Individuals' perceptions of health and well-being in the context of stereotactic radiosurgery for benign brain tumour: A longitudinal qualitative investigation.

BACKGROUND AND OBJECTIVES: Treatment-related outcomes after Gamma Knife Stereotactic Radiosurgery (GKSRS) for benign brain tumour are well-established; yet patient reported outcomes have been largely overlooked. This study explored individuals' perspectives of their health and well-being prior to and following GKSRS. METHOD: Twenty adults (65% female) aged 24-71 years with benign brain tumour were recruited from a major metropolitan hospital and assessed approximately one week prior to, two weeks after, and at three months following GKSRS. They completed telephone-based interviews focusing on general health, symptoms, and well-being. Interviews were transcribed and analysed using thematic analysis. RESULTS: Three major themes characterized individuals' perceptions of their health and well-being. "Understanding my Illness and Treatment" reflected individuals' efforts to make sense of their illness and symptoms to reduce ambiguity and increase sense of control. "Experiencing Gamma Knife" related to expectations of the procedure, outcomes, daily impacts, and emotional reactions. "Adjusting one's Mindset and Coping" characterised how peoples' approaches to coping with their illness were altered over time. CONCLUSIONS: Coping and adjustment is highly individualistic in the context of GKSRS. Over time, most individuals were able to make sense of their illness, adjust their mindset and utilize behavioural strategies and support systems to cope with the long-term effects.

Learning Outcomes of Immersive Technologies in Health Care Student Education: Systematic Review of the Literature.

BACKGROUND: There is a lack of evidence in the literature regarding the learning outcomes of immersive technologies as educational tools for teaching university-level health care students. OBJECTIVE: The aim of this review is to assess the learning outcomes of immersive technologies compared with traditional learning modalities with regard to knowledge and the participants' learning experience in medical, midwifery, and nursing preclinical university education. METHODS: A systematic review was conducted according to the Cochrane Collaboration guidelines. Randomized controlled trials comparing traditional learning methods with virtual, augmented, or mixed reality for the education of medicine, nursing, or midwifery students were evaluated. The identified studies were screened by 2 authors independently. Disagreements were discussed with a third reviewer. The quality of evidence was assessed using the Medical Education Research Study Quality Instrument (MERSQI). The review protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews) in April 2020. RESULTS: Of 15,627 studies, 29 (0.19%) randomized controlled trials (N=2722 students) were included and evaluated using the MERSQI tool. Knowledge gain was found to be equal when immersive technologies were compared with traditional learning modalities; however, the learning experience increased with immersive technologies. The mean MERSQI score was 12.64 (SD 1.6), the median was 12.50, and the mode was 13.50. Immersive technology was predominantly used to teach clinical skills (15/29, 52%), and virtual reality (22/29, 76%) was the most commonly used form of immersive technology. Knowledge was the primary outcome in 97% (28/29) of studies. Approximately 66% (19/29) of studies used validated instruments and scales to assess secondary learning outcomes, including satisfaction, self-efficacy, engagement, and perceptions of the learning experience. Of the 29 studies, 19 (66%) included medical students (1706/2722, 62.67%), 8 (28%) included nursing students (727/2722, 26.71%), and 2 (7%) included both medical and nursing students (289/2722, 10.62%). There were no studies involving midwifery students. The studies were based on the following disciplines: anatomy, basic clinical skills and history-taking skills, neurology, respiratory medicine, acute medicine, dermatology, communication skills, internal medicine, and emergency medicine. CONCLUSIONS: Virtual, augmented, and mixed reality play an important role in the education of preclinical medical and nursing university students. When compared with traditional educational modalities, the learning gain is equal with immersive technologies. Learning outcomes such as student satisfaction, self-efficacy, and engagement all increase with the use of immersive technology, suggesting that it is an optimal tool for education.

Patient perspectives of bedside teaching in an obstetrics, Gynaecology and neonatology hospital.

BACKGROUND: Osler taught doctors to "have no teaching without a patient for a text, and the best teaching is that taught by the patient himself". Bedside teaching (BST) facilitates clinical practice of skills, teaches empathy, instils confidence and builds on patient-doctor relationships. However, its use has declined dramatically due to concerns regarding privacy and autonomy. Most of the research in this area concentrates on medical student or academic opinion of BST using survey based methods. This qualitative study aimed to explore the patient's experiences and opinions of BST. METHODS: With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients who had participated in a BST tutorial were invited to participate and gave written consent after discussion with a study researcher. RESULTS: Twenty-two patients were interviewed (obstetrics ante-natal [n = 10], obstetrics post-natal [n = 5] and gynaecology [n = 7]) ranging from ages 24-80 yrs. Four major themes were identified, with 11 sub-themes. The major themes included (i) Professional Mannerisms (ii) Privacy and Personal Wellbeing (iii) Quality of Patient Experience of BST and (iv) Clinical Experience and Learning Importance. The reaction of patients toward teaching at the bedside was altruistic and positive, with importance placed on learning. CONCLUSION: This research supports the concept of patient focused learning, and can reassure faculty that patients largely support its continuation as an integral component in education. Future research aims to extend this assessment to other patient groups with the aim of learning from and improving their experience.

Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial.

BACKGROUND: 2·6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement (RFM), care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardised management, including timely delivery, would alter the incidence of stillbirth. METHODS: This stepped wedge, cluster-randomised trial was done in the UK and Ireland. Participating maternity hospitals were grouped and randomised, using a computer-generated allocation scheme, to one of nine intervention implementation dates (at 3 month intervals). This date was concealed from clusters and the trial team until 3 months before the implementation date. Each participating hospital had three observation periods: a control period from Jan 1, 2014, until randomised date of intervention initiation; a washout period from the implementation date and for 2 months; and the intervention period from the end of the washout period until Dec 31, 2016. Treatment allocation was not concealed from participating women and caregivers. Data were derived from observational maternity data. The primary outcome was incidence of stillbirth. The primary analysis was done according to the intention-to-treat principle, with births analysed according to whether they took place during the control or intervention periods, irrespective of whether the intervention had been implemented as planned. This study is registered with www.ClinicalTrials.gov, number NCT01777022. FINDINGS: 37 hospitals were enrolled in the study. Four hospitals declined participation, and 33 hospitals were randomly assigned to an intervention implementation date. Between Jan 1, 2014, and Dec, 31, 2016, data were collected from 409 175 pregnancies (157 692 deliveries during the control period, 23 623 deliveries in the washout period, and 227 860 deliveries in the intervention period). The incidence of stillbirth was 4·40 per 1000 births during the control period and 4·06 per 1000 births in the intervention period (adjusted odds ratio [aOR] 0·90, 95% CI 0·75-1·07; p=0·23). INTERPRETATION: The RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven. FUNDING: Chief Scientist Office, Scottish Government (CZH/4/882), Tommy's Centre for Maternal and Fetal Health, Sands.

Video-Based Teaching in Patient and Instrument Selection for Operative Vaginal Deliveries.

OBJECTIVE: Worldwide, the rate of operative vaginal deliveries has decreased, and as a result trainees are lacking exposure and training. The aim of this study was to determine whether a video-based masterclass can improve trainees' confidence, comfort, and knowledge in performing second stage labour assessments and selecting appropriate patients and instruments for operative vaginal deliveries. METHODS: Current University of Toronto obstetrics and gynaecology residents were invited to participate. The intervention included two videos on second stage assessment: (1) selecting the appropriate patient and (2) selecting the appropriate instrument for an operative vaginal delivery. Trainees' comfort and confidence were assessed pre- and post-intervention. A focus group was conducted that assessed trainees' knowledge acquisition. Descriptive thematic analysis was performed, and common themes were extracted. RESULTS: On average, residents have performed more vacuum deliveries than forceps deliveries as primary operators (26.4 vs. 7.9). Following the video intervention, there was a statistically significant improvement (P ≤ 0.05) in trainees' comfort in the following areas: (1) understanding the maternal pelvis, (2) choosing instruments, (3) choosing forceps, (4) deciding the location of delivery, (5) identifying favourable clinical factors, and (6) identifying poor prognostic clinical factors. There was no difference in trainees' self-confidence. Major themes from focus group data included new knowledge gained on second stage assessment techniques, new approaches to existing knowledge, and the multiple challenges and barriers that exist to learning. CONCLUSION: Video-based education on second stage labour assessment and operative vaginal delivery improves trainees' comfort and serves as a valuable complementary tool to clinical learning.

Education in Sepsis: A Review for the Clinician of What Works, for Whom, and in What Circumstances.

Sepsis is a major cause of morbidity and mortality in both the general and obstetric populations. Concerns have been raised regarding some cases of substandard care in the management of the septic and there is a real need for continuing multidisciplinary medical education in the recognition and management of the pregnant patient experiencing sepsis. This review aims to summarize studies on medical education in sepsis to both inform clinicians working in obstetrics and gynaecology and to assist in planning educational programs.

Placental Pathology in Relation to Uterine Artery Doppler Findings in Pregnancies with Severe Intrauterine Growth Restriction and Abnormal Umbilical Artery Doppler Changes.

Objectives Current guidelines for diagnosis and management of early-onset intrauterine growth restriction (IUGR) rely on umbilical artery Doppler (UAD), without including uterine artery Doppler (UtAD). We hypothesized that IUGR cases with abnormal UAD but normal UtAD has a different spectrum of placental pathology compared with those with abnormal UtAD. Study Design Retrospective review of pregnancies with sonographic evidence of IUGR and abnormal UAD prior to delivery. Cases with ≥ 1 UtAD record(s) after 18+0 weeks' gestation and placental pathology were included. Cases were stratified according to initial UtAD pulsatility index (PI) values (n = 196): normal (n = 19; PI < 95th centile for gestational age/no notching), intermediate (n = 69; PI ≥ 95th centile/no/unilateral notching) and abnormal (n = 108; PI ≥ 95th centile/bilateral notching). Pregnancy outcomes and placental pathology were compared between groups. Results Women in the normal group delivered later than those in the abnormal group (30.1 ± 3.5 vs. 28.0 ± 3.5 weeks; mean ± standard deviation; p = 0.03). Their placentas exhibited higher rates of chronic intervillositis (15.8 vs. 0.9%; p = 0.01), chorangiosis (15.8 vs. 0.9%; p < 0.0001), and massive perivillous fibrin deposition (21.1 vs. 7.4%; p = 0.05), but had lower rates of uteroplacental vascular insufficiency (26.3 vs. 79.6%; p < 0.0001). Conclusion Approximately 10% of pregnancies with early-onset IUGR and abnormal UAD exhibited normal UtAD waveforms. They delivered later, and their placentas exhibited unusual placental pathologies.

Bridging generation gaps in medical education: a "light bulb moment" at the Association for Medical Education in Europe annual conference in Barcelona.

Generation gaps have been described before and so have ways to deal with them. But they were mainly focused on the teachers. We would like to bridge these generation gaps, not only by creating awareness but also by learning from each other. This leads to better equipped doctors across all generations and promotes lifelong learning instantaneously.

How education changes clinical documentation in early pregnancy.

The aim of this audit was to record medical history taking in the records of women attending with early pregnancy issues in order to assess the effect of training in this area. The medical education intervention comprised of a 30-min interactive tutorial. Retrospective chart review at three time points: pre education (July 2013, n = 45), immediately post-education (August 2013, n = 45) and longer term post-intervention (October 2013, n = 20). Pre-education, medical history was missing in 77.8% of charts compared to 13.4% immediately post-intervention and 10% long-term post-intervention (p < 0.05). Similar findings were noted with regard to documentation of age, surgical history, medications, allergies and last menstrual period (LMP). While there was a high rate of ultrasound investigations, the documentation of these (by placing an image in the chart) improved after the intervention. Education in requirements for medical history taking can improve documentation.

Teaching an Experienced Multidisciplinary Team About Postpartum Hemorrhage: Comparison of Two Different Methods.

OBJECTIVE: Morbidity from postpartum hemorrhage (PPH) affects 20% of pregnancies worldwide and remains a significant cause of maternal mortality. This study compared the impressions of experienced clinicians on the effect of two methods of educational interventions in a MoreOB training program designed to improve recognition and management of PPH. METHODS: Participants were exposed to a traditional didactic lecture and an interactive clinical intervention exercise incorporating video simulation of a PPH event with opportunities for feedback and discussion of how to proceed. They were then invited to respond to a questionnaire regarding their impressions of both methods. RESULTS: Of 150 participants, 110 completed the questionnaire. Respondents considered the interactive format to be more effective (55%) and enjoyable (72%) than the traditional didactic format. The majority (81%), however, still recommended a mixture of both interactive and didactic formats in future events, supported by a multidisciplinary drill. CONCLUSION: Clinical learners value interactivity and mutual reinforcement among varied learning exercises in their educational experiences. Future educational programs may consider incorporating similar methods in order to maximize participants' receptiveness.

Objectif : La morbidité attribuable à l'hémorragie postpartum (HPP) affecte 20 % des grossesses à l'échelle mondiale et demeure une cause importante de mortalité maternelle. Cette étude a comparé les impressions de cliniciens expérimentés quant aux effets de deux méthodes d'intervention pédagogique (dans le cadre d'un programme de formation AMPROOB) conçues pour améliorer la reconnaissance et la prise en charge de l'HPP. Méthodes : Les participants ont pris part à un exposé magistral traditionnel et à un exercice interactif d'intervention clinique alliant la simulation vidéo d'un événement d'HPP à des occasions de formuler des commentaires et de participer à des discussions sur la façon de procéder. Nous les avons par la suite conviés à répondre à un questionnaire au sujet de leurs impressions quant à ces deux méthodes. Résultats : Cent dix des 150 participants ont rempli le questionnaire. Les répondants étaient d'avis que le format interactif était plus efficace (55 %) et plaisant (72 %) que le format magistral traditionnel. La majorité d'entre eux (81 %) ont cependant recommandé l'offre d'une approche mixte intégrant les deux formats dans le cadre des événements à venir, le tout devant alors être soutenu par la tenue d'un exercice d'entraînement multidisciplinaire. Conclusion : Dans le domaine clinique, les apprenants accordent de l'importance à l'interactivité et au renforcement mutuel de divers exercices d'apprentissage dans le cadre de leurs expériences pédagogiques. Les futurs programmes pédagogiques pourraient envisager l'intégration de méthodes semblables afin de maximiser la réceptivité des participants.

Learning From Experience: Development of a Cognitive Task List to Perform a Caesarean Section in the Second Stage of Labour.

OBJECTIVE: Caesarean section at full cervical dilatation is a challenging procedure with a higher risk of fetal and maternal morbidity. We wished to elicit the essential clinical components of a CS at full dilatation performed skilfully and safely. METHODS: We conducted a prospective study with both qualitative (individual interviews) and quantitative (questionnaire) components. In the qualitative components, senior clinicians were interviewed using open-ended questions regarding techniques used for performance of CS at full cervical dilatation. Interviews were recorded and thematic analysis was performed until saturation was achieved. In the second (quantitative) component of the study, clinicians completed a questionnaire regarding tips and techniques to perform a CS at full cervical dilatation. RESULTS: For the qualitative component, 15 clinicians agreed to participate. There was a 90% (n = 27) response rate to the questionnaire. Common themes from both components of the study included the advice to routinely re-examine the patient (with abdominal and vaginal examinations) in the operating room after induction of anaesthesia to determine pelvic architecture, fetal size, and the station of the presenting part, and especially to assess for progress since the initial decision to perform a CS in the labour room. When the decision is made to proceed with CS, the following modifications to a standard CS technique were suggested: first, to make a more superior transverse uterine incision than usual, and second, to secure each uterine angle separately before uterine closure is commenced in order to identify and manage angle extension and thereby minimize blood loss. Other modifications, such as vaginal disimpaction of the fetal head before beginning the operation, were more controversial. Participants developed their own techniques by combining teaching from senior obstetricians, watching others operate, and learning from their own clinical experience. CONCLUSION: There is an increasing role for good quality clinical training programs on how best to perform complex deliveries such as CS at full cervical dilatation. After identifying the essential components of CS at full cervical dilatation reported by multiple skilled clinicians, these can then be translated into a useful educational tool.

Objectif : La tenue d'une césarienne en présence d'une dilatation cervicale complète constitue une intervention difficile qui donne lieu à un risque accru de morbidité fœtale et maternelle. Nous avons cherché à déterminer les composantes cliniques essentielles de la tenue compétente et en toute sûreté d'une césarienne en présence d'une dilatation cervicale complète. Méthodes : Nous avons mené une étude prospective englobant des composantes tant qualitatives (entrevues individuelles) que quantitatives (questionnaire). Dans le cadre des composantes qualitatives, nous avons interviewé des cliniciens expérimentés au moyen de questions ouvertes portant sur les techniques utilisées pour la tenue d'une césarienne en présence d'une dilatation cervicale complète. Ces entrevues ont été enregistrées et une analyse thématique a été menée jusqu'à l'atteinte de la saturation. Dans le cadre de la deuxième composante (quantitative) de l'étude, nous avons demandé aux cliniciens de remplir un questionnaire portant sur les trucs et les techniques permettant de mener une césarienne en présence d'une dilatation cervicale complète. Résultats : Quinze cliniciens ont consenti à participer à la composante qualitative. Le taux de réponse au questionnaire a été de 90 % (n = 27). Parmi les thèmes fréquemment cités dans les deux composantes de l'étude, on trouvait le conseil de procéder systématiquement au réexamen de la patiente (examens abdominaux et vaginaux) dans la salle d'opération à la suite de l'induction de l'anesthésie, de façon à déterminer l'architecture pelvienne, la taille du fœtus et la station de la partie en présentation, et particulièrement en vue d'évaluer l'évolution de la situation depuis la décision initiale de procéder à une césarienne prise dans la salle de travail. Lorsque les intervenants en viennent à la décision de procéder à une césarienne, l'apport des modifications suivantes à la technique standard a été suggéré : premièrement, pratiquer une incision utérine transversale plus supérieure qu'à l'habitude et, deuxièmement, fixer chacun des angles de l'incision utérine séparément avant d'entamer la fermeture de l'utérus, de façon à identifier et à prendre en charge le ou les prolongements possibles des angles de l'incision utérine et ainsi minimiser la perte sanguine. D'autres modifications, telles que la désinclusion vaginale de la tête fœtale avant le début de l'opération, se sont avérées plus controversées. Les participants ont élaboré leurs propres techniques en amalgamant divers éléments (conseils formulés par des obstétriciens expérimentés, observations de la façon de procéder de leurs collègues et leçons tirées de leur propre expérience). Conclusion : Le rôle des programmes de formation clinique de bonne qualité sur la meilleure façon de procéder à des accouchements complexes (comme la césarienne en présence d'une dilatation cervicale complète) devient de plus en plus important. À la suite de leur identification par de multiples cliniciens expérimentés, les composantes essentielles de la tenue d'une césarienne en présence d'une dilatation cervicale complète peuvent être intégrées dans un outil pédagogique utile.

Learning from experience: development of a cognitive task-list to assess the second stage of labour for operative delivery.

OBJECTIVE: Ensuring the availability of operative vaginal delivery is one strategy for reducing the rising Caesarean section rate. However, current training programs appear inadequate. We sought to systematically identify the core steps in assessing women in the second stage of labour for safe operative delivery, and to produce an expert task-list to assist residents and obstetricians in deciding on the safest mode of delivery for their patients. METHODS: Labour and delivery nursing staff of three large university-associated hospitals identified clinicians they considered to be skilled in operative vaginal deliveries. Obstetricians who were identified consistently were invited to participate in the study. Participants were filmed performing their normal assessment of the second stage of labour on a model. Two clinicians reviewed all videos and documented all verbal and non-verbal components of the assessment; these components were grouped into overarching themes and combined into an integrated expert task-list. The task-list was then circulated to all participants for additional comments, checked against SOGC guidelines, and redrafted, allowing production of a final expert task-list. RESULTS: Thirty clinicians were identified by this process and 20 agreed to participate. Themes identified were assessment of suitability, focused history, physical examination including importance of an abdominal examination, strategies to accurately assess fetal position, station, and the likelihood of success, cautionary signs to prompt reassessment in the operating room, and warning signs to abandon operative delivery for Caesarean section. Communication strategies were emphasized. CONCLUSION: Having expert clinicians teach assessment in the second stage of labour is an important step in the education of residents and junior obstetricians to improve confidence in managing the second stage of labour.

Objectif : Le fait d'assurer la disponibilité de l'accouchement vaginal opératoire constitue l'une des stratégies pouvant permettre d'atténuer la hausse des taux de césarienne. Toutefois, les programmes de formation actuels semblent inadéquats. Nous avons cherché à identifier, de façon systématique, les étapes de base de l'évaluation des femmes en étant au deuxième stade du travail afin de déterminer si la tenue d'un accouchement opératoire sûr s'avère possible dans leur cas, ainsi qu'à formuler une liste de tâches spécialisée visant à aider les résidents et les obstétriciens à déterminer le mode d'accouchement le plus sûr pour leurs patientes. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois hôpitaux universitaires d'envergure ont identifié les cliniciens qu'ils considéraient comme étant particulièrement compétents en matière d'accouchements vaginaux opératoires. Les obstétriciens dont les noms revenaient les plus souvent ont été conviés à participer à l'étude. Les participants ont été filmés pendant l'exécution d'une évaluation normale du deuxième stade du travail sur un modèle. Deux cliniciens ont passé en revue toutes les vidéos et ont documenté toutes les composantes verbales et non verbales de l'évaluation; ces composantes ont été groupées en thèmes généraux et combinées sous forme d'une liste de tâches spécialisée intégrée. Cette liste de tâches a par la suite été remise à tous les participants pour qu'ils puissent formuler des commentaires additionnels, vérifiée en fonction des directives cliniques de la SOGC et reformulées, ce qui a permis la production d'une liste de tâches spécialisée finale. Résultats : Trente cliniciens ont ainsi été identifiés et 20 d'entre eux ont consenti à participer à l'étude. Les thèmes identifiés ont été les suivants : évaluation du caractère adéquat de l'intervention, anamnèse ciblée, examen physique (y compris l'importance de la tenue d'un examen abdominal), stratégies permettant de déterminer avec précision la position et la station fœtales (et la probabilité de réussite), signes de mise en garde devant mener à une réévaluation immédiate en salle d'opération et signes d'avertissement devant mener à l'abandon de l'accouchement opératoire au profit de la césarienne. Des stratégies de communication ont été soulignées. Conclusion : Le fait de pouvoir compter sur l'apport de cliniciens spécialisés pour l'enseignement de l'évaluation au cours du deuxième stade du travail constitue un facteur important dans l'éducation des résidents et des obstétriciens débutants, de façon à ce qu'ils puissent gagner en confiance pour ce qui est de la prise en charge du deuxième stade du travail.

Learning From Experience: Development of a Cognitive Task List to Perform a Safe and Successful Non-Rotational Forceps Delivery.

OBJECTIVE: Increased rates of delivery by Caesarean section have resulted in a reduction in rates of instrumental deliveries. This has led to a new educational challenge for teaching and development of skills. In teaching trainees, there are subconscious tasks that the supervising staff may not review because they are automatic. This study aimed to create a new tool to meet this challenge: to identify the core steps required to perform a non-rotational forceps delivery safely and successfully. METHODS: Labour and delivery nursing staff of three large teaching hospitals were asked to identify clinicians they considered to be particularly skilled in non-rotational forceps deliveries. Obstetricians who were identified consistently in this way were invited to participate in the study. After providing written consent, participants were then filmed performing a non-rotational forceps delivery on a model. Two clinicians reviewed all videos and documented verbal and non-verbal components of the assessment. Thematic analysis combined findings into an integrated summary. The initial summary was then circulated to all participants for their approval. RESULTS: Seventeen clinicians were identified and consented. Themes identified included the need for careful assessment of suitability for operative delivery, the role of the multidisciplinary team, the need for careful and appropriate communication with the parents, the technique of delivery itself, and postpartum care and documentation. CONCLUSION: In the core steps identified, the clinicians balanced respect for the "elegant technique" of non-rotational forceps deliveries with careful assessment and knowing when to stop if safety criteria were not met.

Objectif : La hausse des taux d'accouchement par césarienne a entraîné une baisse des taux d'accouchement instrumental. Cette situation a donné lieu à un nouveau défi sur le plan pédagogique en ce qui concerne l'enseignement et l'acquisition de compétences. Dans le cadre de l'enseignement offert aux stagiaires, certaines tâches menées par le subconscient pourraient passer inaperçues (car elles sont automatiques) et donc ne pas être abordées par le personnel de supervision. Cette étude avait pour but de créer un nouvel outil pour relever ce défi : identifier les étapes de base requises pour la réussite d'un accouchement par forceps non rotationnels en toute sûreté. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois hôpitaux universitaires d'envergure ont identifié les cliniciens qu'ils considéraient comme étant particulièrement compétents en matière d'accouchements par forceps non rotationnels. Les obstétriciens dont les noms revenaient les plus souvent ont été conviés à participer à l'étude. Après avoir offert leur consentement par écrit, les participants ont été filmés pendant l'exécution d'un accouchement par forceps non rotationnels sur un modèle. Deux cliniciens ont passé en revue toutes les vidéos et ont documenté toutes les composantes verbales et non verbales de l'évaluation. Une analyse thématique a combiné les résultats en un résumé intégré. Le résumé initial a par la suite été distribué aux participants pour que l'on obtienne leur approbation. Résultats : Dix-sept cliniciens ont ainsi été identifiés et ont consenti à participer à l'étude. Les thèmes identifiés ont été les suivants : la nécessité de procéder à une évaluation rigoureuse de l'admissibilité de la patiente à un accouchement opératoire, le rôle de l'équipe multidisciplinaire, la nécessité d'une communication rigoureuse et adaptée avec les parents, la technique d'accouchement en tant que telle et les soins et la documentation pendant le postpartum. Conclusion : Au moment d'identifier les étapes de base, les cliniciens ont mis en balance leur respect envers « l'élégance de la technique ¼ utilisée pour les accouchements par forceps non rotationnels avec la nécessité de procéder à une évaluation rigoureuse et le fait de savoir quand mettre fin à l'intervention lorsque les critères de sûreté ne peuvent être satisfaits.

Learning From Experience: Qualitative Analysis to Develop a Cognitive Task List for Vaginal Breech Deliveries.

OBJECTIVE: Achieving clinical competence in managing safe vaginal breech delivery (VBD) is challenging in contemporary obstetrics. Novel educational strategies are required, as exposure of obstetric trainees to VBD remains limited. The aim of this study was to identify the verbal and non-verbal skills required to manage VBD through filmed demonstration by experts. METHODS: Labour and delivery nursing staff at three large university-affiliated hospitals identified clinicians whom they considered skilled in VBD. Obstetricians consistently identified were invited to participate in the study. Participants were filmed performing a VBD on a birth simulator while discussing their assessment, technique, and providing clinical pearls based on their experience. Two study members reviewed all videos and documented verbal and non-verbal components of the assessment, grouped them into common themes, and produced an integrated summary. This was circulated to all participants and reviewed by senior obstetricians from outside Canada. RESULTS: Seventeen clinicians were identified; 12 (70%) consented to participation. Themes identified were meticulous assessment and pre-pregnancy counselling; roles of the multidisciplinary team; need for careful and appropriate communication with parents; specific techniques of the delivery; and postpartum care and documentation. A clinical task list was generated based on this analysis. CONCLUSION: Derived from clinicians with extensive experience, we have developed a comprehensive task list outlining the important features involved in safe VBD. Common themes in the experts' teaching for safe VBD included rigorous antepartum selection and counselling, appreciation for when to convert to Caesarean section, and a "hands off" delivery technique.

Objectif : De nos jours, dans le domaine de l'obstétrique, il est difficile d'acquérir les compétences cliniques nécessaires à la tenue d'un accouchement vaginal du siège (AVS) en toute sûreté. Des stratégies pédagogiques novatrices sont requises, puisque l'exposition des stagiaires en obstétrique à l'AVS demeure limitée. Cette étude avait pour objectif d'identifier, au moyen de démonstrations filmées par des spécialistes, les compétences verbales et non verbales nécessaires à la prise en charge de l'AVS. Méthodes : Les membres du personnel infirmier de la salle de travail et d'accouchement de trois importants hôpitaux universitaires ont identifié les cliniciens qu'ils considéraient comme étant compétents en matière d'AVS. Les obstétriciens les plus souvent identifiés ont été conviés à participer à l'étude. Les participants ont été filmés alors qu'ils procédaient à un AVS sur un simulateur d'accouchement; à ces occasions, nous leur avons également demandé de nous entretenir de leur évaluation et de leur technique, ainsi que de nous fournir des conseils cliniques issus de leur expérience. Deux membres de l'étude ont passé en revue toutes les vidéos et ont documenté les composantes verbales et non verbales de l'évaluation, les ont groupées en thèmes communs et en ont rédigé une synthèse. Cette synthèse a été transmise à tous les participants et a été analysée par des obstétriciens expérimentés de l'étranger. Résultats : Dix-sept cliniciens ont été identifiés; 12 (70 %) ont consenti à participer à l'étude. Parmi les thèmes identifiés, on trouvait les suivants : évaluation méticuleuse et counseling prégrossesse; rôles de l'équipe multidisciplinaire; nécessité d'une communication attentive et adéquate avec les parents; techniques d'accouchement particulières; et documentation et soins postpartum. Une liste des tâches cliniques a été générée en fonction des résultats de cette analyse. Conclusion : En nous inspirant de cliniciens vastement expérimentés, nous avons élaboré une liste exhaustive de tâches soulignant les caractéristiques importantes de la tenue d'un AVS en toute sûreté. Parmi les thèmes courants relevés par ces spécialistes à ce sujet, on trouvait la tenue antepartum d'une sélection et d'un counseling rigoureux, les connaissances requises pour savoir quand convertir l'intervention en césarienne et l'utilisation d'une technique d'accouchement « passive ¼ (hands off).

Learning From Experience: Qualitative Analysis to Develop a Cognitive Task List for Kielland Forceps Deliveries.

OBJECTIVE: Fetal malposition is a common indication for Caesarean section in the second stage of labour. Rotational (Kielland) forceps are a valuable tool in select situations for successful vaginal delivery; however, learning opportunities are scarce. Our aim was to identify the verbal and non-verbal components of performing a safe Kielland forceps delivery through filmed demonstrations by expert practitioners on models to develop a task list for training purposes. METHODS: Labour and delivery nurses at three university-affiliated hospitals identified clinicians whom they considered skilled in Kielland forceps deliveries. These physicians gave consent and were filmed performing Kielland forceps deliveries on a model, describing their assessment and technique and sharing clinical pearls based on their experience. Two clinicians reviewed the videos independently and recorded verbal and non-verbal components of the assessment; thematic analysis was performed and a core task list was developed. The algorithm was circulated to participants to ensure consensus. RESULTS: Eleven clinicians were identified; eight participated. Common themes were prevention of persistent malposition where possible, a thorough assessment to determine suitability for forceps delivery, roles of the multidisciplinary team, description of the Kielland forceps and technical aspects related to their use, the importance of communication with the parents and the team (including consent, debriefing, and documentation), and "red flags" that indicate the need to stop when safety criteria cannot be met. CONCLUSION: Development of a cognitive task list, derived from years of experience with Kielland forceps deliveries by expert clinicians, provides an inclusive algorithm that may facilitate standardized resident training to enhance education in rotational forceps deliveries.

Objectif : La malposition fœtale constitue une indication courante menant à la tenue d'une césarienne au cours du deuxième stade du travail. Les forceps de Kielland sont un outil utile dans certaines situations pour assurer la réussite de l'accouchement vaginal; toutefois, les occasions d'en apprendre l'utilisation se font rares. Nous avions pour objectif d'identifier les composantes verbales et non verbales de la tenue en toute sûreté d'un accouchement au moyen de forceps de Kielland en filmant des démonstrations menées par des praticiens spécialisés sur des modèles, et ce, dans le but de rédiger une liste de tâches à des fins pédagogiques. Méthodes : Les infirmières du service d'obstétrique de trois hôpitaux universitaires ont identifié les cliniciens qu'elles considéraient comme étant compétents en ce qui concerne les accouchements par forceps de Kielland. Ces médecins ont consenti à l'entreprise et ont été filmés pendant l'exécution d'un accouchement par forceps de Kielland sur un modèle; pendant cette simulation, ils ont pris soin de décrire leur évaluation et leur technique, en plus de partager des conseils cliniques fondés sur leur expérience. Deux cliniciens ont passé en revue les vidéos de façon indépendante et ont consigné les composantes verbales et non verbales de l'évaluation; une analyse thématique a été menée et une liste de tâches de base a été élaborée. L'algorithme a été distribué aux participants afin d'assurer un consensus. Résultats : Onze cliniciens ont été identifiés; huit d'entre eux ont consenti à participer au projet. Les thèmes communs ont été la prévention de la malposition persistante (dans la mesure du possible), une évaluation exhaustive visant à déterminer la pertinence de la tenue d'un accouchement par forceps, les rôles de l'équipe multidisciplinaire, la description des forceps de Kielland et les aspects techniques associés à leur utilisation, l'importance de la communication avec les parents et l'équipe (y compris le consentement, le débreffage et la documentation), et les « signaux d'alarme ¼ qui indiquent la nécessité de mettre fin à l'intervention lorsque les critères d'innocuité ne peuvent être assurés. Conclusion : L'élaboration d'une liste de tâches cognitives, tirée des années d'expérience de cliniciens spécialisés en ce qui a trait à la tenue d'accouchements par forceps de Kielland, offre un riche algorithme qui pourrait faciliter la standardisation de la formation des résidents, de façon à améliorer l'enseignement de tels accouchements.

Investigating the Impact of Reproductive Coercion and Intimate Partner Violence on Psychological and Sexual Wellbeing.

Emerging research suggests that reproductive coercion and abuse (RCA), like intimate partner violence (IPV), is associated with poorer mental and sexual health outcomes, including greater symptoms of post-traumatic stress disorder (PTSD) and depression and poorer markers of physical and sexual health such as sexually transmitted infections, unplanned pregnancies and lowered sexual agency. Although victims/survivors of RCA report long-lasting impacts on future relationships, including fear and anxiety, little is known about impacts of RCA on anxiety and general wellbeing, nor emotional and mental components of sexual health that comprise a person's sexual self-concept. With community samples of participants in Australia, we conducted two studies to explore the impact of RCA and IPV on psychological (study 1) and sexual (study 2) health outcomes. Study 1 (n = 368) found that experiencing IPV and RCA both significantly and uniquely contributed to poorer mental health outcomes. After controlling for age and IPV, RCA significantly predicted symptoms of depression, anxiety, stress, PTSD, and reduced satisfaction with life. Study 2 (n = 329) found that IPV and RCA differentially predicted various components of sexual health. IPV predicted decreased sexual satisfaction and increased sexual anxiety, depression, and fear of sexual encounters. After controlling for age and IPV, RCA significantly and uniquely predicted lower levels of sexual assertiveness and increased sexual depression and fear of sexual encounters, but not sexual satisfaction or anxiety. We conclude that RCA is associated with significant psychological distress and a negative sexual self-concept that may impact future relationships. Screening for both IPV and RCA across settings is warranted.

PhenoID, a language model normalizer of physical examinations from genetics clinical notes.

Background: Phenotypes identified during dysmorphology physical examinations are critical to genetic diagnosis and nearly universally documented as free-text in the electronic health record (EHR). Variation in how phenotypes are recorded in free-text makes large-scale computational analysis extremely challenging. Existing natural language processing (NLP) approaches to address phenotype extraction are trained largely on the biomedical literature or on case vignettes rather than actual EHR data. Methods: We implemented a tailored system at the Children's Hospital of Philadelpia that allows clinicians to document dysmorphology physical exam findings. From the underlying data, we manually annotated a corpus of 3136 organ system observations using the Human Phenotype Ontology (HPO). We provide this corpus publicly. We trained a transformer based NLP system to identify HPO terms from exam observations. The pipeline includes an extractor, which identifies tokens in the sentence expected to contain an HPO term, and a normalizer, which uses those tokens together with the original observation to determine the specific term mentioned. Findings: We find that our labeler and normalizer NLP pipeline, which we call PhenoID, achieves state-of-the-art performance for the dysmorphology physical exam phenotype extraction task. PhenoID's performance on the test set was 0.717, compared to the nearest baseline system (Pheno-Tagger) performance of 0.633. An analysis of our system's normalization errors shows possible imperfections in the HPO terminology itself but also reveals a lack of semantic understanding by our transformer models. Interpretation: Transformers-based NLP models are a promising approach to genetic phenotype extraction and, with recent development of larger pre-trained causal language models, may improve semantic understanding in the future. We believe our results also have direct applicability to more general extraction of medical signs and symptoms. Funding: US National Institutes of Health.