Measuring Physical Function in the PICU: Development and Testing of a Children's Version (Age 2-18 yr) of the Chelsea Critical Care Physical Assessment Tool.

OBJECTIVES: To adapt and develop a reliable and easily administered outcome measure of physical and respiratory function in critically ill children in the PICU. DESIGN: Modified Delphi study to adapt the Chelsea Critical Care Physical Assessment (CPAx) tool for use in children 2-18 years old, with subsequent prospective testing in a single-center cohort. SETTING: Single-center tertiary PICU. SUBJECTS: Delphi process in 27 panelists (including physiotherapists, occupational therapists, and pediatric intensivists from seven countries from January 2018 to March 2018). Cohort study in 54 patients admitted to PICU for greater than 24 hours over a 3-month period (April 2018 to June 2018), with median age 5.5 years (interquartile range [IQR], 3-12.75 yr), 33 of 54 male, and 38 of 54 invasively ventilated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three Delphi iterations were required to reach greater than or equal to 80% consensus in all the children's CPAx (cCPAx) items. In the subsequent cohort study, six physiotherapists used the cCPAx tool and scored 54 participants, with a total 106 observations. The median cCPAx tool score was 14.50 (IQR, 3-25) out of a possible total of 50. Inter-rater reliability for 30 randomly selected participants was excellent (intraclass correlation coefficient, 0.998). Completion rate of cCPAx in the 54 patients occurred in 78 of 106 occasions (74%). CONCLUSIONS: The cCPAx tool content that was developed using Delphi methodology provided a feasible and clinically relevant tool for use in assessing physical morbidity in PICU patients 2-18 years old. Overall, the cCPAx scores were low, demonstrating low levels of physical function and high levels of immobility during PICU care.

Who performs neonatal hip assessment: is there a cause for concern?

OBJECTIVE: The UK falls behind other European countries in the early detection of developmental dysplasia of the hip (DDH) and screening strategies differ for early detection. Clinical detection of DDH is challenging and recognised to be dependent on examiner experience. No studies exist assessing the number of personnel currently involved in such assessments.Our objective was to review the current screening procedure by studying a cohort of newborn babies in one teaching hospital and assess the number of health professionals involved in neonatal hip assessment and the number of examinations undertaken during one period by each individual. METHODS: This was a retrospective observational study assessing all babies born consecutively over a 14-week period in 2020. Record of each initial baby check was obtained from BadgerNet. Follow-up data on ultrasound or orthopaedic outpatient referrals were obtained from clinical records. RESULTS: 1037 babies were examined by 65 individual examiners representing 9 different healthcare professional groups. The range of examinations conducted per examiner was 1-97 with a median of 5.5 examinations per person. 49% of individuals examined 5 or less babies across the 14 weeks, with 18% only performing 1 examination. Of the six babies (0.48%) treated for DDH, one was picked up on neonatal assessment. CONCLUSION: In a system where so many examiners are involved in neonatal hip assessment, the experience is limited for most examiners. Currently high rates of late presentation of DDH are observed locally, which are in accordance with published national experience. The potential association merits further investigation.

Assessment and management of vestibular migraine within ENT.

OBJECTIVE: Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic. METHOD: Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine. RESULTS: A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging. CONCLUSION: This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.

American Indian/Alaska Native men are less likely to receive prostate-specific antigen testing and digital rectal exams from primary care providers than White men: a secondary analysis of the National Ambulatory Medical Care Survey from 2012-2018.

PURPOSE: (1) Identify the proportion of primary care visits in which American Indian/Alaska Native (AI/AN) men receive a prostate-specific antigen test (PSAT)and/or a digital rectal exam (DRE), (2) describe characteristics of primary care visits in which AI/AN receive PSA and/or DRE, and (3) identify whether AI/AN receive PSA and/or DRE less often than non-Hispanic White (nHW) men. METHODS: This was a secondary analysis of the National Ambulatory Medical Care Survey (NAMCS) during 2013-2016 and 2018 and the NAMCS Community Health Center (CHC) datasets from 2012-2015. Weighted bivariate and multivariable tests analyzed the data to account for the complex survey design. RESULTS: For AI/AN men, 1.67 per 100 visits (95% CI = 0-4.24) included a PSATs (or PSAT) and 0 visits included a DRE between 2013-2016 and 2018. The rate of PSA for non-AI/AN men was 9.35 per 100 visits (95% CI = 7.78-10.91) and 2.52 per 100 visits (95% CI = 1.61-3.42) for DRE. AI/AN men were significantly less likely to receive a PSA than nHW men (aOR = 0.09, 95% CI = 0.01-0.83). In CHCs, AI/AN men experienced 4.26 PSAT per 100 visits (95% CI = 0.96-7.57) compared to 5.00 PSAT per 100 visits (95% CI = 4.40-5.68) for non-AI/AN men. DRE rates for AI/AN men was 0.63 per 100 visits (95% CI = 0-1.61) compared to 1.05 per 100 (95% CI = 0.74-1.37) for non-AI/AN men. There was not a statistically significant disparity in the CHC data regarding PSA (OR = 0.91, 95% CI = 0.42-1.98) or DRE (OR = 0.75, 95% CI = 0.15-3.74), compared to nHW men. CONCLUSION: Efforts are needed to better understand why providers may not use PSA and DRE with AI/AN men compared to nHW men.

Collaboration readiness: Developing standards for interprofessional formative assessment.

BACKGROUND: Graduate nursing education strives to promote collaborative practice on interprofessional teams. However, measuring collaboration during formative stages of professional development is rare. Few assessments are available to determine whether graduates of nursing education programs have met the required accreditation benchmarks. This project evaluates two performance standards for assessing collaboration during formative assessments. METHOD: Formative assessment of communication and collaboration skills was explored for 62 entry-level Master's students in nursing, using a team-based objective structured clinical examination (OSCE) involving two patient simulations and assessment checklists, and comparing normative (relative standard) and criterion-referenced (absolute standard) methods. RESULTS: Mean percentages of behaviors using the normative approach indicated a range of performance levels for particular communication and collaboration behaviors. Criterion-referenced standards were higher than normative standards from actual student performance. CONCLUSION: This method improves assessment of collaboration through OSCEs using normative and criterion-referenced standards. We recommend using both methods jointly when setting standards or qualifying scores.

[Contribution and limits of "OSCE", "long-case" and "global end-of-placement marking" as end-of-rotation assessment methods. Experience from two internal medicine wards]. / Apport et limites des « ECOS ¼, « examen clinique au lit du malade ¼ et « appréciation globale de stage ¼ comme modalité d'évaluation de fin de stage. Expérience de deux services de médecine interne.

INTRODUCTION: During placements, there is an opportunity to learn clinical skills and to assess their application. However, it represents two different goals. The validity of an end-of-placement assessment is questionable, as the medical competency is contextual. We decided to evaluate the contribution and limits of different assessment modalities as an end-of-placement assessment. MATERIAL AND METHODS: Internal medicine clerks were assessed using the Mini-Cex grid by a structured objective clinical examination (OSCE), a long-case clinical examination (LCE) and a global end-of-placement marking (GEPM). Following these evaluations, students and teachers fulfilled an open questionnaire. RESULTS: In 2021, 41 students and 16 teachers participated in the study. Physical examination was evaluated in 0%, 97% et 76% of cases during OSCE, LCE and GEPM, respectively; teaching skills were assessed for 100, 42 et 49% of students in OSCE, LCE and GEPM, respectively. As compared to OSCE, there was a perceived superiority of LCE regarding its formative value (P=0.07 and P=0.03) and its summative value (P=0.0007 and P=0.02), for students and teachers, respectively. Qualitative analysis highlights the breadth of clinical skills that could be assessed during OSCE stations. Integration into a team was an additional skill that could specifically be assessed during GEPM. GEPM could also take into account the progress made during placement. CONCLUSION: Despite its subjectivity, LCE seemed to be the preferred modality for an end-of-rotation assessment.

Evaluation of the consistency of neonatal skin injury assessment using clinical images and the metric and graduated colour tool.

AIM: To evaluate consistency in the assessment of neonatal skin injuries. MATERIALS AND METHODS: Injury images collected during a multicentre period prevalence study (n = 297) were screened for optimal quality before 60 images, stratified for size and colour, were randomly selected for assessment by three neonatal and two adult specialists. The principal investigator's assessments were the baseline for comparison and consistency. Injury characteristics and assessments were reported as descriptive statistics. Comparison of injury assessments for colour and stage were calculated using Chi-square, with p-value of <0.05 considered significant. RESULTS: Neonatal specialists assessed injury elements more confidently than adult specialists reporting 59-60 (98-100%) injuries visible compared to 51-53 (85-93%) respectively. Neonatal specialists attributed mechanical force to 93% of the skin injuries compared to 70% by adult specialists. Consistency of colour assessment was achieved more often with neonatal specialists (n = 50, 85%), compared to adult specialists (n = 41, 73%). Neonatal specialists' consistency for injury staging (n = 107, 60%) was higher compared to adult specialists who were uncertain (n = 8,16%) and less consistent (n = 47, 44%). When comparing specialists as a group, consistency with baseline assessment was significantly different between neonatal and adult specialists for colour (p < 0.010) and injury stage (p < 0.009). CONCLUSION: Field of expertise (neonatal versus adult) differences were noted likely related to experience and understanding of empirical differences between neonatal and adult skin structure and maturity. These results highlight the need for specialist neonatal skin injury and wound training for clinicians involved in assessment, treatment and best practices for neonates.

Assessment of screening programs as a strategy for early detection of oral cancer: a systematic review.

The present study is a systematic review of the evaluation of screening programs as a strategy for early detection of oral cancer. The aim of this study was to assess whether screening through visual inspection is able to identify injuries in early stages, to increase survival, and to decrease the incidence and mortality of oral cancer. Studies using visual inspection to screen for oral cancer and potentially malignant lesions in apparently healthy individuals over 18 years without previous diagnosis of the disease were included. The MEDLINE/PubMed, Cochrane databases Library, EMBASE, and LILACS, including manual search and gray literature, were searched through January 2021 with no language or date restrictions. The risk of bias and the methodological quality were evaluated according to the appropriate tool for each study design. The analysis of the results was narrative. Seventeen studies were reviewed that included cohort, accuracy, and randomized clinical trial studies. The tracking type performed was opportunistic and organized in a variety of environments. The age of participants ranged between 18 and 60 years old and, in some programs, only people with risk habits for oral cancer were included. The screeners were healthcare professionals, physicians, and dentists. Two studies reported data on the incidence rate of severe cases and mortality and showed a reduction when patients were at risk for the disease and participated in the program more than once. A limitation of this review was the great variability observed in the estimates of the screening effectiveness among the studies, which made comparisons difficult. If a screening program is continuous and able to ensure the inclusion of high-risk individuals, it can contribute to improvement in survival rates with a change of stage and can have a significant impact on incidence and mortality due to the disease. Registration in the Open Science Framebook (OSF) with the osf.io/zg8nr link.

Objective structured clinical examinations (OSCEs) for students' training and assessment in the French respiratory medicine departments in 2021: An overview.

BACKGROUND: Medical professional performances can be assessed by objective structured clinical examinations (OSCEs) where medical trainees go through a series of simulated clinical situations. OSCEs are now the gold standard for the assessment of medical students' competence during their training. In France, the first national OSCEs will take place in May 2024 and respiratory teachers will be involved in this reform and will use OSCEs for students' training and assessment in respiratory medicine. Students training regarding this final OSCE may vary across medical faculties and may impact students' results. Therefore, we aimed to provide a national overview of OSCE's training performed by respiratory teachers and their interest in developing a common French databank of OSCEs. METHODS: We conducted a national anonymous online survey among the members of the French college of respiratory teachers (CEP), from 2021 February the 15th to 2021 June the 15th. The survey consisted of 32 questions. RESULTS: Among 118 French pulmonologists teachers, 52 (45%) responded to the survey. We received a response from at least one of each of the French Medical Universities. Twenty-two (42%) had received specific training on how to conduct an OSCE. Twenty-eight (54%) of respondents used OSCEs for training purposes and 24 (46%) for assessment purposes, for less than 1 year in more than half of the participants. The average satisfaction scores out of 10 about OSCEs was 7.3 ± 1.7 for training and 7.4 ± 1.5 for students' assessment. Respondents were willing (8.9 ± 1.8 out of ten) to develop a common databank to share OSCEs subjects in respiratory medicine in France. CONCLUSIONS: This survey confirms heterogeneity in the training and the use of OSCEs among French respiratory teachers. However, a common national databank could be a useful tool to reduce these disparities.

The reliability of clinical assessment of distal radioulnar joint instability.

Accurate assessment of distal radioulnar joint (DRUJ) stability is increasingly recognized as an important part of clinical examination of the wrist. The ability of 30 specialist UK hand surgeons to clinically determine the stability of four volunteers' wrists was assessed. Volunteers' wrist stability had previously been confirmed with a validated measurement rig. Use of the wrist ballottement test as the primary examination technique yielded a positive predictive value of 81%, a negative predictive value of 55%, a specificity of 94% and a sensitivity of only 24%, for the detection of DRUJ instability. No correlation between background speciality (orthopaedic versus plastic surgery), nor years of clinical experience was found. Clinical assessment of DRUJ instability among experienced clinicians appears unreliable and instability is typically under recognized. Previous research to date using this clinical assessment method as a parameter of success is therefore brought into question.Level of evidence: IV.

An Ultrasound Screening Exam During Medicare Wellness Visits May Be Beneficial.

OBJECTIVES: The physical exam component of a periodic health visit in the elderly has not been considered useful. Standard Medicare Wellness visits require no physical exam beyond blood pressure and most physicians perform limited exams during these visits. The objective of this study was to test the feasibility, potential benefit, and costs of performing a screening ultrasound (US) exam during Medicare Wellness visits. METHODS: A physician examiner at an academic internal medicine primary care clinic performed a screening US exam targeting important abnormalities of patients 65-85 years old during a Medicare Wellness visit. The primary care physician (PCP) recorded the follow-up items for each abnormality identified by the US examiner and assessed the benefit of each abnormality for the participant. Abnormality benefit, net exam benefit per participant, follow-up items and costs, participant survey results, and exam duration were assessed. RESULTS: Participants numbered 108. Total abnormalities numbered 283 and new diagnoses were 172. Positive benefit scores were assigned to 38.8%, neutral (zero) scores to 59.4%, and negative benefit scores to 1.8% of abnormalities. Net benefit scores per participant were positive in 63.9%, 0 in 34.3%, and negative in 1.8%. Follow-up items were infrequent resulting in 76% of participants without follow-up cost. Participant survey showed excellent acceptance of the exam. CONCLUSIONS: The US screening exam identified frequent abnormalities in Medicare Wellness patients. The assessed benefits were rarely negative and often mild to moderately positive, with important new chronic conditions identified. Follow-up costs were low when the PCPs were also US experts.

Predictors of Operative Intervention in Patients With Lactic Acidosis.

BACKGROUND: Lactate levels in clinical practice are often used as a quantitative indicator for the severity of hypoperfusion and the responsiveness to therapeutic interventions. In the hospital acute care setting, lactic acidosis combined with the appropriate clinical exam signs warrants surgical evaluation. The purpose of our study was to evaluate all surgical consults for lactic acidosis in a single community hospital to identify what cofactors were most often predictive of the need for surgical management and operative intervention. MATERIALS AND METHODS: A retrospective chart review within a 5-year period was conducted on all consultations to general surgery in which patients additionally had lactic acidosis defined as >2mEq. Within this population, various subjective and objective parameters were evaluated. Final analysis compared these parameters between patients with lactic acidosis who underwent surgical intervention and those who did not require operative intervention. RESULTS: Within the 5-year period, 432 patients met our criteria of a surgical consult placed for lactic acidosis. Final results from the highest quality statistical model showed significant variables as diffuse tenderness on physical exam (P-value = .0010, Odds Ratio (OR) = 2.77) and focal tenderness on physical exam (P-value = .0440, OR = 1.76). The presence of peritoneal signs (P-value = .0521, OR = 2.02) resulted in operative intervention twice as often in patients with lactic acidosis. DISCUSSION: To better appropriate health care costs, measures need to be taken to ensure resources are being utilized properly. In patients with lactic acidosis, one should go "back to the basics" with the physical examination to determine which patients truly need a surgical consultation.

Respiratory assessment: undertaking a physical examination of the chest in adults.

Nurses frequently encounter patients in respiratory distress or with respiratory complications, whether from acute disease or a long-term condition. A physical examination of the chest should be conducted as part of a comprehensive respiratory assessment of the patient, and should follow a systematic approach that includes inspection, palpation, percussion and auscultation. Nurses undertaking these hands-on components of respiratory assessments need to have adequate knowledge of the procedures involved, as well as practical skills that need to be practised under supervision. This article outlines how to undertake a physical examination of the chest in adults.

Development and evaluation of the focused assessment of sonographic pathologies in the intensive care unit (FASP-ICU) protocol.

BACKGROUND: The use of ultrasonography in the intensive care unit (ICU) is steadily increasing but is usually restricted to examinations of single organs or organ systems. In this study, we combine the ultrasound approaches the most relevant to ICU to design a whole-body ultrasound (WBU) protocol. Recommendations and training schemes for WBU are sparse and lack conclusive evidence. Our aim was therefore to define the range and prevalence of abnormalities detectable by WBU to develop a simple and fast bedside examination protocol, and to evaluate the value of routine surveillance WBU in ICU patients. METHODS: A protocol for focused assessments of sonographic abnormalities of the ocular, vascular, pulmonary, cardiac and abdominal systems was developed to evaluate 99 predefined sonographic entities on the day of admission and on days 3, 6, 10 and 15 of the ICU admission. The study was a clinical prospective single-center trial in 111 consecutive patients admitted to the surgical ICUs of a tertiary university hospital. RESULTS: A total of 3003 abnormalities demonstrable by sonography were detected in 1275 individual scans of organ systems and 4395 individual single-organ examinations. The rate of previously undetected abnormalities ranged from 6.4 ± 4.2 on the day of admission to 2.9 ± 1.8 on day 15. Based on the sonographic findings, intensive care therapy was altered following 45.1% of examinations. Mean examination time was 18.7 ± 3.2 min, or 1.6 invested minutes per detected abnormality. CONCLUSIONS: Performing the WBU protocol led to therapy changes in 45.1% of the time. Detected sonographic abnormalities showed a high rate of change in the course of the serial assessments, underlining the value of routine ultrasound examinations in the ICU. Trial registration The study was registered in the German Clinical Trials Register (DRKS, 7 April 2017; retrospectively registered) under the identifier DRKS00010428.

Cellulitis: A Review of Pathogenesis, Diagnosis, and Management.

Cellulitis is a common skin infection resulting in increasing hospitalizations and health care costs. There is no gold standard diagnostic test, making cellulitis a potentially challenging condition to distinguish from other mimickers. Physical examination typically demonstrates poorly demarcated unilateral erythema with warmth and tenderness. Thorough history and clinical examination can narrow the differential diagnosis of cellulitis and minimize unnecessary hospitalization. Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit.

Spanish translation and linguistic validation of the North Star Ambulatory Assessment for Duchenne muscular dystrophy functional evaluation. / Traducción al español y validación lingüística de la escala North Star Ambulatory Assessment para la evaluación funcional de la distrofia muscular de Duchenne.

INTRODUCTION: There is a need for reliable and properly validated outcome measures in Duchenne muscular dystrophy, both to monitor functional impairment and to assess the impact of new therapies. OBJECTIVE: We aimed to perform a translation of the North Star Ambulatory Assessment scale into Spanish and a linguistic validation of the resulting Spanish version. MATERIALS AND METHODS: A structured multistage process based on international guidelines was used, with the following steps: translation (preparation, forward translation, reconciliation, back translation, back translation review, clinicians' review), linguistic validation though pilot testing (cognitive interviewing, medical review, review of results and final changes), and finalization (proofreading, final report). RESULTS: No major difficulties were found during translation steps. Few changes were needed to reconcile forward translations. The linguistic validation process required several meetings to solve comprehension difficulties due to subtle nuances in the meaning of some words. The pilot study was carried out in 10 practitioners from different places in Spain, including both physiotherapists and specialists and registrars in physical medicine and rehabilitation. A total of 6 comments were obtained, including 2 comments on starting positions for items 4-5 (stand on one leg) and item 10 (stand on heels) and 2 comments on scoring instructions for item 3 (stand up from chair) and item 14 (jump). CONCLUSION: Our study has resulted in a convenient and reliable instrument for the quantification of functional abilities in boys with Duchenne muscular dystrophy in Spain. Our innovations in methods and our results could be used as a suggested template for the North Star Ambulatory Assessment linguistic validation in other languages.

TITLE: Traducción al español y validación lingüística de la escala North Star Ambulatory Assessment para la evaluación funcional de la distrofia muscular de Duchenne.Introducción. En la distrofia muscular de Duchenne son necesarias medidas de evaluación fiables y validadas para el seguimiento del deterioro funcional y de los efectos de los nuevos tratamientos. Objetivo. Se realizó una traducción, seguida de validación lingüística, de la escala North Star Ambulatory Assessment al español. Materiales y métodos. Se utilizó un proceso estructurado, de múltiples etapas, basado en las guías internacionales, con los siguientes pasos: traducción (preparación, traducción directa, reconciliación, retrotraducción, revisión de la retrotraducción y revisión por médicos clínicos), validación lingüística mediante una prueba piloto (entrevista cognitiva, revisión médica, revisión de resultados y ajustes finales) y finalización (revisión de pruebas e informe final). Resultados. No surgieron dificultades importantes durante los pasos de traducción. La reconciliación de las traducciones directas requirió pocos cambios. En la validación lingüística fueron precisas varias reuniones para resolver dificultades de comprensión, en matices sutiles, en el significado de algunas palabras. El estudio piloto se realizó con 10 especialistas clínicos de diferentes lugares de España (fisioterapeutas y especialistas o residentes de medicina física y rehabilitación). Hubo seis comentarios, dos de ellos sobre las posiciones de partida en los ítems 4-5 (de pie sobre un solo pie) y 13 (de pie sobre los talones), y dos sobre las instrucciones de puntuación para los ítems 3 (levantarse de la silla) y 14 (saltar). Conclusión. Nuestro estudio ha proporcionado un instrumento cómodo y fiable para cuantificar las capacidades funcionales en niños con distrofia muscular de Duchenne en España. Las innovaciones en el método y nuestros resultados podrían usarse como modelo para la validación lingüística en otros idiomas.

Sleep Assessment for Sleep Problems in Children.

The breadth of childhood sleep problems is broad and can be associated with biologic, psychiatric, behavioral, social, and environmental processes. Unrecognized childhood sleep problems may threaten daytime behaviors and negatively impact school and psychosocial functioning. Left unattended, overall child biopsychosocial development may be impaired. Thus, identifying and addressing sleep problems has potential to optimize childhood health, development, and overall well-being. Nurses need to be cognizant of detrimental impacts of child sleep deprivation and advocate for appropriate sleep assessments while offering sleep education to parents and children.

Virtually prepared! Student-led online clinical assessment.

The transition of medical education from a face-to-face to virtual setting due to the ongoing COVID-19 restrictions has been challenging. While both students and educators have now somewhat settled into new teaching methods, from Zoom™ lectures to online tutorials, the adaption of clinical skills teaching to the virtual setting has lagged behind. As a result, many students have been left feeling anxious and concerned about practicing practical and communication skills that are central to being a competent and safe doctor. In light of this, medical students at the Queen's University Belfast General Practice (GP) Society organised a series of virtual, mock Objective Structured Clinical Examinations (OSCEs) for students in Years 2-5 conducted via Zoom™. Medical students and doctors acted as examiners and simulated patients (SPs) with 'breakout rooms' being used to simulate distinct OSCE stations. This collaborative project was well received by participants and doctors alike, who found the virtual OSCEs improved their confidence in performing key clinical skills and virtual consultations. As medical students ourselves, we gained early career exposure to designing and delivering assessments and developed transferable skills, relevant both to medicine and teaching. Lastly, the peer-led approach disrupted the traditional hierarchy in medical education. Students are a key, and often overlooked, resource to overcoming challenges in medical education and educators should encourage students to become involved in medical education at an early stage in their careers.

Using Biometric Technology for Telehealth and Telerehabilitation.

This article discusses the use of physical and biometric sensors in telerehabilitation. It also discusses synchronous tele-physical assessment using haptics and augmented reality and asynchronous physical assessment using remote pose estimation. The article additionally focuses on computational models that have the potential to monitor and evaluate changes in kinematic and kinetic properties during telerehabilitation using biometric sensors such as electromyography and other wearable and noncontact sensors based on force and speed. And finally, the article discusses how virtual reality environments can be facilitated in telerehabilitation.