Prenatal assessment of congenital diaphragmatic hernia at north american fetal therapy network centers: A continued plea for standardization.

INTRODUCTION: Prenatal work-up for congenital diaphragmatic hernia (CDH) is important for risk stratification, standardization, counseling, and optimal therapeutic choice. To determine current practice patterns regarding prenatal CDH work-up, including prenatal ultrasound and magnetic resonance imaging (MRI) use, and to identify areas for standardization of such evaluation between fetal centers. METHODS: A survey regarding prenatal CDH work-up was sent to each member center of the North American Fetal Therapy Network (NAFTNet) (n = 36). RESULTS: All responded. Sonographic measurement of lung-to-head ratio (LHR) was determined by all, 89% (32/36) of which routinely calculate observed-to-expected LHR. The method for measuring LHR varied: 58% (21/36) used a "trace" method, 25% (9/36) used "longest axis," and 17% (6/36) used an "antero-posterior" method. Fetal MRI was routinely used in 78% (28/36) of centers, but there was significant variability in fetal lung volume measurement. Whereas all generated a total fetal lung volume, the planes, methodology and references values varied significantly. All evaluated liver position, 71% (20/28) evaluated stomach position and 54% (15/28) quantified the degree of liver herniation. More consistency in workup was seen between centers offering fetal intervention. CONCLUSION: Prenatal CDH work-up and management differs considerably among North American fetal diagnostic centers, highlighting a need for its standardization.

Qualitative Assessment of Barriers and Ideal Wellness Programming Among Rural Firefighters.

OBJECTIVE: The purpose of this study was to determine and assess the perceived physical and psychosocial barriers to, and the constitution of, ideal health and wellness programming among rural firefighters. METHODS: Open-ended, semi-structured interviews were conducted and recorded on 40 rural, structural firefighters. Responses to each question were qualitatively analyzed to determine themes. RESULTS: Several themes emerged in regards to the physical and psychosocial stressors of the profession. Three themes emerged relating to the self-perceived barriers to overall health and wellness. There was also agreement in the components of an "ideal" workplace health and wellness program to help overcome perceived barriers. CONCLUSIONS: The themes that emerged from the interviews with this population are similar to firefighters who work in a more urban area. This indicates that the stressors and barriers firefighters face may be occupation, and not location, driven.

Development of a High-Fidelity Simulator for Teaching Chorionic Villus Sampling.

OBJECTIVE: The objective of this study was to develop a synthetic high-fidelity simulator for teaching chorionic villus sampling. METHODS: Working with a medical sculptor, the authors developed a simulator, constructed from various synthetic rubber materials, of a gravid female pelvis, including the vulva, vagina, cervix, and a 13-week-sized uterus with a gestational sac. RESULTS: This simulator is high fidelity and durable, and it does not require any organic materials. Maternal-fetal medicine trainees valued this educational tool. CONCLUSION: This novel, high-fidelity simulator is an additional tool for educators involved in teaching chorionic villus sampling.

Airway compromise in the fetus and neonate: Prenatal assessment and perinatal management.

The fetus with a potentially obstructed airway can be identified on routine antenatal imaging. These cases should be referred to fetal care centers, which have the necessary expertise to fully evaluate and manage these fetuses and neonates appropriately. Complete airway obstruction may result in fetal hydrops and intrauterine demise. If a newborn infant has a compromised airway at delivery, the inability to secure its airway quickly may result in a hypoxic cerebral insult or death. In the most severely affected cases, prenatal, perinatal, or postnatal surgical intervention may be necessary. The timing of such an intervention will depend on the exact cause of the airway obstruction, other associated findings and the anticipated difficulty in establishing an airway at delivery. Fetal ultrasound and magnetic resonance imaging can differentiate between intrinsic and extrinsic airway obstruction, which allows for the optimal planning and management of the delivery and neonatal resuscitation.

Anonymous peer assessment of medication management reviews.

OBJECTIVES: To investigate whether pharmacy students' anonymous peer assessment of a medication management review (MMR) was constructive, consistent with the feedback provided by an expert tutor, and enhanced the students' learning experience. DESIGN: Fourth-year undergraduate pharmacy students were randomly and anonymously assigned to a partner and participated in an online peer assessment of their partner's MMR. ASSESSMENT: An independent expert graded a randomly selected sample of the MMR's using a schedule developed for the study. A second expert evaluated the quality of the peer and expert feedback. Students also completed a questionnaire and participated in a focus group interview. Student peers gave significantly higher marks than an expert for the same MMR; however, no significant difference between the quality of written feedback between the students and expert was detected. The majority of students agreed that this activity was a useful learning experience. CONCLUSIONS: Anonymous peer assessment is an effective means of providing additional constructive feedback on student performance on the medication review process. Exposure to other students' work and the giving and receiving of peer feedback were perceived as valuable by students.

Best practices assessment to guide curricular change in a bachelor of pharmacy program.

OBJECTIVES: To identify best practices in global pharmacy education and curriculum design as the basis for decisions about major curriculum change in an existing 4-year bachelor of pharmacy curriculum. DESIGN: We investigated international best-practice standards, conducted semi-structured interviews with faculty members, and used standardized instruments to investigate student perceptions of the existing curriculum and how they approached their learning. ASSESSMENT: Faculty recommendations included horizontal and vertical integration of curriculum content to replace the previous discipline-based approach; and a theme-based structure underpinned by a detailed statement of learning outcomes that describe the knowledge, skills, and attitudinal milestones to be achieved each year and by the time of graduation. The triangulation of student survey data highlighted issues that needed to be addressed at the individual course unit level, with a particular focus on feedback, assessment, and workload. CONCLUSIONS: The results of the curriculum review provided clear guidance for decisions relating to major curriculum change. An ongoing program of staff development will address the wide range of learning and teaching issues identified by both staff members and students. The results of our investigation of students' approaches to learning will also be used to guide staff development workshops, focusing on strategies to promote "meaningful learning."

MRI of the fetal eyes: morphologic and biometric assessment for abnormal development with ultrasonographic and clinicopathologic correlation.

BACKGROUND: Currently ocular biometric measurements are defined by US and are measured from the orbital walls. These bony landmarks cannot be seen by MRI, and therefore these measurements cannot be directly applied. OBJECTIVE: To define measurements of normal growth of the fetal eyes using MRI. MATERIALS AND METHODS: Transorbital views were analyzed in 198 fetal MR examinations. The ocular diameter (OD) and interocular and binocular distances (IOD and BOD) were measured and were plotted against gestational age. Fetuses with abnormalities affecting the eyes were evaluated separately. RESULTS: Of 198 scans, 146 had suitable images, 35 of which were abnormal. Normal growth of BOD, IOD and OD were determined, and compared with the respective already established US data. CONCLUSION: Normal growth charts were derived from a cohort of 111 normal fetuses. Because the margins of the vitreous are inside the bony orbit, at the same gestational age measurements of the BOD and OD are always less than the corresponding measurements by US, and those of the IOD are always more. Normal growth charts for MRI can now be used to support suspected diagnoses of orbital and ocular pathologies and the syndromes that give rise to them, and many examples are demonstrated.

The fetal cerebellar vermis: assessment for abnormal development by ultrasonography and magnetic resonance imaging.

Fetal magnetic resonance provides a new tool in the imaging of the posterior fossa and is proving useful in cases that are difficult to assess sonographically by allowing further assessment of the fourth ventricle, cisterna magna, and vermian growth and development. We describe various criteria with which to evaluate vermian growth, including vermian biometry and the relationship between the superior and inferior lobes. We demonstrate 2 markers of normal vermian development: the primary fissure and fastigial point. We illustrate the tegmento-vermian angle, "closure" of the fourth ventricle, and communication of the fourth ventricle with the basal cisterns during development and in several disorders. We correlate those features with the expected embryological course of development and illustrate identification of these features and associated abnormalities of the posterior fossa, brain stem, and central nervous system in mid-trimester scans of fetuses with abnormal development. Correlation with contemporaneous ultrasound examinations is demonstrated.

Flow cytometric assessment of feto-maternal hemorrhage; a comparison with Betke-Kleihauer.

OBJECTIVES: Assessing the number of fetal cells in the maternal circulation quantifies the volume of feto-maternal hemorrhage, enhancing the ability to provide effective prevention of Rhesus (Rh) allommunization and appropriate fetal surveillance in cases of significant feto-maternal hemorrhage. METHODS: Having developed a standard curve with maternal samples spiked with known volumes of fetal red blood cells, we used a flow cytometric method using fluorescent labeled antihemoglobin F to quantitate fetal cells in the maternal circulatory system in two groups of women undergoing chorionic villus sampling (CVS), by either biopsy forceps or cannula aspiration (n = 170 women). We compared these results with the gold standard, the Betke-Kleihauer test. RESULTS: Our results show good correlation between the flow cytometric method and the traditional Betke-Kleihauer method for fetal red cell quantitation (r(2) = 0.99). Fetal red blood cells were identified in 10 women by the Betke-Kleihauer method, and in 26 women by flow cytometry. CVS was not associated with an increase in feto-maternal hemorrhage. CONCLUSION: Flow cytometry was both more sensitive and more timely for the quantitation of feto-maternal hemorrhage than was Betke-Kleihauer.

The association of socioeconomic status and psychosocial and physical workplace factors with musculoskeletal injury in hospital workers.

BACKGROUND: The combined effect of socioeconomic, organizational, psychosocial, and physical factors on work-related musculoskeletal disorders (WRMSDs) were studied in a heterogeneous, socioeconomically diverse sample (cases and their matched referents) of hospital workers. METHODS: Cases were defined by a new acute or cumulative work-related musculoskeletal injury; referents were matched by job group, shift length, or at random. Information was obtained through telephone interviews and on-site ergonomics observation. Questionnaire items included sociodemographic variables, lost work time, work effectiveness, health status, pain/disability, and psychosocial working conditions using Effort Reward Imbalance (ERI) and Demand-Control (DC) models. Two multivariate models were tested: Model 1 included occupation as a predictor; Model 2 included education-income as a predictor. RESULTS: Cases reported greater pain, disability, lost time, and decreased work effectiveness than the referents. Model 1 was statistically significant for neck/upper extremity injury (Chi-square = 19.3, P = 0.01), back/lower extremity injury (Chi-square = 14.0, P = 0.05), and all injuries combined (Chi-square = 25.4, P = 0.001). "Other Clinical" occupations (34% mental health workers) had the highest risk of injury (OR 4.5: 95%CI, 1.7-12.1) for all injuries. The ERI ratio was a significant predictor for neck and upper extremity (OR 1.5: 95%CI, 1.1-1.9) and all injuries (OR 1.3; 95%CI, 1.04-1.5), per SD change in score. CONCLUSIONS: In this study, the risk of WRMSDs was more strongly influenced by specific psychosocial and physical job-related exposures than by broad socioeconomic factors such as education and income.

Measuring the physical demands of work in hospital settings: design and implementation of an ergonomics assessment.

BACKGROUND: Assessing the physical demands of the heterogeneous jobs in hospitals requires appropriate and validated assessment methodologies. METHODS: As part of an integrated assessment, we adapted Rapid Entire Body Assessment (REBA), using it in a work sampling mode facilitated by a hand-held personal digital assistant, expanding it with selected items from the UC Computer Use Checklist, and developed a scoring algorithm for ergonomics risk factors for the upper (UB) and lower body (LB). RESULTS: The inter-rater reliability kappa was 0.54 for UB and 0.66 for LB. The scoring algorithm demonstrated significant variation (ANOVA p<0.05) by occupation in anticipated directions (administrators ranked lowest; support staff ranked highest on both scores). A supplemental self-assessment measure of spinal loading correlated with high strain LB scores (r=0.30; p<0.001). CONCLUSION: We developed and validated a scoring algorithm incorporating a revised REBA schema adding computer use items, appropriate for ergonomics assessment across a range of hospital jobs.