Simulation in the field of transfusion medicine: Scope and utility.

Simulation in medical education has made significant inroads in most of the specialties in some form or the other. Transfusion medicine, as a branch, being a new specialty, is imbibing a few things from the world of simulation and provides immense scope for its utilization, given its broad applicability as well as necessity. In the current Indian scenario of transfusion medicine, wherein the transfusion process has undergone significant changes involving critical steps, with fewer but can be serious complications arising due to the transfusion process, it is desirable for students and the staff involved to practice on the simulators to attain the desired level of competency as it allows the practice of hands-on invasive procedures before performing the actual process. The principles, pedagogies, and educational strategies with their modalities used in health care simulation like case-based scenarios, physical models, computer systems, standardized patients, mannequins, virtual reality, and integrated simulators are all being used and the scope for improvisation is always in the fore with technical advancements. The transfusion and related activities include significant risks, so regular training is essential. The costs are also reasonably high, and focusing on being time-efficient is essential as many scenarios need immediate attention and management. Simulation in transfusion medicine has farsighted returns wherein there is the possibility of defining goals and objectives and ensuring that they could be adjusted to the individual learners as per their knowledge and skill level. The simulations can be set up that can train as well as assess cognitive, affective, and psychomotor domains simultaneously in transfusion using multiple modalities.

Comparison between MCQ, Extended matching questions (EMQ) and Script concordance test (SCT) for assessment among first-year medical students - A pilot study.

BACKGROUND: Single-best response types of MCQs are commonly used tools in medical assessment. However, these are not particularly apt for the assessment of higher-order thinking skills (HOTS) among students. Assessment of HOTS and clinical reasoning skills requires unexplored tools like extended matching questions (EMQs) and SCTs. The aim is to assess HOTS and clinical reasoning skills during formative assessment among medical students post a simulation-based education (SBE) using EMQ and SCT on the topic of shock and collect student perceptions regarding new assessment tools. METHODS AND MATERIAL: The research is an observational descriptive study. Fifty-two first-year medical students were asked to take a formative assessment consisting of 20 MCQs, 6 EMQs, and 2 SCT post a SBE during July 2022 on the topic of shock. MCQs were categorized into themes of aetiology, pathophysiology, and management of shock. These categorized MCQs were compared and analyzed with EMQs and SCTs prepared on the same themes. The data analysis by a one-way analysis of variance (ANOVA) was conducted to compare the difference in per cent mean scores of MCQ with EMQ and MCQ with SCT. RESULTS: The overall mean scores and also under the theme of aetiology and management, the student's score in MCQ were higher than EMQ and SCT and the difference was statistically significant with the P value (≤0.001). CONCLUSIONS: Students scored better in familiar assessment tools like MCQ, but majority of the students were of the opinion that EMQ tested the delivered content better and SCT tested the clinical application better.

Perioperative crisis resource management simulation training in anaesthesia.

Simulation-based education is now recognised to be a valuable tool to impart both technical and non-technical skills to healthcare professionals of all levels. Simulation is an well accepted educational tool for cultivating teamwork skills among residents globally. Simulation-based education encompasses diverse modalities, ranging from task trainers and simulated patients to sophisticated high-fidelity patient simulators. Notably, anaesthesiologists globally were early advocates of integrating simulation into education, particularly to instruct anaesthesia residents about the intricacies of perioperative crisis resource management and collaborative interdisciplinary teamwork. Given the inherent high-risk nature of anaesthesia, where effective teamwork is pivotal to averting adverse patient outcomes, and also to improve overall outcome of the patient, simulation training becomes imperative. This narrative review delves into the contemporary landscape of simulation training in perioperative anaesthesia management, examining the pedagogical approaches, simulators, techniques and technologies employed to facilitate this training.

Manifesto for healthcare simulation practice.

A pandemic has sent the world into chaos. It has not only upended our lives; hundreds of thousands of lives have already been tragically lost. The global crisis has been disruptive, even a threat, to healthcare simulation, affecting all aspects of operations from education to employment. While simulationists around the world have responded to this crisis, it has also provided a stimulus for the continued evolution of simulation. We have crafted a manifesto for action, incorporating a more comprehensive understanding of healthcare simulation, beyond tool, technique or experience, to understanding it now as a professional practice. Healthcare simulation as a practice forms the foundation for the three tenets comprising the manifesto: safety, advocacy and leadership. Using these three tenets, we can powerfully shape the resilience of healthcare simulation practice for now and for the future. Our call to action for all simulationists is to adopt a commitment to comprehensive safety, to advocate collaboratively and to lead ethically.

Process of medical simulator development: An approach based on personal experience.

With increasing demand for simulators from the healthcare community and increasingly sophisticated technology being used in the manufacture of medical simulators, the manufacture of healthcare simulators has become a multifaceted undertaking. Based on our experience in the field and our diverse backgrounds, we explore the processes and issues related to the development of these simulators and suggest ways for the developing teams to collaborate and coordinate with each other to achieve a successful outcome.

The impact factor of an open access journal does not contribute to an article's citations.

Background Citations of papers are positively influenced by the journal's impact factor (IF). For non-open access (non-OA) journals, this influence may be due to the fact that high-IF journals are more often purchased by libraries, and are therefore more often available to researchers, than low-IF journals. This positive influence has not, however, been shown specifically for papers published in open access (OA) journals, which are universally accessible, and do not need library purchase. It is therefore important to ascertain if the IF influences citations in OA journals too. Methods 203 randomized controlled trials (102 OA and 101 non-OA) published in January 2011 were included in the study. Five-year citations for papers published in OA journals were compared to those for non-OA journals. Source papers were derived from PubMed. Citations were retrieved from Web of Science, Scopus, and Google Scholar databases. The Thompson-Reuter's IF was used. Results OA journals were found to have significantly more citations overall compared to non-OA journals (median 15.5 vs 12, p=0.039). The IF did not correlate with citations for OA journals (Spearman's rho =0.187, p=0.60). The increase in the citations with increasing IF was minimal for OA journals (beta coefficient = 3.346, 95% CI -0.464, 7.156, p=0.084). In contrast, the IF did show moderate correlation with citations for articles published in non-OA journals (Spearman's rho=0.514, p<0.001). The increase in the number of citations was also significant (beta coefficient = 4.347, 95% CI 2.42, 6.274, p<0.001). Conclusion It is better to publish in an OA journal for more citations. It may not be worth paying high publishing fees for higher IF journals, because there is minimal gain in terms of increased number of citations. On the other hand, if one wishes to publish in a non-OA journal, it is better to choose one with a high IF.

Injury to ulnar collateral ligament of thumb.

Injury of the ulnar collateral ligament (UCL) of thumb can be incapacitating if untreated or not treated properly. This injury is notorious for frequently being missed by inexperienced health care personnel in emergency departments. It has frequently been described in skiers, but also occurs in other sports such as rugby, soccer, handball, basketball, volleyball and even after a handshake. The UCL of the thumb acts as a primary restraint to valgus stress and is injured if hyperabduction and hyperextension forces are applied to the first metacarpophalangeal joint. The diagnosis is best established clinically, though MRI is the imaging modality of choice. Many treatment options exist, surgical treatment being offered depending on various factors, including timing of presentation (acute or chronic), grade (severity of injury), displacement (Stener lesion), location of tear (mid-substance or peripheral), associated or concomitant surrounding tissue injury (bone, volar plate, etc.), and patient-related factors (occupational demands, etc.). This review aims to identify the optimal diagnostic techniques and management options for UCL injury available thus far.

Role of simulation in arthroscopy training.

Arthroscopy uses a completely different skill set compared with open orthopedic surgery. Hitherto, arthroscopy had not been given enough emphasis in the core orthopedic curricula. Simulation has been seen as an excellent way to teach the skills required in arthroscopy. The simulators used for arthroscopy training can be broadly classified into physical simulators such as cadavers, animals, models and box trainers, virtual-reality simulators, and hybrid simulators that combine virtual-reality simulation with physical components that allow real tactile feedback. The advantages and disadvantages of each of these types have been described in this article. The factors that determine skill acquisition using these simulators have been highlighted. In conclusion, simulation seems to be a valuable tool for arthroscopy training, although further studies are needed to state whether this translates into better operative skill on real patients.

Causes of stress and their change with repeated sessions as perceived by undergraduate medical students during high-fidelity trauma simulation.

BACKGROUND: It is known that simulation training is associated with stress for the trainees, at all levels of trainee experience. We explored the factors which were perceived by the trainees to cause them the maximum stress related to their simulation experience and their temporal changes over three simulation sessions. METHODS: Ninety-seven final year medical students were administered a Likert-type questionnaire on perceived stressors after trauma simulation training. These stressors were classified as intrapsychic (relating to internal feelings); interpersonal (relating to interaction with others) and interactive (related to interaction with the simulated patient). Non-parametric tests were used for statistical analysis. RESULTS: Death of the simulated patient scored highest of all stressors. When the median scores for intrapsychic, interpersonal or interactive items were plotted session-wise, three distinct types of graphs were obtained. Eight of 13 items had a decrease in perceived stress scores from the first to the second session. Only 'death of the simulated patient' showed a significant increase in the score from the second to the third session. CONCLUSION: Undergraduate medical trainees experienced stress due to various factors during their first simulation session, which reduced with repeated sessions. However, perceived stress related to simulated death of a patient continued to remain high even after two repetitions. We suggest that simulation training programmes for undergraduate medical students should have at least one repeat session to reduce the stress and that facilitators should consider keeping the simulated patient alive throughout the training sessions.

Qualities of an effective teacher: what do medical teachers think?

BACKGROUND: Effective teaching in medicine is essential to produce good quality doctors. A number of studies have attempted to identify the characteristics of an effective teacher. However, most of literature regarding an effective medical teacher includes student ratings or expert opinions. Furthermore, interdisciplinary studies for the same are even fewer. We did a cross-sectional study of the characteristics of effective teachers from their own perspective across medicine and dentistry disciplines. METHODS: A questionnaire comprising of 24 statements relating to perceived qualities of effective teachers was prepared and used. The study population included the faculty of medicine and dentistry at the institution. Respondents were asked to mark their response to each statement based on a 5-point Likert scale ranging from strongly disagree to strongly agree. These statements were grouped these into four main subgroups, viz. Class room behaviour/instructional delivery, interaction with students, personal qualities and professional development, and analysed with respect to discipline, cultural background, gender and teaching experience using SPSS v 13.0. For bivariate analysis, t-test and one way ANOVA were used. Multiple linear regression for multivariate analysis was used to control confounding variables. RESULTS: The top three desirable qualities of an effective teacher in our study were knowledge of subject, enthusiasm and communication skills. Faculty with longer teaching experienced ranked classroom behaviour/instructional delivery higher than their less experienced counterparts. There was no difference of perspectives based on cultural background, gender or discipline (medicine and dentistry). CONCLUSION: This study found that the faculty perspectives were similar, regardless of the discipline, gender and cultural background. Furthermore, on review of literature similar findings are seen in studies done in allied medical and non-medical fields. These findings support common teacher training programs for the teachers of all disciplines, rather than having separate training programs exclusively for medical teachers. Logistically, this would make it much easier to arrange such programs in universities or colleges with different faculties or disciplines.

Charcot neuroarthropathy of the foot and ankle.

Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, especially affecting the foot and ankle and leading to considerable morbidity. It can also affect other joints such as the wrist, knee, spine and shoulder. This disease, described originally in reference to syphilis, is now one of the most common associates of diabetes mellitus. As the number of diabetics increase, the incidence of CN is bound to rise. Faster initial diagnosis and prompt institution of treatment may help to reduce its sequelae. There should be a low threshold for ordering investigations to assist coming to this diagnosis. No single investigation is the gold standard. Recent studies on pathogenesis and development of newer investigation modalities have helped to clarify the mystery of its pathogenesis and of its diagnosis in the acute phase. Various complementary investigations together allow the correct diagnosis to be made. Osteomyelitis continues to be confused with acute CN. Hybrid positron emission tomography has shown some promise in differentiating these conditions. A multispecialty approach involving diabetologists, orthopaedists and podiatrists should be used to tackle this difficult problem. The aim of this article is to describe current knowledge about CN with particular reference to the status of diagnostic indicators and management options.

Medical simulation: Overview, and application to wound modelling and management.

Simulation in medical education is progressing in leaps and bounds. The need for simulation in medical education and training is increasing because of a) overall increase in the number of medical students vis-à-vis the availability of patients; b) increasing awareness among patients of their rights and consequent increase in litigations and c) tremendous improvement in simulation technology which makes simulation more and more realistic. Simulation in wound care can be divided into use of simulation in wound modelling (to test the effect of projectiles on the body) and simulation for training in wound management. Though this science is still in its infancy, more and more researchers are now devising both low-technology and high-technology (virtual reality) simulators in this field. It is believed that simulator training will eventually translate into better wound care in real patients, though this will be the subject of further research.

Cellular events and biomarkers of wound healing.

Researchers have identified several of the cellular events associated with wound healing. Platelets, neutrophils, macrophages, and fibroblasts primarily contribute to the process. They release cytokines including interleukins (ILs) and TNF-α, and growth factors, of which platelet-derived growth factor (PDGF) is perhaps the most important. The cytokines and growth factors manipulate the inflammatory phase of healing. Cytokines are chemotactic for white cells and fibroblasts, while the growth factors initiate fibroblast and keratinocyte proliferation. Inflammation is followed by the proliferation of fibroblasts, which lay down the extracellular matrix. Simultaneously, various white cells and other connective tissue cells release both the matrix metalloproteinases (MMPs) and the tissue inhibitors of these metalloproteinases (TIMPs). MMPs remove damaged structural proteins such as collagen, while the fibroblasts lay down fresh extracellular matrix proteins. Fluid collected from acute, healing wounds contains growth factors, and stimulates fibroblast proliferation, but fluid collected from chronic, nonhealing wounds does not. Fibroblasts from chronic wounds do not respond to chronic wound fluid, probably because the fibroblasts of these wounds have lost the receptors that respond to cytokines and growth factors. Nonhealing wounds contain high levels of IL1, IL6, and MMPs, and an abnormally high MMP/TIMP ratio. Clinical examination of wounds inconsistently predicts which wounds will heal when procedures like secondary closure are planned. Surgeons therefore hope that these chemicals can be used as biomarkers of wounds which have impaired ability to heal. There is also evidence that the application of growth factors like PDGF will help the healing of chronic, nonhealing wounds.

Early elevation of intra-abdominal pressure after laparotomy for secondary peritonitis: a predictor of relaparotomy?

BACKGROUND: Patients with secondary peritonitis often require relaparotomy; however, there is no consensus about the criteria for selecting patients who would benefit from early relaparotomy. Our goal was to evaluate whether elevated intra-abdominal pressure (IAP) during the early postoperative period could predict the need for relaparotomy. METHODS: A total of 102 consecutive adult patients with acute intra-abdominal conditions were admitted for laparotomy. Seventy-eight patients, who were diagnosed with secondary peritonitis at index surgery, underwent serial measurements of IAP. The primary outcomes measured in the study were incidence of postoperative peritonitis and mortality. RESULTS: Thirty-two of 78 patients with secondary peritonitis (41%) developed elevated IAP postoperatively. Sixteen (20.5%) of 78 patients developed postoperative peritonitis. Twelve of these 16 patients (75%) with postoperative peritonitis had significantly elevated IAP (P = 0.002) during the immediate postoperative period. Regression analysis revealed elevated IAP (P = 0.055) to be third most predictive of postoperative peritonitis in patients who underwent laparotomy for secondary peritonitis, after septic shock at admission (P = 0.012) and POSSUM score (P = 0.018). CONCLUSION: Our study shows that development of elevated IAP during the early postoperative period can increase the risk of postoperative peritonitis. IAP measured during the immediate postoperative period can be used as a predictor of early relaparotomy.

Role of gastric bypass in patients with unresectable advanced carcinoma of stomach.

CONTEXT: Role of bypass as a palliative surgery for advanced gastric cancer remains controversial. AIMS: To determine the role of bypass in advanced gastric cancer in comparision to resection as gold standard. DESIGN: Hospital-based retrospective outcome as study. METHODS: Patients were divided into three groups: group I (gastric resection), group II (bypass) and group III (exploratory laparotomy alone). The three groups were analysed for palliation of symptoms, operative morbidity and mortality and survival. STATISTICAL ANALYSIS USED: Chi-square, Fischer, One-way Anova, Unpaired-t, Kaplan-Meier analysis. RESULTS: In-hospital morbidity was 19.38% (19 patients) for the entire study group. Bypass group had a lower morbidity rate as compared to the resection group (p=0.029). In-hospital mortality rate was 6.12% (6 patients) for the entire study group. Mortality rates did not differ between the groups. Patient satisfaction with palliation of symptoms was similar between gastric bypass and resection. Gastric resection group had significantly better survival (p=0.002) compared to the nonresective procedures. However, gastric bypass did not confer any survival benefit over exploratory laparotomy (p=0.501). CONCLUSIONS: Gastric bypass can be done when resection is not possible as it palliates symptoms on par with resection and is associated with low operative morbidity though it does not improve the survival outlook of patients.

Role of gastric bypass in patients with unresectable advanced carcinoma of stomach.

CONTEXT: Role of bypass as a palliative surgery for advanced gastric cancer remains controversial. AIMS: To determine the role of bypass in advanced gastric cancer in comparision to resection as gold standard. DESIGN: Hospital based retrospective outcome study METHODS: Patients were divided into three groups: group I (gastric resection), group II (bypass) and group III (exploratory laparotomy alone). The three groups were analysed for palliation of symptoms, operative morbidity & mortality and survival. STATISTICAL ANALYSIS USED: Chi-square, Fischer, One-way Anova, Unpaired-t, Kaplan-Meier analysis RESULTS: In-hospital morbidity was 19.38% (19 patients) for the entire study group. Bypass group had a lower morbidity rate as compared to the resection group (p=0.029). Inhospital mortality rate was 6.12% (6 patients) for the entire study group. Mortality rates did not differ between the groups. Patient satisfaction with palliation of symptoms was similar between gastric bypass and resection. Gastric resection group had significantly better survival (p=0.002) compared to the non resective procedures. However, gastric bypass did not confer any survival benefit over exploratory laparotomy. (p=0.501)kw]Conclusions Gastric bypass can be done when resection is not possible as it palliates symptoms on par with resection and is associated with low operative morbidity though it does not improve the survival outlook of patients.

Predicting anastomotic disruption after emergent small bowel surgery.

BACKGROUND/AIMS: Small bowel anastomoses performed in the emergent setting have a high risk of leakage. Attention to technical detail is imperative but does not guarantee success in these situations. We sought out factors that could play a role in the process of anastomotic dehiscence under these conditions. METHODS: 70 patients underwent 74 emergency small bowel anastomoses over a 21-month period in our institution during this prospective study. Patients with anastomotic disruption formed the case group and those without, the control group. Several preoperative, intraoperative and postoperative variables identified at the outset of the study were analyzed for possible associations with anastomotic dehiscence. RESULTS: Suture line disruption occurred in 26 of 74 anastomoses (35%). The duration of symptoms before presentation did not differ significantly between groups. Hypoalbuminemia (p = 0.004), hyponatremia at presentation (p = 0.012), and intraoperative hypotension (p = 0.042) were found to be significantly associated with disruption. Neither the nature of the primary pathology in the bowel nor the anastomotic level had a significant bearing on anastomotic leakage. CONCLUSION: Risk factors for leakage of emergent small bowel anastomoses include hypoalbuminemia, hyponatremia at presentation, and intraoperative hypotension. Under these circumstances, the creation of a temporary stoma or exteriorization may be a wiser option than primary anastomosis.