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Social and political changes have introduced new sources of stressors for children. Two studies of 7- to 12-year-old children (n = 194; n = 402) identified stressors from their perspective, compared them to items in existing instruments, analyzed changes in stressors over the past 30 years, and determined the need for a new instrument. The children named 908 stressors that were inductively sorted into 54 mutually exclusive categories of stressors. Only 24% to 50% of the categories were represented in existing instruments. Stressors that emerged in 2000 included being alone, tests, family fighting, too many things to do, and boyfriend/girlfriend issues. These findings provide insight into differences between adults' versus children's perspectives on stressors and invite speculation on the reasons why new stressors emerge over the years. The findings also support the need for a new instrument that captures the full range of stressors that children experience today. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine quality improvement outcomes following the pilot implementation of an in-situ simulation designed to enhance surgical safety checklist performance., Background: OR Black Box (ORBB) technology allows near real-time assessment for surgical safety checklist performance. Before our study, timeout quality was 73.3%, compliance was 99.9%, and engagement was 89.7% (n=1993 cases); Debrief Quality was 76.0%, compliance was 66.9%, and engagement was 66.7% (n=1842 cases)., Methods: This IRB-approved study used prospective convergent multi-methods. During 2 months, a 15-minute in-situ simulation, incorporating rapid cycle deliberate practice, was implemented for OR teams. ORBB analytics generated Timeout and Debrief scores for actual operations performed by surgeons who participated in simulation (Sim-group) versus those who did not (No-sim group) over 6 months, including 2 months pre-intervention, during-intervention, and post-intervention. Inductive content analysis was performed based on simulation discussions to determine team member perspectives., Results: Thirty simulations with 163 interprofessional participants were conducted. ORBB data from 1570 cases were analyzed. Scores were significantly better for the Sim-group compared with the No-sim group for debrief quality (84% vs. 79% P<0.001, during-intervention), compliance (73% vs. 66%, P<0.001, post-intervention), and engagement (80% vs. 73%, P=0.012, during-intervention). There were no between-group differences for Timeout scores. Thematic analysis identified 2 primary categories: "culture of safety" and "policy.", Conclusions: This simulation-based QI intervention created a psychologically safe training environment for OR teams. The novel use of ORBB technology facilitated outcome analysis and showed significantly better Debrief scores for simulation-trained surgeons compared with nontrained surgeons., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Simulation-based education (SBE) provides experiential learning, improvement in quality of care, and reduction in errors. In 2011, the Association of American Medical Colleges described adoption of SBE in 68.0% of medical schools and 25.0% of teaching hospitals. We sought to examine current trends of SBE integration in American undergraduate medical education since previous publications., Methods: From 2016 to 2019, University of Texas Southwestern Medical Center postgraduate year 1 residents were invited to participate in a survey assessing medical school simulation experience with 26 clinical tasks from three categories: procedural, communication, and other. Deidentified results were analyzed to assess demographics including sex, specialty, residency program type, allopathic versus osteopathic medical school, and medical school region., Results: Nine hundred sixty-seven of 1047 (92.3%) responses were obtained, representing 139 US medical schools, 91% from allopathic training. Of procedural tasks, most simulated was suturing (n = 848, 89.6%) and least simulated was thoracentesis (n = 737, 80.9%). Of communication tasks, most simulated was taking a history (n = 475, 51.1% reporting simulation >30) and least simulated (never or ≤1) were obtaining a consent (n = 669, 73.2%) and disclosing a medical error (n = 666, 72.4%). Of other tasks, most simulated was chest compressions (n = 898, 96.0%) and least simulated was operating a defibrillator (n = 206, 22.1%). Results were similar regardless of procedural or nonprocedural program. There was no significant difference in SBE exposure between allopathic and osteopathic students ( P = 0.89). Two participants (0.002%) reported no simulation exposure., Conclusions: Our study is the first to describe a high prevalence of SBE adoption in medical schools nationwide since the Association of American Medical Colleges' 2011 publication, with overall equal exposure for students regardless of residency type and allopathic or osteopathic medical school. Despite widespread adoption of simulation, opportunities remain to expand SBE use to teach critically important communication skills., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Society for Simulation in Healthcare.)

In this pre- and postintervention study, we demonstrate the feasibility and effectiveness of comprehensive simulation-based personal protective equipment (PPE) training amid the COVID-19 pandemic. With rapid-cycle, deliberate practice feedback, simulation-based training can improve the learners' sense of confidence and security while standardizing PPE protocols., (© The Author(s) 2022.)

Objectives: To perform a review of the literature on the role of simulation-based training (SBT) in healthcare-associated infection (HAI) prevention and to highlight the importance of SBT as an educational tool in infection prevention., Methods: We reviewed English language publications from PubMed to select original articles that utilized SBT as the primary mode of education for infection prevention efforts in acute-care hospitals., Results: Overall, 27 publications utilized SBT as primary mode of education for HAI prevention in acute-care hospitals. Training included the following: hand hygiene in 3 studies (11%), standard precaution in 1 study (4%), disaster preparedness in 4 studies (15%), central-line-associated blood stream infection (CLABSI) prevention in 14 studies (52%), catheter-associated urinary tract infection (CAUTI) prevention in 2 studies (7%), surgical site infection prevention in 2 studies (7%), and ventilatory associated pneumonia prevention in 1 study (4%). SBT improved learner's sense of competence and confidence, increased knowledge and compliance in infection prevention measures, decreased HAI rates, and reduced healthcare costs., Conclusion: SBT can function as a teaching tool in day-to-day infection prevention efforts as well as in disaster preparedness. SBT is underutilized in infection prevention but can serve as a crucial educational tool., (© The Author(s) 2022.)

Purpose: Due to the pandemic, we restructured our medical student knot-tying simulation to a virtual format. This study evaluated curriculum feasibility and effectiveness., Methods: Over 4 weeks, second-year medical students ( n  = 229) viewed a video tutorial (task demonstration, errors, scoring) and self-practiced to proficiency (no critical errors, < 2 min) using at-home suture kits (simple interrupted suture, instrument tie, penrose drain model). Optional virtual tutoring sessions were offered. Students submitted video performance for proficiency verification. Two sets of 14 videos were viewed by two surgeons until inter-rater reliability (IRR) was established. Students scoring "needs remediation" attended virtual remediation sessions. Non-parametric statistics were performed using RStudio., Results: All 229 medical students completed the curriculum within 1-4 h; 1.3% attended an optional tutorial. All videos were assessed: 4.8% "exceeds expectations", 60.7% "meets expectations", and 34.5% "needs remediation." All 79 needing remediation due to critical errors achieved proficiency during 1-h group sessions. IRR Cohen's κ was 0.69 (initial) and 1.0 (ultimate). Task completion time was 56 (47-68) s (median [IQR]); p  < 0.01 between all pairs. Students rated the overall curriculum (79.2%) and overall curriculum and video tutorial effectiveness (92.7%) as "agree" or "strongly agree". No definitive preference emerged regarding virtual versus in-person formats; however, 80.2% affirmed wanting other at-home skills curricula. Comments supported home practice as lower stress; remediation students valued direct formative feedback., Conclusions: A completely virtual 1-month knot-tying simulation is feasible and effective in achieving proficiency using video-based assessment and as-needed remediation strategies for a large student class., Competing Interests: Conflict of interestThe authors have no relevant financial or non-financial interests to disclose., (© The Author(s), under exclusive licence to Association for Surgical Education 2022.)

The lichenoid tissue reaction pattern generally signifies cytotoxic damage to the epithelium. When such reaction pattern occurs on vulvar skin or mucosa, the effects can result in considerable morbidity. None of the entities discussed in this review are entirely unique to the vulva, however, some entities may classically occur at this site, while others tend to be widespread diseases that may incidentally affect vulvar skin and mucosa. Given the complex anatomy of the vulva and the bridging of a site showing both keratinizing squamous epithelium and non-keratinizing squamous mucosa, histopathologic features may display variation in presentation. Although identification of a "lichenoid reaction pattern" alone may provide insight into the disease process, understanding of clinical presentation and specific sites of involvement, along with recognition of the nuanced features of the disease entities can help establish a specific diagnosis. Accurate histopathologic diagnoses by pathologists can improve the ability for treating clinicians to implement timely and effective treatment., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Autoantibodies to interferon γ, part of the first line of defense in the human immune response, constitutes a rare form of an acquired immunodeficiency in HIV-uninfected adults that can predispose to disseminated atypical mycobacterial infection. Particularly, this has been described in people of Southeast Asian origin. In this case report, we describe a previously healthy, Laotian man who presented with skin lesions consistent with Sweet syndrome that were later found to be precipitated by disseminated atypical mycobacterial disease. Extensive immunological workup revealed the patient to have autoantibodies to interferon γ, rendering him susceptible to this infection. Our report demonstrates a complex case with a multilayered diagnosis, while inviting perspective from multiple specialties. This enigmatic case emphasizes the importance of a broad differential with special attention to demographics while demonstrating the difficulty in treating certain atypical infections that are inherently multidrug resistant.

Background: Metastatic melanoma in sentinel lymph nodes is often elusive to detect with morphology alone. Per American Joint Committee on Cancer staging guidelines, a single atypical melanocyte in lymph node qualifies as metastasis, whether identified by morphology or immunohistochemistry, but single cell staining must be convincing. We propose that the use of a second immunohistochemical run performed on a single slide will allow for more confident diagnosis of micrometastases., Materials and Methods: We designed a technical study to determine whether a second antibody application on previously stained slides can successfully detect the same population of cells. Melanocytic neoplasms were stained with SOX-10 using Ventana Benchmark Ultra stainers, coverslipped, and examined, followed by coverslip removal and application of MART-1 (Ventana A103). The order of antibody application and chromagen detection kit (AP-RED vs. DAB) was reversed to establish reliability and robustness of the protocol., Results: All melanocytes marked with SOX-10 and MART-1, and produced a range of staining quality that varied based on order of stain application and chromagen kit were used. The optimal combination was red MART-1 applied first followed by brown SOX-10 applied second., Conclusions: Consecutive staining of melanocytes with SOX-10 and MART-1 may improve diagnostic confidence of melanocyte identification, particularly in detection of single cell, micrometastases in sentinel lymph nodes or in situations where dual immunohistochemical stains may be unavailable.

The Philippine Islands are one of the most biologically diverse archipelagoes in the world. Current taxonomy, however, may underestimate levels of avian diversity and endemism in these islands. Although species limits can be difficult to determine among allopatric populations, quantitative methods for comparing phenotypic and genotypic data can provide useful metrics of divergence among populations and identify those that merit consideration for elevation to full species status. Using a conceptual approach that integrates genetic and phenotypic data, we compared populations among 48 species, estimating genetic divergence (p-distance) using the mtDNA marker ND2 and comparing plumage and morphometrics of museum study skins. Using conservative speciation thresholds, pairwise comparisons of genetic and phenotypic divergence suggested possible species-level divergences in more than half of the species studied (25 out of 48). In speciation process space, divergence routes were heterogeneous among taxa. Nearly all populations that surpassed high genotypic divergence thresholds were Passeriformes, and non-Passeriformes populations surpassed high phenotypic divergence thresholds more commonly than expected by chance. Overall, there was an apparent logarithmic increase in phenotypic divergence with respect to genetic divergence, suggesting the possibility that divergence among these lineages may initially be driven by divergent selection in this allopatric system. Also, genetic endemism was high among sampled islands. Higher taxonomy affected divergence in genotype and phenotype. Although broader lineage, genetic, phenotypic, and numeric sampling is needed to further explore heterogeneity among divergence processes and to accurately assess species-level diversity in these taxa, our results support the need for substantial taxonomic revisions among Philippine birds. The conservation implications are profound.

Objective: Excess cortisol production (Cushing syndrome, CS) is a chronic disease affecting many organ systems and impacting quality of life (QoL). This study analyzed factors associated with self-reported QoL, including aspects related to the diagnosis and treatment modalities of CS., Methods: In collaboration with the Cushing's Support and Research Foundation (CSRF), surveys using a validated QoL instrument were sent to CSRF members. Data were analyzed for associations between QoL and demographic, treatment, and disease factors., Results: A total of 269 patients completed the survey. Respondents were 89.9% female, and the mean age was 48 years (SD 12, range 16-76). Respondents visited a median of 4 physicians (range 1-40) prior to the diagnosis of CS, with a median of 5 years (mean 7, SD 5, range 1-30) to obtain a diagnosis, showing a statistically significant negative correlation (P<.001). In one-quarter of cases, someone other than a physician suggested the diagnosis. Multiple regression analysis demonstrated that remission status, time to diagnosis, radiation therapy, and hypopituitarism were significant predictors of QoL. There was no association between QoL and patient's sex, age, replacement steroid use, having follow-up with an endocrinologist, or surgical approach., Conclusion: This is one of the largest QoL studies of CS patients and provides information for treatment and education goals. It is notable that early diagnosis and treatment was the major predictor of better QoL after achieving remission from disease, highlighting the need for awareness about the disorder. Patients in remission had better QoL, emphasizing the importance of disease control.

Background: The long-term consequences of stress on the surgeon are unknown. One manifestation of stress is burnout. The purpose of this study was to measure the prevalence of burnout in actively practicing American surgeons., Methods: The Maslach Burnout Inventory and a questionnaire of our own design were sent to 1706 graduates of various University of Michigan surgical residencies (1222) and members of the Midwest Surgical Association (484). The response rate was 44%. Responses from 582 actively practicing surgeons were the sample used for analysis., Results: Thirty-two percent of actively practicing surgeons showed "high" levels of emotional exhaustion, 13% showed "high" levels of depersonalization, and 4% showed evidence for low personal accomplishment. Younger surgeons were more susceptible to burnout (r = -0.28, P <.01). Burnout was not related to caseload, practice setting, or percent of patients insured by a health maintenance organization. Important etiologic factors were a sense that work was "overwhelming" (r = 0.61, P <.01), a perceived imbalance between career, family, and personal growth (r = -0.56), P <.01), perceptions that career was unrewarding (r = -0.42, P <.01), and lack of autonomy or decision involvement (r = -0.39, P <.01). A strong association was noted between burnout elements and a desire to retire early (r = 0.50, P <.01)., Conclusions: Burnout is an important problem for actively practicing American surgeons. These data could be used to modify existing surgical training curricula or as an aid to surgical leadership when negotiating about the surgical work environment.

This study compared the orbicularis oculi muscle to the adductor pollicis muscle during vecuronium blockade. The orbicularis oculi muscle was found to be more resistant to and recovered from vecuronium neuromuscular blockade faster than the adductor pollicis muscle. Thus, caution should be utilized when assessing neuromuscular block with the orbicularis oculi muscle.