Effectiveness of simulation in psychiatry for nursing students, nurses and nurse practitioners: A systematic review and meta-analysis.

AIMS: Mental disorders constitute one of the main causes of disease and disability worldwide. While nurses are often at the frontline of mental health care, they have limited access to dedicated psychiatric training opportunities. Simulation training may foster the development of the appropriate competencies required when supporting people with mental disorders. To evaluate the effectiveness of simulation training in psychiatry for nursing students, nurses and nurse practitioners. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Eight electronic databases, trial registries, key journals and reference lists of selected studies were searched from inception to August 20, 2020 without language restriction. REVIEW METHODS: We included randomized and non-randomized controlled studies and single group pre/post studies. Cochrane Risk of Bias tool 2.0 was used for randomized controlled study appraisal, and the Medical Education Research Study Quality instrument was completed for all other studies. Meta-analysis was restricted to randomized controlled studies. The other studies were synthesized narratively. The main outcomes were based on Kirkpatrick levels. RESULTS: A total of 118 studies (6738 participants) were found. Interventions included simulated patients (n = 55), role-plays (n = 40), virtual reality (n = 12), manikins (n = 9) and voice simulations (n = 9). Meta-analyses based on 11 randomized controlled studies found a significant large effect size on skills at immediate post-test for simulation compared with active control; and a small and medium effect size on learners' attitudes for simulation compared with inactive control, at immediate post-test and at three-month follow-up respectively. Three quarters of non-randomized controlled studies and pre/post-tests assessing attitudes and skills showed significant differences, and three quarters of participants in randomized controlled studies and pre/post-tests showed significant differences in behaviours. Among the few studies assessing people with mental health outcomes, almost all reported significant differences. CONCLUSION: These findings support the effectiveness of simulation training in psychiatric nursing throughout professional development grades, despite heterogeneity in methods and simulation interventions.

Simulation in psychiatry for medical doctors: A systematic review and meta-analysis.

CONTEXT: Most medical doctors are likely to work with patients experiencing mental health conditions. However, educational opportunities for medical doctors to achieve professional development in the field of psychiatry are often limited. Simulation training in psychiatry may be a useful tool to foster this development. OBJECTIVES: The purpose of this study was to assess the effectiveness of simulation training in psychiatry for medical students, postgraduate trainees and medical doctors. METHODS: For this systematic review and meta-analysis, we searched eight electronic databases and trial registries up to 31 August 2018. We manually searched key journals and the reference lists of selected studies. We included randomised and non-randomised controlled studies and single group pre- and post-test studies. Our main outcomes were based on Kirkpatrick levels. We included data only from randomised controlled trials (RCTs) using random-effects models. RESULTS: From 46 571 studies identified, we selected 163 studies and combined 27 RCTs. Interventions included simulation by role-play (n = 69), simulated patients (n = 72), virtual reality (n = 22), manikin (n = 5) and voice simulation (n = 2). Meta-analysis found significant differences at immediate post-tests for simulation compared with active and inactive control groups for attitudes (standardised mean difference [SMD] = 0.52, 95% confidence interval [CI] 0.31-0.73 [I2  = 0.0%] and SMD = 0.28, 95% CI 0.04-0.53 [I2  = 52.0%], respectively), skills (SMD = 1.37, 95% CI 0.56-2.18 [I2  = 93.0%] and SMD = 1.49, 95% CI 0.39-2.58 [I2  = 93.0%], respectively), knowledge (SMD = 1.22, 95% CI 0.57-1.88 [I2  = 0.0%] and SMD = 0.72, 95% CI 0.14-1.30 [I2  = 80.0%], respectively), and behaviours (SMD = 1.07, 95% CI 0.49-1.65 [I2  = 68.0%] and SMD = 0.45, 95% CI 0.11-0.79 [I2  = 41.0%], respectively). Significant differences in terms of patient benefit and doctors' behaviours and skills were found at the 3-month follow-up. CONCLUSIONS: Despite heterogeneity in methods and simulation interventions, our findings demonstrate the effectiveness of simulation training in psychiatry training.

Determinants of long-term outcome in ICU survivors: results from the FROG-ICU study.

BACKGROUND: Intensive care unit (ICU) survivors have reduced long-term survival compared to the general population. Identifying parameters at ICU discharge that are associated with poor long-term outcomes may prove useful in targeting an at-risk population. The main objective of the study was to identify clinical and biological determinants of death in the year following ICU discharge. METHODS: FROG-ICU was a prospective, observational, multicenter cohort study of ICU survivors followed 1 year after discharge, including 21 medical, surgical or mixed ICUs in France and Belgium. All consecutive patients admitted to intensive care with a requirement for invasive mechanical ventilation and/or vasoactive drug support for more than 24 h following ICU admission and discharged from ICU were included. The main outcome measure was all-cause mortality at 1 year after ICU discharge. Clinical and biological parameters on ICU discharge were measured, including the circulating cardiovascular biomarkers N-terminal pro-B type natriuretic peptide, high-sensitive troponin I, bioactive-adrenomedullin and soluble-ST2. Socioeconomic status was assessed using a validated deprivation index (FDep). RESULTS: Of 1570 patients discharged alive from the ICU, 333 (21%) died over the following year. Multivariable analysis identified age, comorbidity, red blood cell transfusion, ICU length of stay and abnormalities in common clinical factors at the time of ICU discharge (low systolic blood pressure, temperature, total protein, platelet and white cell count) as independent factors associated with 1-year mortality. Elevated biomarkers of cardiac and vascular failure independently associated with 1-year death when they are added to multivariable model, with an almost 3-fold increase in the risk of death when combined (adjusted odds ratio 2.84 (95% confidence interval 1.73-4.65), p < 0.001). CONCLUSIONS: The FROG-ICU study identified, at the time of ICU discharge, potentially actionable clinical and biological factors associated with poor long-term outcome after ICU discharge. Those factors may guide discharge planning and directed interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT01367093 . Registered on 6 June 2011.

Fixed versus variable practice for teaching medical students the management of pediatric asthma exacerbations using simulation.

Simulation-based trainings represent an interesting approach to teach medical students the management of pediatric asthma exacerbations (PAEs). In this study, we compared two pedagogical approaches, training students once on three different scenarios of PAEs versus training students three times on the same scenario of PAE. Eighty-five third-year medical students, novice learners for the management of PAEs, were randomized and trained. Students were assessed twice, 1 week and 4 months after the training, on a scenario of PAE new to both groups and on scenarios used during the training. The main outcome was the performance score on the new scenario of PAE at 1 week, assessed on a checklist custom-designed for the study. All students progressed rapidly and acquired excellent skills. One week after the training, there was no difference between the two groups on all the scenarios tested, including the new scenario of PAE (median performance score (IQR) of 8.3 (7.4-10.0) in the variation group versus 8.0 (6.0-10.0) in the repetition group (p = 0.16)). Four months later, the performance of the two groups remained similar. CONCLUSION: Varying practice with different scenarios was equivalent to repetitive practice on the same scenario for novice learners, with both methods leading to transfer and long-term retention of the skills acquired during the training. What is known: • Simulation-based trainings represent an interesting approach to teach medical students the management of pediatric asthma exacerbations. • It is unclear whether students would benefit more from repetitive practice on the same scenario of asthma exacerbation or from practice on different scenarios in terms of transfer of skills. What is new: • An individual 30-min training on the management of pediatric asthma exacerbations using simulation allows transfer and long-term retention of the skills acquired. • Varying practice with different scenarios is equivalent to repetitive practice on the same scenario in terms of transfer of skills.

A systematic review of serious games in asthma education.

BACKGROUND: Serious games may be useful tools for asthma education. The objectives of this systematic review were to identify the available articles on serious games designed to educate patients and the general public about asthma and to assess their impact on patient's knowledge, behavior, and clinical outcomes related to asthma. METHODS: PubMed, EMBASE, Cochrane Library, PsychInfo, and Web of Science were systematically searched from January 1980 to December 2015 for studies investigating serious games in asthma education. Two investigators independently assessed studies against inclusion criteria and rated those included on indicators of quality. Investigators extracted data on serious games' content and learning objectives, and on outcomes following Kirkpatrick classification. RESULTS: A total of 12 articles were found to be relevant, describing a total of 10 serious games. All serious games were directed toward children, with eight games for children with asthma and two for school-based intervention. The average Medical Education Research Study Quality Instrument score was 13.9 of 18, which is high. Most of the serious games were associated with high rates of satisfaction and improvement in children's knowledge. Seven studies evaluated the impact of serious games on clinical outcomes and found no significant difference relative to control groups. CONCLUSIONS: Although serious games designed for asthma education have evolved with advances in technology, results of their evaluation remained similar across studies, with clear improvements in knowledge but little or no change in behaviors and clinical outcomes.

Serious game versus online course for pretraining medical students before a simulation-based mastery learning course on cardiopulmonary resuscitation: A randomised controlled study.

BACKGROUND: Although both recorded lectures and serious games have been used to pretrain health professionals before simulation training on cardiopulmonary resuscitation, they have never been compared. OBJECTIVE: The aim of this study was to compare an online course and a serious game for pretraining medical students before simulation-based mastery learning on the management of sudden cardiac arrest. DESIGN: A randomised controlled trial. Participants were pretrained using the online course or the serious game on day 1 and day 7. On day 8, each participant was evaluated repeatedly on a scenario of cardiac arrest until reaching a minimum passing score. SETTING: Department of Simulation in Healthcare in a French medical faculty. PARTICIPANTS: Eighty-two volunteer second-year medical students participated between June and October 2016 and 79 were assessed for primary outcome. INTERVENTIONS: The serious game used was Staying Alive, which involved a 3D realistic environment, and the online course involved a PowerPoint lecture. MAIN OUTCOME MEASURES: The median total training time needed for students to reach the minimum passing score on day 8. This same outcome was also assessed 4 months later. RESULTS: The median training time (interquartile range) necessary for students to reach the minimum passing score was similar between the two groups: 20.5 (15.8 to 30.3) minutes in the serious game group versus 23 (15 to 32) minutes in the online course group, P = 0.51. Achieving an appropriate degree of chest compression was the most difficult requirement to fulfil for students in both groups. Four months later, the median training time decreased significantly in both groups, but no correlation was found at an individual level with the training times observed on day 8. CONCLUSION: The serious game used in this study was not superior to an online course to pretrain medical students in the management of a cardiac arrest. The absence of any correlation between the performances of students evaluated during two training sessions separated by 4 months suggests that some elements in the management of cardiac arrest such as compression depth can only be partially learned and retained after a simulation-based training. TRIAL REGISTRATION: ClinicalTrials.gov-NCT02758119.

Cancer despite immunosurveillance: immunoselection and immunosubversion.

Numerous innate and adaptive immune effector cells and molecules participate in the recognition and destruction of cancer cells, a process that is known as cancer immunosurveillance. But cancer cells avoid such immunosurveillance through the outgrowth of poorly immunogenic tumour-cell variants (immunoselection) and through subversion of the immune system (immunosubversion). At the early stages of carcinogenesis, cell-intrinsic barriers to tumour development seem to be associated with stimulation of an active antitumour immune response, whereas overt tumour development seems to correlate with changes in the immunogenic properties of tumour cells. The permanent success of treatments for cancer might depend on using immunogenic chemotherapy to re-establish antitumour immune responses.

[Innovations in medical undergraduate pathology education: The Paris Descartes medicine faculty experience]. / Nouveaux outils et nouvelles méthodes pour l'enseignement de l'anatomie pathologique. Retour d'expérience à la faculté de médecine Paris Descartes.

At the Paris Descartes medicine faculty, we tested some newly developed tools to enhance the pedagogic value of the pathology teaching. In our faculty, this teaching is largely multidisciplinary and integrated in various teaching units; a large part is dedicated to practice works with thirteen 90min sessions. Virtual slides have been used for years in numerous medicine faculties; we successfully implemented this tool by adding contextual annotations, which facilitate students revising. We showed that rewarding students' assiduity enhanced their exam success. To do so, we now propose a short continuous assessment exam at the beginning of each practice session in the form of electronic multi-choice questions. Finally, we now propose a completely computerized final exam, on touchpads, that enhanced its docimologic value.

New insights into virtual medical education and assess- ment, Serious Games, and Digital Platforms.

Medical education and evaluation, for both initial and continuing medical training of healthcare professionals, is experiencing profound conceptual and technical changes in the era of the digital society and economy. Using the concepts of active and blended learning, acquisition and maintenance of knowledge, skills and attitudes (KSA) now passes through upstream work before entering the Faculty of Medicine on Internet (MOOC, SPOC, OER), restitution in flipped and contextualized classrooms to solve problems and learn to learn, and ultimately on virtual platforms using mannequins (avatars) in virtual environ- ments, without risk to patients and actors. Here we provide some examples of this revolu- tion, and their development prospects.

The IKK complex contributes to the induction of autophagy.

In response to stress, cells start transcriptional and transcription-independent programs that can lead to adaptation or death. Here, we show that multiple inducers of autophagy, including nutrient depletion, trigger the activation of the IKK (IkappaB kinase) complex that is best known for its essential role in the activation of the transcription factor NF-kappaB by stress. Constitutively active IKK subunits stimulated autophagy and transduced multiple signals that operate in starvation-induced autophagy, including the phosphorylation of AMPK and JNK1. Genetic inhibition of the nuclear translocation of NF-kappaB or ablation of the p65/RelA NF-kappaB subunit failed to suppress IKK-induced autophagy, indicating that IKK can promote the autophagic pathway in an NF-kappaB-independent manner. In murine and human cells, knockout and/or knockdown of IKK subunits (but not that of p65) prevented the induction of autophagy in response to multiple stimuli. Moreover, the knockout of IKK-beta suppressed the activation of autophagy by food deprivation or rapamycin injections in vivo, in mice. Altogether, these results indicate that IKK has a cardinal role in the stimulation of autophagy by physiological and pharmacological stimuli.

Calreticulin exposure dictates the immunogenicity of cancer cell death.

Anthracyclin-treated tumor cells are particularly effective in eliciting an anticancer immune response, whereas other DNA-damaging agents such as etoposide and mitomycin C do not induce immunogenic cell death. Here we show that anthracyclins induce the rapid, preapoptotic translocation of calreticulin (CRT) to the cell surface. Blockade or knockdown of CRT suppressed the phagocytosis of anthracyclin-treated tumor cells by dendritic cells and abolished their immunogenicity in mice. The anthracyclin-induced CRT translocation was mimicked by inhibition of the protein phosphatase 1/GADD34 complex. Administration of recombinant CRT or inhibitors of protein phosphatase 1/GADD34 restored the immunogenicity of cell death elicited by etoposide and mitomycin C, and enhanced their antitumor effects in vivo. These data identify CRT as a key feature determining anticancer immune responses and delineate a possible strategy for immunogenic chemotherapy.

Toll-like receptor 4-dependent contribution of the immune system to anticancer chemotherapy and radiotherapy.

Conventional cancer treatments rely on radiotherapy and chemotherapy. Such treatments supposedly mediate their effects via the direct elimination of tumor cells. Here we show that the success of some protocols for anticancer therapy depends on innate and adaptive antitumor immune responses. We describe in both mice and humans a previously unrecognized pathway for the activation of tumor antigen-specific T-cell immunity that involves secretion of the high-mobility-group box 1 (HMGB1) alarmin protein by dying tumor cells and the action of HMGB1 on Toll-like receptor 4 (TLR4) expressed by dendritic cells (DCs). During chemotherapy or radiotherapy, DCs require signaling through TLR4 and its adaptor MyD88 for efficient processing and cross-presentation of antigen from dying tumor cells. Patients with breast cancer who carry a TLR4 loss-of-function allele relapse more quickly after radiotherapy and chemotherapy than those carrying the normal TLR4 allele. These results delineate a clinically relevant immunoadjuvant pathway triggered by tumor cell death.

Recombinant human activated protein C for adults with septic shock: a randomized controlled trial.

RATIONALE: A decade after drotrecogin alfa (activated) (DAA) was released on the market worldwide, its benefit-to-risk ratio remains a matter of debate. OBJECTIVES: The current investigator-led trial was designed to evaluate the efficacy and safety of DAA, in combination with low-dose steroids, in adults with persistent septic shock. METHODS: This was a multicenter (24 intensive care units), placebo-controlled, double-blind, 2 × 2 factorial design trial in which adults with persistent septic shock and no contraindication to DAA were randomly assigned to DAA alone (24 µg/kg/h for 96 h), hydrocortisone and fludrocortisone alone, their respective combinations, or their respective placebos. Primary outcome was mortality rate on Day 90. MEASUREMENTS AND MAIN RESULTS: On October 25, 2011, the trial was suspended after the withdrawal from the market of DAA. The Scientific Committee decided to continue the trial according to a two parallel group design comparing low-dose steroids with their placebos and to analyze the effects of DAA on patients included before trial suspension. At the time trial was suspended, 411 patients had been recruited, 208 had received DAA, and 203 had received its placebo. There was no significant interaction between DAA and low-dose steroids (P = 0.47). On Day 90, there were 99 deaths (47.6%) among the 208 patients receiving DAA and 94 deaths (46.3%) among the 203 patients receiving placebo (P = 0.79). There was no evidence of a difference between DAA and its placebo for any secondary outcomes or serious adverse events. CONCLUSIONS: In adults with established and severe septic shock, DAA showed no evidence of benefit or harm. Clinical trial registered with www.clinicaltrials.gov (NCT00625209).

Chemotherapy and radiotherapy: cryptic anticancer vaccines.

An attractive, yet hitherto unproven concept predicts that the promotion of tumor regression should elicit the host's immune response against residual tumor cells to achieve an optimal therapeutic effect. In a way, chemo- or radiotherapy must trigger "danger signals" emitted from immunogenic cell death and hence elicit "danger associated molecular patterns" to stimulate powerful anticancer immune responses. Here, based on the recent experimental and clinical evidence, we will discuss the molecular identity of the multiple checkpoints that dictate the success of "immunogenic chemotherapy" at the levels of the drug, of the tumor cell and of the host immune system.

[From the theory to the practice of simulation in healthcare]. / La simulation en santé, de la théorie à la pratique.

Simulation in healthcare is directly inspired by high-risk industries such as the aeronautical industry. The recent rapid growth in its use in healthcare is explained by the need to improve the quality and safety of care. It must go hand in hand with the development of a real safety culture.

Mechanisms of pre-apoptotic calreticulin exposure in immunogenic cell death.

Dying tumour cells can elicit a potent anticancer immune response by exposing the calreticulin (CRT)/ERp57 complex on the cell surface before the cells manifest any signs of apoptosis. Here, we enumerate elements of the pathway that mediates pre-apoptotic CRT/ERp57 exposure in response to several immunogenic anticancer agents. Early activation of the endoplasmic reticulum (ER)-sessile kinase PERK leads to phosphorylation of the translation initiation factor eIF2alpha, followed by partial activation of caspase-8 (but not caspase-3), caspase-8-mediated cleavage of the ER protein BAP31 and conformational activation of Bax and Bak. Finally, a pool of CRT that has transited the Golgi apparatus is secreted by SNARE-dependent exocytosis. Knock-in mutation of eIF2alpha (to make it non-phosphorylatable) or BAP31 (to render it uncleavable), depletion of PERK, caspase-8, BAP31, Bax, Bak or SNAREs abolished CRT/ERp57 exposure induced by anthracyclines, oxaliplatin and ultraviolet C light. Depletion of PERK, caspase-8 or SNAREs had no effect on cell death induced by anthracyclines, yet abolished the immunogenicity of cell death, which could be restored by absorbing recombinant CRT to the cell surface.

An observational study of the fresh frozen plasma: red blood cell ratio in postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage is the leading cause of maternal death worldwide. Recent data from trauma patients and patients with hemorrhagic shock have suggested that an increased fresh frozen plasma:red blood cell (FFP:RBC) ratio may be of benefit in massive bleeding. We addressed this issue in cases of severe postpartum hemorrhage. METHODS: We reviewed data from all patients diagnosed with severe postpartum hemorrhage during a 4-year period (2006-2009). Patients who were treated with sulprostone and required transfusion within 6 hours of delivery were included in the study and were divided into 2 groups according to their response to sulprostone: bleeding controlled with sulprostone alone (sulprostone group) and bleeding requiring an additional advanced interventional procedure including arterial angiographic embolization and/or surgical procedures (arterial ligation, B-Lynch suture, or hysterectomy; intervention group). The requirement or no requirement for advanced procedures constituted the primary end point of the study. Propensity scoring was used to assess the effect of a high FFP:RBC ratio on bleeding control. RESULTS: Among 12,226 deliveries during the study period, 142 (1.1%) were complicated by severe postpartum hemorrhage. Bleeding was controlled with sulprostone alone in 90 patients (63%). Advanced interventional procedures were required for 52 patients (37%). Forty-one patients were transfused with both RBCs and FFP. The FFP:RBC ratio increased over the study period (P < 0.001), from 1:1.8 at the start to 1:1.1 at the end of the study period. After propensity score modeling (inverse probability of treatment weighting), a high FFP:RBC ratio was associated with lower odds for advanced interventional procedures (odds ratio [95% confidence interval], 1.25 [1.07-1.47]; P = 0.008). There were no deaths, severe organ dysfunction, or other complications as a consequence of severe postpartum hemorrhage. CONCLUSIONS: In this retrospective study, a higher FFP:RBC ratio was associated with a lower requirement for advanced interventional procedures in the setting of postpartum hemorrhage. The benefits of transfusion using a higher FFP:RBC ratio should be confirmed by randomized-controlled trials.

Medical Students' Learning Process During Simulated Patient Consultations in Psychiatry: A Grounded Theory Study.

INTRODUCTION: Recent changes in psychiatric care and teaching, which limit patient contact for medical students, can be partially overcome by simulation-based education in psychiatry. The authors explored the learning processes of medical students during meetings with simulated patients to inform efforts to improve this teaching. METHODS: After recruiting 81 undergraduate medical students from 3 universities to participate in 6 simulation sessions in psychiatry, the authors purposively sampled 21 students to participate in face-to-face individual semistructured interviews analyzed with constructivist grounded theory. Integration of this analysis with those of the simulation consultation videotapes and the debriefing audiotapes improved the triangulation process. RESULTS: Three organizational themes were identified: developing and structuring representations of psychiatry; integrating subjectivity into learning; and refining and developing psychiatric praxis. Given the broad and in-depth learning that occurs, simulation in psychiatry should respect content validity of SP portrayals to ensure appropriate learning. However, psychological fidelity seems to provide adequate realism while retaining feasibility. Psychiatric simulation also requires the encouragement of student self-confidence and well-being. Within a reflective framework, simulation triggers cognitive reframing, which can alleviate fears and prejudice toward people with mental disorders. CONCLUSIONS: The holistic interactive learning process involved in simulation can address the complexity of the personal and interpersonal features needed in psychiatry.

Caspase-dependent immunogenicity of doxorubicin-induced tumor cell death.

Systemic anticancer chemotherapy is immunosuppressive and mostly induces nonimmunogenic tumor cell death. Here, we show that even in the absence of any adjuvant, tumor cells dying in response to anthracyclins can elicit an effective antitumor immune response that suppresses the growth of inoculated tumors or leads to the regression of established neoplasia. Although both antracyclins and mitomycin C induced apoptosis with caspase activation, only anthracyclin-induced immunogenic cell death was immunogenic. Caspase inhibition by Z-VAD-fmk or transfection with the baculovirus inhibitor p35 did not inhibit doxorubicin (DX)-induced cell death, yet suppressed the immunogenicity of dying tumor cells in several rodent models of neoplasia. Depletion of dendritic cells (DCs) or CD8+T cells abolished the immune response against DX-treated apoptotic tumor cells in vivo. Caspase inhibition suppressed the capacity of DX-killed cells to be phagocytosed by DCs, yet had no effect on their capacity to elicit DC maturation. Freshly excised tumors became immunogenic upon DX treatment in vitro, and intratumoral inoculation of DX could trigger the regression of established tumors in immunocompetent mice. These results delineate a procedure for the generation of cancer vaccines and the stimulation of anti-neoplastic immune responses in vivo.