical staff were immersed in two mental health emergency response and clinical deterioration scenarios and debriefing sessions. Self-efficacy was evaluated using a 10-item validated tool which addressed non-technical skills of Leadership, Management, Communication, and Teamwork. The sample consisted of 122 clinical staff, with the majority from mental health wards (52%; n = 63) who were nurses (68%; n = 83). Mean self-efficacy scores increased significantly across the three time points (F = 11.555; df = 2; P = 0.000). Post hoc pairwise comparisons showed that self-efficacy scores increased between pretest (mean 62.9; n = 122) and posttest 1 (mean 83.2; n = 122) and follow up, 3 months later (posttest 2; mean 81.9; n = 24). Between pre- and posttest 1, significant improvements in self-efficacy were observed for both the Leadership/Management domain (t = 8.2; df 119; P < 0.000; 95% CI 13.3-21.7) and the Communication/Teamwork domain (t = 8.0; df 119; P < 0.000; 95% CI 11.1-18.4). Immersive simulation with high fidelity education was found to be effective in improving hospital nursing and medical staffs' confidence, when responding to incidents of aggression/violence and clinical deterioration of a mental health patient., (© 2022 John Wiley & Sons Australia, Ltd.)

Sialography is used for diagnosis of obstructive salivary gland diseases and prior to sialendoscopy. Three-dimensional cone beam computerized tomography (CBCT) sialography allows imaging and measurement of salivary duct structures. Salivary gland endoscopy has a long learning curve. The aim of this retrospective study is to create an anatomical quantitative guide of different distances and angles significant for endoscopy. Twenty-six CBCT sialographies of healthy parotid ducts were included. Outcome parameters included diameters, distances, angles and number of minor tributaries. Results show the average distance from the papilla to the curvature of the gland was 41.5 mm (Q1 36.97 mm-Q3 45.32 mm), with an angle of 126.9° (Q1 107.58°-Q3 135.6°) of the curvature and a distance of 35.25 mm (±7.81 mm) between the curvature and the hilus. The mean width of the duct was 0.8 mm (Q1 0.7 mm-Q3 1.15 mm) at its narrowest and 2 mm (Q1 1.4 mm-Q3 2.2 mm) at its widest. This is the first anatomical quantitative study of the parotid duct in relation to sialendoscopy.

Background: Dietary habits, food intake and oral health are important factors for general health. The aim of these present study was to assess the association between implant-supported fixed oral rehabilitation and glycemia, by monitoring HbA1c values before and after implant-supported prostheses (ISP) delivery to diabetic individuals. Methods: Retrospective, cohort study based on dental records. All treatments were performed by experienced oral and maxillofacial surgeons and experienced prosthodontists. Inclusion criteria: ISP delivery, diagnosis of diabetes in the medical files, consecutive individuals. Variables included—primary outcome—differences (delta) in HbA1c values prior to implant placement and one year after ISP delivery, early implant failure (EIF). Confounding factors included age, gender, physical status, smoking, implant jaw location, implant length, implant width, total implant count per individual. Results: Statistically significant (p < 0.01) decrease in HbA1c from 7.10 ± 1.09% to 6.66 ± 1.02% following ISP delivery was recorded. The mean HbA1c delta was 0.44 ± 0.73%, where 39.0% of the patients had a significant improvement (delta decrease > 0.5%). Univariate and multivariate model using logistic regression at individual level showed that initial high HbA1c levels was the only factor positively predicting improvement (OR = 1.96, CI [1.22, 3.14], p < 0.01). Univariate model at implant level demonstrated that implants placed in the anterior maxilla also contributed to significant improvement in HbA1c values. Multivariate analysis at implant level was similar to individual level. Number of missing teeth did not affect the results significantly. Conclusion: ISP delivery to partially or completely edentulous diabetic individuals may improve HbA1c balance. The mechanism awaits future elucidation.

Summary Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology., Competing Interests: Competing interests: Andrew Kirkpatrick has consulted for Zoll, Innovative Trauma Care, CSL Behring and SAM Medical Corporations, and is the principal investigator of a prospective randomized controlled trial that is partially supported by the Acelity Corporation (https://clinicaltrials.gov/ct2/show/NCT03163095). No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Purpose: Treatment alternatives based on implant-supported prostheses (ISPs) may be almost impossible in cases with extremely atrophic mandibles. Vertical bone augmentation is then the only possibility to achieve an ISP., Materials and Methods: The consequences of vertical augmentation in extremely atrophic mandibles (≤ 10-mm bone height) of edentulous patients using allogeneic block grafts via a submental approach were assessed. The recorded parameters were sex, age, physical status, hospitalization duration, postoperative complications, implant characteristics (length, diameter), early and late implant failure (yes/no; primary outcome variable). Bone height was measured at three points using the pre-grafting and pre-implant placement CBCT imaging. The difference between the measurements was defined as bone gain (primary outcome variable)., Results: Sixteen patients (2 men, 14 women) were included. The preoperative bone height ranged from 4 to 10 mm. A mean of 5.3 ± 1 months was allowed for graft consolidation. The average bone height gain was 11.2 ± 3.1 mm. Two to six dental implants were placed in the grafted bone. Early implant failure occurred in 4 out of 73 (5.5%). Follow-up ranged from 12 to 92 (mean: 48 ± 30) months. All patients were followed for more than a year, and two additional late implant failures were recorded, rendering a 92% cumulative survival rate., Conclusion: Bone grafting using allogeneic bone blocks via a submental approach seems to be a promising solution for reconstruction of the extremely atrophic mandible.

Background Procedural simulation enhances early endoscopy training. Multiple commercial simulators are available; however, their application is limited by cost and poor user compliance. First-person "shooter" (FPS) video games are popular. In this study, we aimed to show that a novel in-house designed colonoscope controller used to play an FPS video game shares similar constructs with real-life endoscopy. Methodology Participants completed the first three levels on an FPS video game, Portal (Valve Corporation, Bellevue, WA), first using a conventional controller and then the modified endoscope controller. A total of 12 expert endoscopists and 12 surgical residents with minimal endoscopy experience were evaluated based on completion time, button presses, and hand motion analyses. Results Experts outperformed novices for completion time (expert: 944 seconds; novice: 1,515 seconds; p = 0.006) and hand movements (expert: 1,263.1; novice: 2,052.6; p = 0.004) in using the novel colonoscope controller. There was no difference in button presses or total path length traveled. Furthermore, performance did not differ using conventional game controls. Conclusions Experts outperformed novices using the endoscope but not the conventional controller with respect to the economy of movement and completion time. This result confirms that our endoscope-controlled video game shares similar paradigms with real-life endoscopy and serves as a first step toward creating a more enjoyable and cheaper alternative to commercially available endoscopy simulators., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Johnson et al.)

Objectives: Assess clinical, imaging, operative, and post-operative characteristics of drug-induced vs. non-drug-induced sialolithiasis that are termed 'other etiologies of sialolithiasis.', Materials and Methods: Data collected from a retrospective cohort of 96 patients who underwent intra-oral sialolith removal operations were categorized as patient disease characteristics, physical examination results, and imaging and therapeutic features. Patients were divided into two groups based on having drug-induced sialolithiasis (DIS) vs. other etiologies of sialolithiasis (OES). Patients who consumed any medication for chronic conditions were regarded as DIS. Statistical analyses were conducted to elucidate differences and similarities between the two groups., Results: There were 60 patients in the DIS group and 36 in the OES group. DIS patients were significantly older (average age 57.9 vs. 39.8 years, respectively), with no gender predilection. Statins and anti-hypertensive medications were most commonly consumed. Presenting symptoms including number of past swellings, salty tasting saliva, pain, and antibiotic treatment were similar between the groups; mealtime-related swelling of the gland was noted in a higher proportion of OES patients (51.5% vs. 37%, respectively). Analysis of sialolith size and location from fixed anatomical landmarks on the mandible were not different between groups, and the most frequent sialolith location was the hilus gland in DIS vs. intra-glandular in OES patients. Sialolith removal operation time was significantly shorter for DIS patients (45 ± 11.5 vs. 61.1 ± 18.1 minutes)., Conclusion: Drug-induced sialolithiasis may be regarded as a unique entity with a typical clinical age, presenting symptoms, imaging characteristics, and surgery duration., Clinical Relevance: Clinicians should be aware of the above-mentioned differences when treating patients with sialolithiasis and anticipate a more challenging sialolith removal procedure for other etiologies of sialolithiasis, possibly due to underlying anatomical factors of the duct system. When treating drug-induced sialolithiasis, clinicians can expect a shorter operation time with a similar success rate and hospitalization time as with a younger, healthier population with other sialolithiasis etiologies., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Objective: The aim of this study was to retrospectively evaluate clinical outcomes after closure of oroantral fistulae with concomitant Caldwell-Luc operations (OFCLOs) with or without inferior meatal antrostomy (IMA)., Study Design: Records from consecutive OFCLOs carried out over a 12-year period at the oral and maxillofacial surgery department at a single medical center were reviewed. Background data included age, sex, medical status, indications, and etiologies. Outcome data included operative time, hospitalization time, and postoperative use of analgesics and complications., Results: From 2002 to 2013, 54 male patients (58%), 39 female patients (42%) (mean age 50 years; range 12-84 years) underwent OFCLOs. IMA was carried out in 66 cases (70%). All patients had minimal complications. We found statistically significant shorter operating times (72 vs 84 minutes), shorter postoperative hospitalization times (4.1 vs 5.6 days), lower need of analgesics (1.44 vs 2.88 per day), and fewer complications (11% vs 38%) when IMA was not used., Conclusions: IMA during OFCLOs carries increased morbidity without apparent benefits. Its routine use should, therefore, be discontinued., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Abstract: The aim of this report is to describe the combination of Crouzon syndrome and acanthosis nigricans with fibrous dysplasia of the maxilla. The diagnosis of fibrous dysplasia was confirmed clinically and pathologically during Le Fort III osteotomy and midface advancement with distraction osteogenesis. Crouzon syndrome with acanthosis nigricans is a known syndrome with an incidence of 1:1,000,000. This is the first report in the literature of Crouzon syndrome and acanthosis nigricans combined with fibrous dysplasia. As all 3 pathologies are related to fibroblasts, they may be different manifestations of malfunction of a single molecular pathway. The detection of fibrous dysplasia in a patient with Crouzon syndrome and acanthosis nigricans is important because it may complicate midface osteotomies and fixation of the hardware on the bones during craniofacial surgery., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 by Mutaz B. Habal, MD.)

Long standing, asymptomatic, well-demarcated erythema of the hard palate with a histopathological psoriasiform pattern comprises a challenging diagnosis. We present a series of patients with such clinical and histological findings and discuss the possible diagnoses. We collected all patients with palatal erythematous lesions that had well-documented clinical examination. Excluded were patients with definitive diagnosis of oral infections (e.g. candidiasis), neoplastic/pre-neoplastic lesions, auto-immune diseases, reactive lesions, blood disorders and vascular malformations. Thirteen patients (six females, seven males, age range 11-56 years) were included. Histopathologically, a psoriasiform pattern was observed in all biopsied lesions. One patient was diagnosed with hereditary mucoepithelial dysplasia (HMD) and four with cutaneous psoriasis. The remaining eight patients were otherwise healthy. A combination of persistent, asymptomatic palatal erythematous lesion with psoriasis-like histopathology may represent an oral manifestation of HMD or psoriasis, concomitant to extra-oral features. In lack of any known medical background, the term "oral psoriasiform mucositis" is suggested.

Background: Telementoring facilitates the coordination of advanced medical care in rural, remote or austere environments. Because the interpersonal element of telementoring has been relatively underexplored, we conducted a scoping review to identify strategies to improve communication in telementoring., Methods: Two independent reviewers searched all English-language articles in MEDLINE and Scopus from 1964 to 2017, as well as reference lists of relevant articles to identify articles addressing telementored interactions between health care providers. Search results were gathered in June 2017 and updated in January 2018. Identified articles were categorized by theme., Results: We identified 144 articles, of which 56 met our inclusion criteria. Forty-one articles focused on improving dispatcher-directed cardiopulmonary resuscitation (CPR). Major themes included the importance of language in identifying out-of-hospital cardiac arrest and how to provide instructions to enable administration of effective CPR. A standardized approach with scripted questions was associated with improved detection of out-of-hospital cardiac arrest, and a concise script was associated with improved CPR quality compared to no mentoring, unscripted mentoring or more complex instructions. Six articles focused on physician-physician consultation. Use of a handover tool that highlighted critical information outperformed an unstructured approach regarding transmission of vital information. Nine articles examined telementoring in trauma resuscitation. A common theme was the need to establish an understanding between mentor and provider regarding the limitations of the provider and his or her environment., Conclusion: The available data suggest that standardization coupled with short, concise validated scripts could improve efficacy, safety and engagement. Improvements will require multidisciplinary input, practice and deliberate efforts to address barriers., Competing Interests: None declared, (© 2020 Joule Inc. or its licensors.)

Background: Although auditing is embedded into clinical culture, data collection tends to be retrospective, requires expertise, and is time consuming., Local Problem: Clinical audit data are needed in real time to manage patient safety issues., Methods: An iterative approach was undertaken to develop the electronic audit tool with a cross-sectional survey used for evaluation., Interventions: The Combined Bedside and Risk Assessment (CoBRA) audit tool captures patient safety risk and compliance such as falls, pressure injuries, and infections., Results: More than 17 956 safety audits were collected on randomly selected inpatients. Monthly audits completion average is 96% (n = 614). Patient safety risk mitigation is available in real time. Stakeholders stated that the CoBRA tool was useful in educating patients on risks (n = 141; 78.3%), improved patient care (n = 120; 67.4%), and prompted staff to modify patient care based on CoBRA findings (n = 98; 54%)., Conclusions: The electronic CoBRA process facilitates patient safety risk mitigation and data transparency.

Introduction: Competency-based frameworks are common in surgical training. However, the optimal use of standardized technical assessments is not well defined. We investigated the effect of rater training (RT) on the reliability and validity of four assessment tools., Materials and Methods: Forty-Seven surgeons were randomized to RT (N = 24) and no training (N = 23) groups. A task-specific checklist, pass-fail, visual analog, and OSATS global rating scale (GRS) were used to assess trainee knot-tying and suturing tasks. Delayed assessment was performed two weeks later. Internal consistency, intra/inter-rater reliability, and construct validity were measured., Results: The GRS had superior reliability and validity compared to the other tools regardless of training. No significant differences between training groups was found. However, the RT group trended to improved reliability for all tools at both assessments., Conclusions: RT did not lead to significant improvements in skills assessments. Standardized assessments (OSATS GRS) are preferred due to their superior reliability and validity over other methods. Despite findings, we believe more effective training methods or repeated sessions may be required for sustained and significant effects., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Mental health disorders are estimated to affect between 10% and 20% of women who access maternity services and can be defined as a public health issue due to the potential consequences for women, children and families. Detecting problems early in pregnancy can significantly improve outcomes for women and their families. However, mental health problems are not being consistently identified in routine midwifery practice and little is known from current literature about midwives' practice in relation to current national guidelines or the impact models of care have on assessing maternal mental health., Objective: To identify midwives' views about barriers and facilitators to screening for mental health in pregnancy using current UK guidelines., Design: Nine community midwives from a single district general hospital in the south of England were recruited to take part in focus groups. Thematic analysis was used to extract key themes from the data., Findings: Three key themes were identified from the focus groups and included system factors, social factors and trust. Barriers and facilitators to screening maternal mental health were associated with the initial 'booking' appointment' and differences in models of care. Barriers to screening were defined as high workload, poor continuity, and a lack of trust between women and midwives., Conclusions: This study highlights key barriers and facilitators associated with mental health screening during pregnancy, including issues of trust and uncertainty about women's willingness to disclose mental health conditions. Further research is required to evaluate the relationship between women and midwives in contemporary practice and the influence this may have on maternal mental health., Competing Interests: Declaration of Competing Interest None declared, (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background and Objectives : Smoking has been found to interfere with wound healing processes. Therefore, the purpose of this study was to compare surgical treatment of oroantral fistulae (OAFs) in smokers and non-smokers. Materials and Methods: Medical records of all consecutive patients who underwent surgical closure of OAFs between 2003 and 2016 at the oral and maxillofacial surgery department, Rabin Medical Center, Israel were reviewed. Patients' demographic data, preoperative signs and symptoms, surgical method of repair, and postoperative complications were recorded. Results: The cohort consisted of 38 smokers and 59 non-smokers. Age and gender distributions were similar in both groups. The main etiology in both groups was tooth extraction, followed by pre-prosthetic surgery in smokers and odontogenic infection in non-smokers ( p = 0.02). Preoperative conditions were not significantly different between smokers and non-smokers in terms of size of soft tissue fistula and bony defect, chronic sinusitis and foreign bodies inside the sinus. OAFs were repaired by local soft tissue flaps without consideration of smoking status. Smokers experienced more moderate-severe postoperative pain ( p = 0.05) and requested more weak opioids ( p = 0.06). Postoperative complications included infection, delayed wound healing, residual OAF, pain, sensory disturbances and sino nasal symptoms. These were mostly minor and tended to be more frequent in smokers ( p = 0.35). Successful closure of OAFs was obtained in all patients except one smoker who required revision surgery. Conclusions: Smokers may be more susceptible to OAFs secondary to preprosthetic surgery. In this cohort, there was no statistically significant difference in outcome between smokers and non-smokers in terms of failure. However, smokers tended to have more severe postoperative pain and discomfort and to experience more postoperative complications. Further studies with larger sample sizes should be conducted to validate these results.

Background: Education programs teaching crisis resource management (CRM) skills (problem solving, situational awareness, resource utilization, communication, and leadership) have been shown to positively affect learner competence in handling crisis events. As part of an education program, a high-fidelity simulation program was used as a learning intervention to teach these skills to practicing nurses., Method: In this repeated-measures observational study, 11 RNs were evaluated at four time points, measuring the effect of an education program on observed performance of CRM skills. Performance was measured using the Ottawa Global Rating Scale and a checklist tool., Results: Statistically significant changes in mean scores occurred between times one and two, and nonstatistically significant improvement occurred in means overall., Conclusion: This study adds evidence of the effectiveness of high-fidelity simulation education and highlights the need for further research. [J Contin Educ Nurs. 2020;51(6):257-266.]., (Copyright 2020, SLACK Incorporated.)

The aim of this study was to determine the origin (human, bovine or porcine) and the concentration of the fecal sources of contamination in waters from Santa Lucía basin and Uruguay River in Uruguay by using host-specific viral markers (adenoviruses and polyomaviruses) as microbial source tracking (MST). Between June 2015 and May 2016, monthly collections of surface water samples were performed in six sites in Santa Lucía basin and four sites in Uruguay River (n = 120 samples). Viral concentration was carried out using an absorption-elution method. Detection and quantification of human and porcine adenovirus (HAdV and PAdV, respectively) and human and bovine polyomavirus (HPyV and BoPyV, respectively) were performed by quantitative PCR (qPCR). To evaluate the infectivity of circulating HAdV, an integrated cell culture-qPCR (ICC-qPCR) was used. A logistic regression analysis was carried out to estimate the influence of environmental variables on the virus presence in surface waters. Overall, HAdV was the prevalent (18%; 21/120) followed by BoPyV (11%; 13/120) and HPyV (3%; 3/120), whereas PAdV was not detected in this study. The mean concentration ranged from 1.5 × 10 4 genomic copies/L (gc/L) for HAdV to 1.8 × 10 2 gc/L for HPyV. Infective HAdVs were observed in two out of ten analyzed samples. A significant effect of environmental temperature (p = 0.001) and river (p = 0.012) on the presence of human viruses was found. These results suggest that fecal contamination could affect the water quality of these rivers, showing deficiencies in the procedure of sewage discharge from regional cities, livestock and dairy farms.

Background: Complications due to influenza are contributory factors for maternal deaths in the United Kingdom (UK). Less than half of all pregnant women in the UK receive the influenza vaccination. Increasing immunisation rates for seasonal influenza in pregnant women must remain a public health priority., Method: A retrospective cohort study was undertaken, utilising the electronic health record of 4817 women who had given birth at a South London NHS Hospital from 1st January-31st December 2015. The data were then analysed to determine if there were any common characteristics of the women who received or did not receive the seasonal influenza vaccination., Results: It was found that ethnic origin, age at booking, planned pregnancy, parity, and booking in the first trimester were significant predictors for receiving the seasonal influenza vaccination. Index of Multiple Deprivation Deciles, speaking English without a translator, and booking season were not clinically or statistically significant predictors for receiving the seasonal influenza vaccination., Conclusions: There are common characteristics that are associated with receiving and not receiving the seasonal influenza vaccination for women who gave birth in South London during 2015. These results could be useful to antenatal health professionals working in similarly diverse areas, and to influence the public health agenda. This research ascertains which women in the cohort did not receive the vaccination; future research should explore the factors which affect vaccine uptake and potential strategies to improve vaccination rates., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: Our goal was to perform a scoping systematic review of the literature on the use of intravenous immunoglobulins (IVIG) for refractory status epilepticus (RSE) in adults., Method: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to May 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers., Results: Twenty-four original articles were identified. A total of 33 adult patients were described as receiving IVIG for RSE. Seizure reduction/control with IVIG occurred in 15 of the 33 patients (45.4%), with 1 (3.0%) and 14 (42.4%) displaying partial and complete responses respectively. No adverse events were recorded., Conclusion: Oxford level 4, GRADE D evidence exists to suggest an unclear impact of IVIG therapy in adult RSE. Routine use of IVIG in adult RSE cannot be recommended at this time., (Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Purpose: Our goal was to perform a scoping systematic review of the literature on the use of plasmapheresis or plasma exchange (PE) for refractory status epilepticus (RSE) in adults., Methods: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to May 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers., Results: Twenty-two original articles were identified. Twenty-seven adult patients were described in these articles, with a variety of autoimmune conditions leading to RSE. Seizure response with the application of PE therapy occurred in 14 of the 27 patients (51.9%), with 1 (3.7%) and 13 (48.1%) displaying partial and complete responses respectively. Generalized RSE was the most likely seizure subtype to respond to PE therapy. One patient had recorded an adverse events related to PE therapy., Conclusions: Oxford level 4, GRADE D evidence exists to suggest an uncertain response of adult autoimmune RSE to PE therapy. Thus, the routine application of PE therapy for adult autoimmune RSE cannot be recommended at this time., (Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background: Our goal was to perform a scoping systematic review of the literature on the use of plasmapheresis or plasma exchange (PE) for refractory status epilepticus (RSE) in children., Methods: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to May 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers., Results: Twenty-two original articles were identified, with 37 pediatric patients. The mean age of the patients was 8.3 years (age median: 8.5, range: 0.6 years-17 years). Seizure response to PE therapy occurred in 9 of the 37 patients (24.3%) included in the review, with 7 patients (18.9%) displaying resolution of seizures and 2 patients (5.4%) displaying a partial reduction in seizure volume. Twenty-eight of the 37 patients (75.7%) had no response to PE therapy. No adverse events were recorded., Conclusions: Oxford level 4, GRADE D evidence exists to suggest little to no benefit of PE in pediatric RSE. Routine application of PE for pediatric RSE cannot be recommended at this time., (Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background: The catalyst to revise the graduate nurse program at an inner city hospital was a major service reconfiguration, which reduced services, staffing and graduate nurse positions. Parameters for the new program were that it was evidence-based and could function within the reduced resources., Objective: Review current literature and design an evidence-based transition program., Methods: Eight databases were searched for primary and secondary research and unpublished theses (2004-2014), which were then hand searched. Eighty-three articles were reviewed and 50 retained as they informed development of a program designed to actively promote the graduates' transition from undergraduate to independent health professional., Results: Three key concepts emerged from the literature: the graduates' need for support, socialisation and facilitated learning opportunities. This article reviews the literature and outlines a program designed to maximise these concepts in an evidence-based transition program. Proposed evaluation tools are identified for use throughout the program.

Edentulous patients with advanced resorption of the mandible (atrophic mandible) suffer major discomfort when using dentures. Furthermore, placing dental implants is impossible due to lack of sufficient bone volume. In the past, several methods of bone grafting to the anterior mandible have been proposed. Most of them were unpredictable in either the short or long-term. In 2002 a technique for bone grafting of the anterior mandible via a submental approach was published. A wide reflection of the soft tissue was followed by implant placement. Autogenous particulate posterior iliac crest bone graft was used. The presence of the implants did not allow for contraction of the soft tissue and bone resorption. The addition of bone volume to the chin improved the facial aesthetics of the patients due to a fuller appearance of the chin and tightening of the skin of the neck. The submental approach changes the spatial orientation of the surgeon and placement of implants in the correct location and angle become challenging. Placement of the implants too far buccally was a prosthetic problem. A major disadvantage of autogenous bone grafting is the necessity to operate a donor site. The increasing experience in use of allogenic bone grafts with resorbable collagen membranes, allowed us to modify the submental approach for bone grafting of the anterior atrophic mandible, avoiding a donor site surgery. We chose to perform the bone graft as a first stage surgery, in which, via a submental approach allogenic bone blocks were adapted and fixated to the anterior mandible with titanium screws, xenograft and resorbable collagen membranes were used. A few months (>4) were allowed for graft consolidation and then a second stage surgery was performed, via an intraoral approach dental implants were placed. In this way we avoided loss of orientation and had a familiar setting for implant location and angulation. Five patients with atrophic mandibles were treated using this surgical protocol. Based on cone beam CT imaging, average bone height in the anterior mandible prior to treatment was 5.52 mm. After bone graft, the average gain in bone height was 12.74 mm. No major post-operative complications were noted. After bone graft consolidation, 4 or 5 dental implants were placed, most of the implants used were longer than 11.5 mm. 22 implants were placed, out of which 21 integrated (95.5%). Some of the patients were rehabilitated with overdentures and locators and some with PFM bridges. All patients were followed up for more than a year and no implant failure was recorded. Bone grafting to the anterior mandible using allogenic blocks with collagen membranes via a submental approach with second stage implant placement seems to be a viable solution for rehabilitation of the atrophic mandible.

Objective: Warnings of L-carnitine induced seizures are recorded on product monographs and pharmacy databases, without any referenced literature. This medication can potentially improve the hospital course in those patients with valproic acid (VPA) induced hyperammonemic encephalopathy, but may be withheld because of this warning. The goal was to perform an extensive systematic review of the literature to document the incidence of levocarnitine (L-carnitine) induced seizures in those patients on VPA therapy., Methods: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to June 2015), and reference lists of relevant articles were searched. The strength of evidence was to be adjudicated using both the Oxford and GRADE methodology by two independent reviewers., Results: We failed to identify a single study implicating L-carnitine supplementation leading to seizures in any patient on VPA therapy. This contradicts all quoted, but unsubstantiated, concerns on product monographs and pharmacy databases related to seizure induction/propagation with L-carnitine supplementation., Conclusion: There is no literature available to support claims of L-carnitine induced seizures during supplementation in patients on VPA therapy for seizures. This contradicts quoted, but not referenced, concerns on the product monograph. In patients suffering from hypocarnitinemia or hyperammonemic encephalopathy while on VPA, L-carnitine supplementation can be considered knowing there is no data to support seizure propagation or induction with administration of this supplement., (Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)