Gender Differences in Clinical Performance Assessment of Internal Medicine Residents: A Longitudinal Analysis of the Influence of Faculty and Trainee Gender.

PURPOSE: Competency-based medical education relies on equitable assessment. This study examined the influence of faculty and trainee gender on assessments of internal medicine (IM) resident performance over time. METHOD: A longitudinal analysis of clinical performance assessments from 7 U.S. IM residency programs (July 2014-June 2019) was conducted. Core competency scores (patient care [PC], medical knowledge [MK], practice-based learning and improvement [PBLI], systems-based practice [SBP], professionalism [PROF], and interpersonal and communication skills [ICS]) were standardized across programs. Cross-classified mixed-effects linear regression evaluated the relationship between gender and standardized competency scores within training programs, while adjusting for multiple variables including IM In Training Examination percentile rank. RESULTS: Data included 9,346 evaluations by 1,011 faculty (552 [55%] men, 459 [45%] women) for 664 residents (358 [54%] men, 306 [46%] women). Initially, women residents' scores were significantly lower than men's in PC (estimated difference [standard error ] -0.097 [0.033], P = .004), MK (-0.145 [0.034], P < .001), and PBLI -0.090 [0.040], P = .022). PC, MK, PBLI, and SBP scores increased more over time for women residents than men (PC: 0.050 [0.015], P = .001; MK: 0.052 [0.015], P = .001; PBLI: 0.036 [0.018], P = .048; SBP: 0.036 [0.016], P = .027). PROF and ICS scores were comparable across gender. There was a significant interaction between faculty gender and postgraduate year (PGY) across all competencies but none between resident gender, faculty gender, and PGY, indicating that men and women faculty rated residents differently over time but were consistent in how they rated men and women residents. CONCLUSIONS: Gender-based assessment differences were variable across competencies and time. Women residents had lower scores initially but greater gains in "hard skill" (MK, PC, and PBLI) than in "soft skill" (ICS and PROF) competencies, suggesting assessment inequities. Efforts to ensure equitable assessment are needed.

Impact of planting density and shoot thinning on alstroemeria flowering, soil attributes and cost economics.

A field experiment was conducted to assess the impact of various planting densities and levels of shoot thinning on cut flower yield, quality, soil chemical properties and cost economics in the commercially cultivated alstroemeria cultivar 'Capri'. The experiment involved three planting densities (4, 6 and 8 plants/m2) along with three shoot thinning levels (10 %, 20 % and 30 %). It was observed that higher planting density (4 plants/m2) promoted the length of cut stem, early bud formation, and flowering, optimal quality parameters, including maximum stem thickness, cut stem weight, floret quantity/stem, floret size, number of flowering stems/plant (yield) and vase life. Exclusive use of higher vegetative mass removal (30 % shoot thinning) was found to improve quality parameters such as the length of cut stem, number of flowering stems, stem thickness, weight of cut stem, floret quantity/stem, floret size, vase life, and early flowering. Soil samples were collected from each treatment and the consequent lab analysis revealed that the lower planting density and shoot thinning level resulted in maximum soil organic carbon, nitrogen, phosphorous and potassium content. In conclusion, planting density of 4 plants/m2 and 30 % shoot thinning emerged as the optimal combination for enhancing quantitative parameters in commercial alstroemeria cultivation. The study underscores the importance of strategic planting practices and vegetative mass management for maximizing yield and quality in alstroemeria production, along with ensuring higher economic returns.

Influence of planting dates and fertilizer modules on yield of chrysanthemum and soil health.

BACKGROUND: Optimum planting date and appropriate fertilizer module are essential facets of chrysanthemum cultivation, to enhance quality yield, and improve soil health. A field-based study was undertaken over multiple growing seasons in 2022 and 2023, where six different planting dates, viz., P1:June 15, P2:June 30, P3:July 15, P4:July 30, P5:August 15 and P6:August 30 and two fertilizer modules, FM1:Jeevamrit @ 30 ml plant-1 and FM2:NPK @ 30 g m-2 were systematically examined using a Randomized Block Design (factorial), replicated thrice. RESULTS: P6 planting resulted in early bud formation (44.03 days) and harvesting stage (90.78 days). Maximum plant height (79.44 cm), plant spread (34.04 cm), cut stem length (68.40 cm), flower diameter (7.83 cm), stem strength (19.38˚), vase life (14.90 days), flowering duration (24.08 days), available soil N (314 kg ha-1), available P (37 kg ha-1), available K (347 kg ha-1), bacterial count (124.87 × 107 cfu g-1 soil), actinomycetes count (60.72 × 102 cfu g-1 soil), fungal count (30.95 × 102 cfu g-1 soil), microbial biomass (48.79 µg g-1 soil), dehydrogenase enzyme (3.64 mg TPF h-1 g-1 soil) and phosphatase enzyme (23.79 mol PNP h-1 g-1 soil) was recorded in P1 planting. Among the fertilization module, minimum days to bud formation (74.94 days) and days to reach the harvesting stage (120.95 days) were recorded with the application of NPK @30 g m-2. However, maximum plant height (60.62 cm), plant spread (23.10 cm), number of cut stems m-2 (43.88), cut stem length (51.34 cm), flower diameter (6.92 cm), stem strength (21.24˚), flowering duration (21.75 days), available soil N (317 kg ha-1), available P (37 kg ha-1) and available K (349 kg ha-1) were also recorded with the application of NPK @300 kg ha-1. Maximum vase life (13.87 days), OC (1.13%), bacterial count (131.65 × 107 cfu g-1 soil), actinomycetes count (60.89 × 102 cfu g-1 soil), fungal count (31.11 × 102 cfu g-1 soil), microbial biomass (51.27 µg g-1 soil), dehydrogenase enzyme (3.77 mg TPF h-1 g-1 soil) and phosphatase enzyme (21.72 mol PNP h-1 g-1 soil) were observed with the application of Jeevamrit @ 30 ml plant-1. CONCLUSION: Early planting (P1) and inorganic fertilization (NPK @ 30 g m-2) resulted in improved yield and soil macronutrient content. The soil microbial population and enzymatic activity were improved with the jeevamrit application. This approach highlights the potential for improved yield and soil health in chrysanthemum cultivation, promoting a more eco-friendly and economically viable agricultural model.

Did the students' satisfaction rates at Avalon University School of Medicine correlate with the occurrence of accreditation site visits?

INTRODUCTION: Accreditation of medical education programs can be observed from different perspectives. Regulatory/accreditation agencies consider it vital to assure a certain level of quality. Other stakeholders may perceive the accreditation process as a negative experience, draining resources, and efforts. Although accreditation may improve the program's governance and administration, its direct or indirect impact on students must be further investigated. This study explores the relationship between the occurrence of accreditation site visits and student satisfaction rates at Avalon University School of Medicine. METHODS: A comparison study was conducted with retrospective satisfaction data from two accreditation cycles at AUSOM. We used the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) student surveys for data collection, and data from 2017, 2019, and 2022 were used. The response rate was 70% (n = 71), 72% (n = 47), and 60% (n = 56) for basic science students and 80% (n = 111), 82% (n = 115), and 70% (n = 76) for clinical students in 2017, 2019, and 2022, respectively. The survey for basic sciences students included 37 questions/items, and the survey for clinical students included 39 questions/items. The responses for the questionnaire were on the five-point Likert scale. The retrospective data were evaluated using the unpaired Wilcoxon-rank sum test. RESULTS: The ratings for the basic science students' survey increased from 2017 to 2019 (first accreditation cycle) only for 11 items/questions and they were increased from 2019 to 2022 for all items/questions. The ratings for clinical science students' surveys increased from 2017 to 2019 (the first accreditation cycle) for all items/questions with a statistically significant p-value. They increased for 28 questions/items from 2019 to 2022, and two items (availability and adequacy of career counseling) showed statistically significant p-values. CONCLUSIONS: The pre-accreditation preparation and the self-evaluation process while correcting the program's deficiencies are essential triggers for the quality improvement process associated with accreditation.

What are the barriers to health professionals' training on gender-affirming care from patients' and clinicians' perspectives?

OBJECTIVE: The aim of the study is to identify the barriers to gender-affirming health care education for providers from the perspectives of patients and providers. METHODS: A qualitative study based on grounded theory was conducted. Participants included transgender and gender diverse (TGD) patients seeking care, as well as resident physicians and attending physicians involved in care of patients seeking gender-affirming care. Semi-structured interviews were conducted over Zoom application and telephone calls. The study was conducted in Boston, Massachusetts, USA from November 2022 until February 2023. RESULTS: Nine attending physicians, eight resident physicians, and fifteen patients were interviewed. Attending physicians noted barriers to include lack of formal training in medical school and residency, lack of adequate opportunities for faculty development to appropriately train resident physicians, lack of opportunities for trainees to provide dedicated clinical care, lack of community engagement initiatives, and need for additional training centered on cultural sensitivity and inclusivity. Resident physicians noted a lack of robust and longitudinal didactic curriculum, deficiency in dedicated clinical time, and inadequacy in interprofessional training as major barriers to their training. They noted that they generally felt unprepared to care for TGD patients. Patients' barriers included difficulty building trust in medical providers' knowledge and skills, being addressed with incorrect names and pronouns, lacking a sense of belonging as a patient, as well as difficulty in arranging care due to lack of a centralized care system. CONCLUSION: Barriers to gender-affirming education include lack of adequate and formal training, lack of professional development opportunities, inadequacy in a multidisciplinary approach to treatment and education, and inadequacy in cultural and sensitivity training. Findings of this qualitative study based on interviews may help facilitate addressing such barriers through creation of routine lecture-based didactic opportunities for providers, investment in faculty development, creation of gender-affirming clinics, providing opportunities for trainees to provide longitudinal care to TGD patients, creation of interdisciplinary training modules, community engagement, and implementation of a multidisciplinary care model, which may help improve gender-affirming care in the long-run.

Insights into flowering mechanisms in apple (Malus × domestica Borkh.) amidst climate change: An exploration of genetic and epigenetic factors.

Apple (Malus × domestica Borkh.) holds a prominent position among global temperate fruit crops, with flowering playing a crucial role in both production and breeding. This review delves into the intricate mechanisms governing apple flowering amidst the backdrop of climate change, acknowledging the profound influence of external and internal factors on biennial bearing, flower bud quality, and ultimately, fruit quality. Notably, the challenge faced in major apple production regions is not an inadequacy of flowers but an excess, leading to compromised fruit quality necessitating thinning practices. Climate change exacerbates these challenges, rendering apple trees more susceptible to crop failure due to unusual weather events, such as reduced winter snowfall, early spring cold weather, and hailstorms during flowering and fruit setting. Altered climatic conditions, exemplified by increased spring warming coupled with sub-freezing temperatures, negatively impact developing flower buds and decrease overall crop production. Furthermore, changing winter conditions affect chilling accumulation, disrupting flower development and synchronicity. Although the physiological perception of apple flowering has been reviewed in the past, the genetic, epigenetic, and multi-omics regulatory mechanisms governing floral induction and flowering are still rarely discussed in the case of apple flowering. This article comprehensively reviews the latest literature encompassing all aspects of apple flowering, aiming to broaden our understanding and address flowering challenges while also laying a solid foundation for future research in developing cultivars that are ideally adapted to climate change.

Analysis of narrative assessments of internal medicine resident performance: are there differences associated with gender or race and ethnicity?

BACKGROUND: Equitable assessment is critical in competency-based medical education. This study explores differences in key characteristics of qualitative assessments (i.e., narrative comments or assessment feedback) of internal medicine postgraduate resident performance associated with gender and race and ethnicity. METHODS: Analysis of narrative comments included in faculty assessments of resident performance from six internal medicine residency programs was conducted. Content analysis was used to assess two key characteristics of comments- valence (overall positive or negative orientation) and specificity (detailed nature and actionability of comment) - via a blinded, multi-analyst approach. Differences in comment valence and specificity with gender and race and ethnicity were assessed using multilevel regression, controlling for multiple covariates including quantitative competency ratings. RESULTS: Data included 3,383 evaluations with narrative comments by 597 faculty of 698 residents, including 45% of comments about women residents and 13.2% about residents who identified with race and ethnicities underrepresented in medicine. Most comments were moderately specific and positive. Comments about women residents were more positive (estimate 0.06, p 0.045) but less specific (estimate - 0.07, p 0.002) compared to men. Women residents were more likely to receive non-specific, weakly specific or no comments (adjusted OR 1.29, p 0.012) and less likely to receive highly specific comments (adjusted OR 0.71, p 0.003) or comments with specific examples of things done well or areas for growth (adjusted OR 0.74, p 0.003) than men. Gendered differences in comment specificity and valence were most notable early in training. Comment specificity and valence did not differ with resident race and ethnicity (specificity: estimate 0.03, p 0.32; valence: estimate - 0.05, p 0.26) or faculty gender (specificity: estimate 0.06, p 0.15; valence: estimate 0.02 p 0.54). CONCLUSION: There were significant differences in the specificity and valence of qualitative assessments associated with resident gender with women receiving more praising but less specific and actionable comments. This suggests a lost opportunity for well-rounded assessment feedback to the disadvantage of women.

Exploring gender and thematic differences in qualitative assessments of internal medicine resident performance.

INTRODUCTION: Evidence suggests gender disparities in medical education assessment, including differences in ratings of competency and narrative comments provided in resident performance assessments. This study explores how gender manifests within the content of qualitative assessments (i.e., narrative comments or performance feedback) of resident performance. METHODS: Qualitative content analysis was used to explore gender-based differences in narrative comments included in faculty assessments of resident performance during inpatient medicine rotations at six Internal Medicine residency programs, 2016-2017. A blinded, multi-analyst approach was employed to identify themes across comments. Patterns in themes with resident gender and post-graduate year (PGY) were explored, focusing on PGY2 and PGY3 when residents are serving in the team leader role. RESULTS: Data included 3,383 evaluations with narrative comments of 385 men (55.2%) and 313 women residents (44.8%). There were thematic differences in narrative comments received by men and women residents and how these themes manifested within comments changed with training time. Compared to men, comments about women had a persistent relationship-orientation and emphasized confidence over training including as interns and in PGY2 and PGY3, when serving as team leader. The relationship-orientation was characterized not only by the residents' communal attributes but also their interpersonal and communication skills, including efforts supporting others and establishing the tone for the team. Comments about women residents often highlighted confidence, including recommendations around behaviors that convey confidence in decision-making and team leadership. DISCUSSION: There were gender-based thematic differences in qualitative assessments. Comments about women resident team leaders highlight relationship building skills and urge confidence and actions that convey confidence as team leader. Persistent attention to communal skills suggests gendered expectations for women resident team leaders and a lost opportunity for well-rounded feedback to the disadvantage of women residents. These findings may inform interventions to promote equitable assessment, such as providing feedback across the competencies.

Calculator for predicting the probability of faculty promotion in an academic medical centre.

OBJECTIVE: The academic medical centre (AMC), with over 2200 faculty members, annually manages approximately 300 appointments and promotions. Considering these large numbers, we explored whether machine learning could predict the probability of obtaining promotional approvals. METHODS: We examined variables related to academic promotion using predictive analytical methods. The data included candidates' publications, the H-index, educational contributions and leadership or service within and outside the AMC. RESULTS: Of the five methods employed, the random forest algorithm was identified as the 'best' model through our leave-one-out cross-validation model evaluation process. CONCLUSIONS: To the best of our knowledge, this is the first study on the AMC. The developed model can be deployed as a 'calculator' to evaluate faculty performance and assist applicants in understanding their chances of promotion based on historical data. Furthermore, it can act as a guide for tenure and promotion committees in candidate review processes. This increases the transparency of the promotion process and aligns faculty aspirations with the AMC's mission and vision. It is possible for other researchers to adopt the algorithms from our analysis and apply them to their data.

Evaluation of the promotion criteria in an academic medical centre in Singapore.

INTRODUCTION: Academic medical centres (AMCs) have the tripartite mission of performing research to advance healthcare delivery, educating future clinicians and providing healthcare services. This study investigates the criteria associated with being promoted in a Singaporean AMC. METHODS: Using a dataset of 255 candidates for promotion at the studied AMC, we employ logistic regression to determine if these factors are associated with the likelihood of promotion. Further, we use interaction effects to test if the relationship between the H-index and likelihood of promotion differs across the academic levels of the candidates. RESULTS: The logistic regression results based on the best of our three tested models suggest that the H-index is positively associated with promotion for those applying to become clinical associate professors (OR=1.43, p=0.01). Moreover, candidates who provide well-developed education portfolios (OR=3.61, p=0.02) and who have held service/leadership roles (OR=6.72, p<0.001) are more likely to be promoted. CONCLUSIONS: This study affirms the correlation between promotion and the advancement criteria outlined by the AMC. This is important for transparency and trust between the AMC and its faculty in their applications for promotion and success in an academic career. Further, our study is one of the few empirical studies linking promotion criteria to promotion outcomes.

The Application of Adaptive Minimum Match k-Nearest Neighbors to Identify At-Risk Students in Health Professions Education.

INTRODUCTION: When learners fail to reach milestones, educators often wonder if any warning signs could have allowed them to intervene sooner. Machine learning can predict which students are at risk for failing a high-stakes certification examination. If predictions can be made well before the examination, educators can meaningfully intervene before students take the examination to reduce their chances of failing. METHODS: The authors used already-collected, first-year student assessment data from 5 cohorts in a single Master of Physician Assistant Studies program to implement an "adaptive minimum match" version of the k-nearest neighbors algorithm using changing numbers of neighbors to predict each student's future examination scores on the Physician Assistant National Certifying Exam (PANCE). Validation occurred in 2 ways by using leave-one-out cross-validation (LOOCV) and by evaluating predictions in a new cohort. RESULTS: "Adaptive minimum match" version of the k-nearest neighbors algorithm achieved an accuracy of 93% in LOOCV. "Adaptive minimum match" version of the k-nearest neighbors algorithm generates a predicted PANCE score for each student one year before they take the examination. Students are classified into extra support, optional extra support, or no extra support categories. Then, one year remains to provide appropriate support to each category of student. DISCUSSION: Predictive analytics can identify at-risk students who might need additional support or remediation before high-stakes certification examinations. Educators can use the included methods and code to generate predicted test outcomes for students. The authors recommend that educators use predictive modeling responsibly and transparently, as one of many tools used to support students. More research is needed to test alternative machine learning methods across a variety of educational programs.

In Situ Simulation as a Tool to Longitudinally Identify and Track Latent Safety Threats in a Structured Quality Improvement Initiative for SARS-CoV-2 Airway Management: A Single-Center Study.

BACKGROUND: In situ simulation has emerged as a powerful tool for identifying latent safety threats (LSTs). After the first wave of the SARS-CoV-2 pandemic, an urban community emergency department (ED) identified opportunities for improvement surrounding acute airway management and particularly focused on infection control precautions, equipment availability, and interprofessional communication during acute resuscitation. Using the Model for Improvement, a hybrid in situ/quality improvement initiative was implemented using Plan-Do-Study-Act (PDSA) cycles to enhance systems for intubating patients with SARS-CoV-2. METHODS: Three PDSA cycles consisting of 10 simulations each were conducted from June 2020 through February 2021. Latent safety threats (LST) were identified through an in situ simulation scenario involving a patient with SARS-CoV-2 in acute respiratory failure. LSTs were collected through structured debriefs focused on (1) infection control, (2) equipment availability, and (3) communication. The SAFER-Matrix was used to score LSTs according to frequency and likelihood of harm by members of the ED QI team (SAFER score). The research team worked with the same QI leaders to implement action plans based on scored threats using cause-and-effect and driver diagrams. The Donabedian model was used to conceptually evaluate the quality of interventions upon conclusion of the third PDSA cycle. RESULTS: The median SAFER score decreased from 10.94 in PDSA cycle 1 to 6.77 in PDSA cycle 2 to 4.71 in PDSA cycle 3. Across all identified LSTs, the SAFER score decreased by 3.114 for every additional PDSA cycle ( P = 0.0167). When evaluating for threats identified as being primarily structure based, there was a decrease in SAFER score of 1.28 per every additional PDSA cycle ( P = 0.001). There was a decrease in total count of LST of 0.20 per additional simulation run ( P = 0.02) after controlling for shift type, census, perceived workload, team size, and prior attendance in simulations across all PDSA cycles. CONCLUSIONS: This study presents a blueprint for the utilization of in situ simulation through multiple waves of the SARS-CoV-2 pandemic to identify LSTs and use the SAFER score as a surrogate marker to monitor the impact of interventions for a safer environment for both medical staff and patients.

Circulatory Cytokine Levels as a Predictor of Disease Severity in COVID-19: A Study from Western India.

Inflammatory response in COVID-19 responsible for acute respiratory distress syndrome (ARDS) and multiorgan failure and play a major role in morbidity and mortality of patients. The present study was undertaken to assess serum level of cytokines and its association with other inflammatory markers and disease severity in COVID-19 and hence their prognostic significance. METHODS: This was a retrospective observational study of 175 admitted COVID-19 patients. The patient's clinical data, laboratory investigations, inflammatory markers and serum level of cytokines [interleukin-1ß (IL-1ß), interleukin-6 (IL-6), interleukin-10 (IL-10) and tumour necrosis factor α (TNFα)] were extracted from their medical records. All patients were divided into three groups viz. group A had asymptomatic patients, group B had mild to moderate ill patients and group C had severe or critical ill patients. Above parameters were analysed and comparative evaluation with severity of disease was done. RESULTS: & In present study 55% patients were asymptomatic, 24% patients were mild to moderate illness and remaining 21% patients had severe or critical illness. Fever, cough, dyspnoea and co-morbidities including hypertension and diabetes were more common in group C. Absolute lymphocyte count (ALC), lymphocyte monocyte ratio (LMR) showed decreasing trend whereas absolute neutrophil count (ANC), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and eosinophil-lymphocyte (ELR) showed increasing trend with increase in disease severity. Serum IL-6 was found to be significantly higher in group C (64.98±111.18pg/mL) as compared to group B (15.51±20.66pg/mL) and group A (5.04±56.1pg/mL) (P<0.001). Receiver operating characteristic (ROC) curve for IL-6 to differentiate the patients with severe disease from asymptomatic and mild symptomatic disease showed a cut-off of 6.75pg/ml. CONCLUSION: Elevated IL-6 levels lead to adverse clinical events so IL-6 level might serve as a potential prognostic marker for severity of disease in COVID-19. Inhibition of IL-6 might be helpful to prevent serious adverse events in COVID-19 infection.

Pituitary hypoplasia is the best MRI predictor of the severity and type of growth hormone deficiency in children with congenital growth hormone deficiency.

OBJECTIVES: Congenital idiopathic growth hormone deficiency (GHD) is associated with various MRI abnormalities, including sellar and extrasellar abnormalities. However, it remains contentious whether MRI brain findings could provide an additional avenue for precisely predicting the differentiation of GHD based on severity and type {isolated GHD or multiple pituitary hormone deficiencies (MPHD)}. This study aimed to ascertain the abnormality that is the best predictor of severity and type of GHD amongst the different MRI findings. METHODS: We conducted an analytical cross-sectional study, including 100 subjects diagnosed with idiopathic GHD. Patients were grouped into severe GHD, partial GHD, and MPHD and into groups based on the presence of pituitary hypoplasia, extrasellar brain abnormalities (EBA), and presence of ectopic posterior pituitary or pituitary stalk abnormalities (EPP/PSA) or both. RESULTS: Sixty six percentage of subjects had isolated GHD, 34% had MPHD, 71% had severe GHD, and 29% had partial GHD. Pituitary hypoplasia was the most common finding, observed in 53% of patients, while 23% had EBA, and 25% had EPP/PSA. Pituitary hypoplasia was observed to be the best predictor of severity of GHD with an odds ratio (OR) of 10.8, followed by EPP/PSA (OR=2.8), and EBA was the weakest predictor (OR=1.8). Pituitary hypoplasia was the only finding to predict MPHD (OR=9.2) significantly. On ROC analysis, a Pituitary height SDS of -2.03 had the best detection threshold for both severe GHD and MPHD. CONCLUSIONS: We observed Pituitary hypoplasia to be not only the most frequent MRI abnormality but also the best predictor of severe GHD and MPHD amongst various sellar and extrasellar abnormalities.

The Addition of High-Technology Into the Stop the Bleed Program Among School Personnel Improves Short-Term Skill Application, Not Long-Term Retention.

INTRODUCTION: The Stop the Bleed (STB) program trains the general public on identifying and treating life-threatening bleeding. Data on efficacy and retention of skills taught through this program are limited, with the role of high-technology modalities to augment the program, such as simulation and feedback devices, untested. METHODS: A convenience sample of 66 school personnel participated in an open-label observational study from January to August 2019. The control group received the standard bleeding control course, while the intervention group received the bleeding control course with addition of a simulation and a feedback device for wound packing. Assessment was performed by STB instructors using performance metrics from prior studies as well as a feedback device. Retention testing was performed 2 to 8 months after intervention. The study was approved by the hospital's institutional review board. RESULTS: The intervention group performed better than the control group on correct tourniquet application [90.3% vs. 71.0%; odds ratio (OR) = 11.28; P = 0.015; 95% confidence interval (CI) = 1.86 to 104.67] wound packing scores (59.5% vs. 29.6%; OR = 0.33; P = 0.007; 95% CI = 9.36 to 56.00) and were more likely to assess their safety (OR = 5.49; P = 0.034; 95% CI = 1.28 to 27.66), and reported higher comfort scores on stepping into an emergency scenario (OR = 11.19; P = 0.004; 95% CI = 2.51 to 63.11), wound packing (OR = 5.16; P = 0.025; 95% CI = 1.35 to 22.46), and using a tourniquet (OR = 11.41; P = 0.003; 95% CI = 2.57 to 67.59). Thirty-one participants (46.9%) were assessed again at retention 2 to 8 months later where scores for tourniquet placement and wound packing were not significantly different in the two groups. CONCLUSIONS: Augmenting STB with simulation and feedback improved both self-reported comfort level and skill set of participants, but the retention of skills was poor in both groups.

High throughput detection and genetic epidemiology of SARS-CoV-2 using COVIDSeq next-generation sequencing.

The rapid emergence of coronavirus disease 2019 (COVID-19) as a global pandemic affecting millions of individuals globally has necessitated sensitive and high-throughput approaches for the diagnosis, surveillance, and determining the genetic epidemiology of SARS-CoV-2. In the present study, we used the COVIDSeq protocol, which involves multiplex-PCR, barcoding, and sequencing of samples for high-throughput detection and deciphering the genetic epidemiology of SARS-CoV-2. We used the approach on 752 clinical samples in duplicates, amounting to a total of 1536 samples which could be sequenced on a single S4 sequencing flow cell on NovaSeq 6000. Our analysis suggests a high concordance between technical duplicates and a high concordance of detection of SARS-CoV-2 between the COVIDSeq as well as RT-PCR approaches. An in-depth analysis revealed a total of six samples in which COVIDSeq detected SARS-CoV-2 in high confidence which were negative in RT-PCR. Additionally, the assay could detect SARS-CoV-2 in 21 samples and 16 samples which were classified inconclusive and pan-sarbeco positive respectively suggesting that COVIDSeq could be used as a confirmatory test. The sequencing approach also enabled insights into the evolution and genetic epidemiology of the SARS-CoV-2 samples. The samples were classified into a total of 3 clades. This study reports two lineages B.1.112 and B.1.99 for the first time in India. This study also revealed 1,143 unique single nucleotide variants and added a total of 73 novel variants identified for the first time. To the best of our knowledge, this is the first report of the COVIDSeq approach for detection and genetic epidemiology of SARS-CoV-2. Our analysis suggests that COVIDSeq could be a potential high sensitivity assay for the detection of SARS-CoV-2, with an additional advantage of enabling the genetic epidemiology of SARS-CoV-2.

A Microdebriefing Crisis Resource Management Program for Simulated Pediatric Resuscitation in a Community Hospital: A Feasibility Study.

INTRODUCTION: Crisis Resource Management (CRM) is a team training tool used in healthcare to enhance team performance and improve patient safety. Our program intends to determine the feasibility of high-fidelity simulation for teaching CRM to an interprofessional team in a community hospital and whether a microdebriefing intervention can improve performance during simulated pediatric resuscitation. METHODS: We conducted a single-center prospective interventional study with 24 teams drawn from 4 departments. The program was divided into an initial assessment simulation case (pre), a 40-minute microdebriefing intervention, and a final assessment simulation case (post). Post and pre results were analyzed for each team using t tests and Wilcoxon signed-rank tests. Primary outcome measures included (a) completion of program, (b) percent enrollment, (c) participant reaction, and (d) support of continued programs on completion. Secondary outcomes included (a) change in teamwork performance, measured by the Clinical Teamwork Scale; (b) change in time to initiation of chest compressions and defibrillation; and (c) pediatric advanced life support adherence, measured by the Clinical Performance Tool. RESULTS: We successfully completed a large-scale training program with high enrollment. Twenty-four teams with 162 participants improved in Clinical Teamwork Scale scores (42.8%-57.5%, P < 0.001), Clinical Performance Tool scores (61.7%-72.1%, P < 0.001), and time to cardiopulmonary resuscitation initiation (70.6-34.3 seconds, P < 0.001). CONCLUSIONS: Our center ran a well-attended, well-received interprofessional program in a community hospital site demonstrating that teaching CRM skills can improve simulated team performance in a diverse experienced cohort.

Bilateral Inferior Petrosal Sinus Sampling in Corticotropin-Dependent Cushing's Syndrome: A Single Center Experience from Western India.

OBJECTIVE: Efficacy of bilateral inferior petrosal sinus sampling (BIPSS) in corticotropin-dependent Cushing's syndrome (CS) for localization and lateralization of excess adrenocorticotropic hormone (ACTH) source, as compared to high-dose dexamethasone suppression test (HDDST) and magnetic resonance imaging (MRI) pituitary, respectively. METHODOLOGY: Thirteen patients with clinically and biochemically confirmed CS underwent HDDST, MRI pituitary, and BIPSS by an experienced team of intervention neurologist, neurosurgeon, and endocrinologist using percutaneous femoral vein approach. RESULTS: Of 13 patients (11 adults and two children) who underwent BIPSS, raised central to peripheral ACTH ratio was achieved in 12 cases, remaining one case being ectopic ACTH secretion (EAS). However, inter IPS gradient >1.4 was achieved in 11 (91.6%) of 12 Cushing's disease (CD) cases before vasopressin stimulation; and in 9 (75%) of 12 CD cases after vasopressin stimulation (P-value 0.583). HDDST suppression of more than 50% was present in only ten cases with CD, falsely negating CD in two cases (16.6%), sensitivity 83.3% and specificity 100%. MRI sella demonstrated pituitary microadenoma in 12 cases and macroadenoma in one case. Lateralization by BIPSS and MRI was concordant in 7 (58.3%) out of 12 cases with CD, with rate of remission after transsphenoidal surgery being higher in patients with concordant lateralization by BIPSS and MRI. CONCLUSIONS: BIPSS is an important investigation to distinguish CD and EAS. BIPSS was superior to HDDST for confirming the source of excess ACTH. Our findings favor the use of BIPSS for localization and pituitary MRI for lateralization of microadenoma.

The Transcriptomic Evidence on the Role of Abdominal Visceral vs. Subcutaneous Adipose Tissue in the Pathophysiology of Diabetes in Asian Indians Indicates the Involvement of Both.

The roles of abdominal visceral (VAT) and subcutaneous adipose tissue (SAT) in the molecular pathogenesis type-2 diabetics (T2D) among Asian Indians showing a "thin fat" phenotype largely remains obscure. In this study, we generated transcription profiles in biopsies of these adipose depots obtained during surgery in 19 diabetics (M: F ratio, 8:11) and 16 (M: F ratio 5:11) age- and BMI-matched non-diabetics. Gene set enrichment analysis (GSEA) was used for comparing transcription profile and showed that 19 gene sets, enriching inflammation and immune system-related pathways, were upregulated in diabetics with F.D.R. <25% and >25%, respectively, in VAT and SAT. Moreover, 13 out of the 19 significantly enriched pathways in VAT were among the top 20 pathways in SAT. On comparison of VAT vs. SAT among diabetics, none of the gene sets were found significant at F.D.R. <25%. The Weighted Gene Correlation Analysis (WGCNA) analysis of the correlation between measures of average gene expression and overall connectivity between VAT and SAT was significantly positive. Several modules of co-expressed genes in both the depots showed a bidirectional correlation with various diabetes-related intermediate phenotypic traits. They enriched several diabetes pathogenicity marker pathways, such as inflammation, adipogenesis, etc. It is concluded that, in Asian Indians, diabetes pathology inflicts similar molecular alternations in VAT and SAT, which are more intense in the former. Both adipose depots possibly play a role in the pathophysiology of T2D, and whether it is protective or pathogenic also depends on the nature of modules of co-expressed genes contained in them.