Preclinical proof of principle for orally delivered Th17 antagonist miniproteins.

Interleukin (IL)-23 and IL-17 are well-validated therapeutic targets in autoinflammatory diseases. Antibodies targeting IL-23 and IL-17 have shown clinical efficacy but are limited by high costs, safety risks, lack of sustained efficacy, and poor patient convenience as they require parenteral administration. Here, we present designed miniproteins inhibiting IL-23R and IL-17 with antibody-like, low picomolar affinities at a fraction of the molecular size. The minibinders potently block cell signaling in vitro and are extremely stable, enabling oral administration and low-cost manufacturing. The orally administered IL-23R minibinder shows efficacy better than a clinical anti-IL-23 antibody in mouse colitis and has a favorable pharmacokinetics (PK) and biodistribution profile in rats. This work demonstrates that orally administered de novo-designed minibinders can reach a therapeutic target past the gut epithelial barrier. With high potency, gut stability, and straightforward manufacturability, de novo-designed minibinders are a promising modality for oral biologics.

Standards of care and determinants of women's satisfaction with delivery services in Nepal: a multi-perspective analysis using data from a health facility-based survey.

BACKGROUND: Compliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women's satisfaction with the services they receive. METHODS: Drawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women's overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women's satisfaction with delivery care services. RESULTS: Deliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the "functional referral system" performed highest (92.0%), while "competent, motivated human resources" performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels. CONCLUSIONS: Nepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.

Changes in health facility readiness for obstetric and neonatal care services in Nepal: an analysis of cross-sectional health facility survey data in 2015 and 2021.

BACKGROUND: Nepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved. METHODS: Cross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs. RESULTS: Despite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent. CONCLUSIONS: The slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased.

Cinemeducation: A mixed methods study on learning through reflective thinking, perspective taking and emotional narratives.

INTRODUCTION: Cinemeducation describes the use of film in medical education. The M23 Cinema (M23C) comprises a film screening and subsequent discussion with experts, affected persons and the audience. Previous research suggests that participating in cinemeducation may affect emotions and attitudes. This study aimed to establish a conceptual framework and explore when learning takes place, how learning occurs and what participants learn during the M23C. METHODS: Informed by focused literature searches, discussions of the authors and the research results, a conceptual framework of the M23C was developed, comprising three dimensions (five distinct phases, learning methodology and potential impact). A mixed method study was undertaken, employing an exploratory sequential design. Initially, the qualitative component was conducted by interviewing everyone involved, comprising focus groups, expert interviews, a group interview and one narrative interview. All qualitative data were analysed using qualitative content analysis. The qualitative findings were used to inform the development of a survey among the participants of M23C evenings. The survey results were analysed descriptively. The findings generated by both data sets were integrated using the "following a thread" protocol and visualised by joint displays. RESULTS: In total, 15 participants in M23C courses, six members of the current and two of the former organising committee, two experts, two affected persons and the initiator of the M23C were included in the qualitative component (n = 28). A total of 503 participants responded to the survey. The qualitative data confirmed the relevance of the five phases and participants described reflective thinking, perspective taking and emotional narratives as the three dimensions of how they learned during the M23C. Participants reported a change in attitudes, enriching their knowledge, experiencing empathy and learning about other health professions. DISCUSSION: Our findings suggest that the M23C as a cinemeducation course provides a unique learning environment in the training of health professionals.

Emergency obstetric and newborn care signal functions: The situation in health facilities in Nepal between 2015 and 2021.

Expanding access to facility-based delivery services and improving the functionality of emergency obstetric and neonatal care (EmONC) are important strategies toward achieving a maternal mortality ratio of 70 deaths per 100,000 live births by 2030. In this study the researchers assess signal functions at designated facilities in Nepal, using Nepal Health Facility Survey data for 2015 and 2021. The functionality of basic and comprehensive EmONC sites was low, declining over the six-year period. Lack of progress may partly be attributed to the COVID-19 pandemic. Nepal needs to expand EmONC sites strategically, strengthen referral systems, improve service readiness, and periodically assess service quality.

Diagnosing virtual patients: the interplay between knowledge and diagnostic activities.

Clinical reasoning theories agree that knowledge and the diagnostic process are associated with diagnostic success. However, the exact contributions of these components of clinical reasoning to diagnostic success remain unclear. This is particularly the case when operationalizing the diagnostic process with diagnostic activities (i.e., teachable practices that generate knowledge). Therefore, we conducted a study investigating to what extent knowledge and diagnostic activities uniquely explain variance in diagnostic success with virtual patients among medical students. The sample consisted of N = 106 medical students in their third to fifth year of university studies in Germany (6-years curriculum). Participants completed professional knowledge tests before diagnosing virtual patients. Diagnostic success with the virtual patients was assessed with diagnostic accuracy as well as a comprehensive diagnostic score to answer the call for more extensive measurement of clinical reasoning outcomes. The three diagnostic activities hypothesis generation, evidence generation, and evidence evaluation were tracked. Professional knowledge predicted performance in terms of the comprehensive diagnostic score and displayed a small association with diagnostic accuracy. Diagnostic activities predicted comprehensive diagnostic score and diagnostic accuracy. Hierarchical regressions showed that the diagnostic activities made a unique contribution to diagnostic success, even when knowledge was taken into account. Our results support the argument that the diagnostic process is more than an embodiment of knowledge and explains variance in diagnostic success over and above knowledge. We discuss possible mechanisms explaining this finding.

Cinemeducation in medicine: a mixed methods study on students' motivations and benefits.

BACKGROUND: Cinemeducation courses are used to supplement more standard teaching formats at medical schools and tend to emphasise biopsychosocial aspects of health. The purpose of this paper is to explore why medical students attend the cinemeducation course M23 Cinema (M23C) at LMU Munich and whether a film screening with a subsequent expert and peer discussion benefits their studies and their future careers as medical doctors. METHODS: An exploratory sequential mixed methods study design was used. Qualitative research, i.e. three focus groups, four expert interviews, one group interview and one narrative interview, was conducted to inform a subsequent quantitative survey. Qualitative data was analysed using qualitative content analysis and quantitative data was analysed descriptively. The findings were integrated using the "following a thread" protocol. RESULTS: In total, 28 people were interviewed and 503 participants responded to the survey distributed at seven M23C screenings. Participants perceive the M23C as informal teaching where they learn about perspectives on certain health topics through the combination of film and discussion while spending time with peers. The reasons for and reported benefits of participation varied with educational background, participation frequency and gender. On average, participants gave 5.7 reasons for attending the M23C. The main reasons for participating were the film, the topic and the ability to discuss these afterwards as well as to spend an evening with peers. Attending the M23C was reported to support the students' memory with regards to certain topics addressed in the M23C when the issues resurface at a later stage, such as during university courses, in the hospital, or in their private life. CONCLUSIONS: The M23C is characterised by its unique combination of film and discussion that encourages participants to reflect upon their opinions, perspectives and experiences. Participating in the M23C amplified the understanding of biopsychosocial aspects of health and illness in students. Thus, cinemeducative approaches such as the M23C may contribute to enabling health professionals to develop and apply humane, empathetic and relational skills.

Assessment of Diagnostic Competences With Standardized Patients Versus Virtual Patients: Experimental Study in the Context of History Taking.

BACKGROUND: Standardized patients (SPs) have been one of the popular assessment methods in clinical teaching for decades, although they are resource intensive. Nowadays, simulated virtual patients (VPs) are increasingly used because they are permanently available and fully scalable to a large audience. However, empirical studies comparing the differential effects of these assessment methods are lacking. Similarly, the relationships between key variables associated with diagnostic competences (ie, diagnostic accuracy and evidence generation) in these assessment methods still require further research. OBJECTIVE: The aim of this study is to compare perceived authenticity, cognitive load, and diagnostic competences in performance-based assessment using SPs and VPs. This study also aims to examine the relationships of perceived authenticity, cognitive load, and quality of evidence generation with diagnostic accuracy. METHODS: We conducted an experimental study with 86 medical students (mean 26.03 years, SD 4.71) focusing on history taking in dyspnea cases. Participants solved three cases with SPs and three cases with VPs in this repeated measures study. After each case, students provided a diagnosis and rated perceived authenticity and cognitive load. The provided diagnosis was scored in terms of diagnostic accuracy; the questions asked by the medical students were rated with respect to their quality of evidence generation. In addition to regular null hypothesis testing, this study used equivalence testing to investigate the absence of meaningful effects. RESULTS: Perceived authenticity (1-tailed t81=11.12; P<.001) was higher for SPs than for VPs. The correlation between diagnostic accuracy and perceived authenticity was very small (r=0.05) and neither equivalent (P=.09) nor statistically significant (P=.32). Cognitive load was equivalent in both assessment methods (t82=2.81; P=.003). Intrinsic cognitive load (1-tailed r=-0.30; P=.003) and extraneous load (1-tailed r=-0.29; P=.003) correlated negatively with the combined score for diagnostic accuracy. The quality of evidence generation was positively related to diagnostic accuracy for VPs (1-tailed r=0.38; P<.001); this finding did not hold for SPs (1-tailed r=0.05; P=.32). Comparing both assessment methods with each other, diagnostic accuracy was higher for SPs than for VPs (2-tailed t85=2.49; P=.01). CONCLUSIONS: The results on perceived authenticity demonstrate that learners experience SPs as more authentic than VPs. As higher amounts of intrinsic and extraneous cognitive loads are detrimental to performance, both types of cognitive load must be monitored and manipulated systematically in the assessment. Diagnostic accuracy was higher for SPs than for VPs, which could potentially negatively affect students' grades with VPs. We identify and discuss possible reasons for this performance difference between both assessment methods.

Learning to diagnose accurately through virtual patients: do reflection phases have an added benefit?

BACKGROUND: Simulation-based learning with virtual patients is a highly effective method that could potentially be further enhanced by including reflection phases. The effectiveness of reflection phases for learning to diagnose has mainly been demonstrated for problem-centered instruction with text-based cases, not for simulation-based learning. To close this research gap, we conducted a study on learning history-taking using virtual patients. In this study, we examined the added benefit of including reflection phases on learning to diagnose accurately, the associations between knowledge and learning, and the diagnostic process. METHODS: A sample of N = 121 medical students completed a three-group experiment with a control group and pre- and posttests. The pretest consisted of a conceptual and strategic knowledge test and virtual patients to be diagnosed. In the learning phase, two intervention groups worked with virtual patients and completed different types of reflection phases, while the control group learned with virtual patients but without reflection phases. The posttest again involved virtual patients. For all virtual patients, diagnostic accuracy was assessed as the primary outcome. Current hypotheses were tracked during reflection phases and in simulation-based learning to measure diagnostic process. RESULTS: Regarding the added benefit of reflection phases, an ANCOVA controlling for pretest performance found no difference in diagnostic accuracy at posttest between the three conditions, F(2, 114) = 0.93, p = .398. Concerning knowledge and learning, both pretest conceptual knowledge and strategic knowledge were not associated with learning to diagnose accurately through reflection phases. Learners' diagnostic process improved during simulation-based learning and the reflection phases. CONCLUSIONS: Reflection phases did not have an added benefit for learning to diagnose accurately in virtual patients. This finding indicates that reflection phases may not be as effective in simulation-based learning as in problem-centered instruction with text-based cases and can be explained with two contextual differences. First, information processing in simulation-based learning uses the verbal channel and the visual channel, while text-based learning only draws on the verbal channel. Second, in simulation-based learning, serial cue cases are used to gather information step-wise, whereas, in text-based learning, whole cases are used that present all data at once.

Design and validation of a disease network of inflammatory processes in the NSG-UC mouse model.

BACKGROUND: Ulcerative colitis (UC) is a highly progressive inflammatory disease that requires the interaction of epithelial, immune, endothelial and muscle cells and fibroblasts. Previous studies suggested two inflammatory conditions in UC-patients: 'acute' and 'remodeling' and that the design of a disease network might improve the understanding of the inflammatory processes. The objective of the study was to design and validate a disease network in the NOD-SCID IL2rγnull (NSG)-UC mouse model to get a better understanding of the inflammatory processes. METHODS: Leukocytes were isolated from the spleen of NSG-UC mice and subjected to flow cytometric analysis. RT-PCR and RNAseq analysis were performed from distal parts of the colon. Based on these analyses and the effects of interleukins, chemokines and growth factors described in the literature, a disease network was designed. To validate the disease network the effect of infliximab and pitrakinra was tested in the NSG-UC model. A clinical- and histological score, frequencies of human leukocytes isolated from spleen and mRNA expression levels from distal parts of the colon were determined. RESULTS: Analysis of leukocytes isolated from the spleen of challenged NSG-UC mice corroborated CD64, CD163 and CD1a expressing CD14+ monocytes, CD1a expressing CD11b+ macrophages and HGF, TARC, IFNγ and TGFß1 mRNA as inflammatory markers. The disease network suggested that a proinflammatory condition elicited by IL-17c and lipids and relayed by cytotoxic T-cells, Th17 cells and CD1a expressing macrophages and monocytes. Conversely, the remodeling condition was evoked by IL-34 and TARC and promoted by Th2 cells and M2 monocytes. Mice benefitted from treatment with infliximab as indicated by the histological- and clinical score. As predicted by the disease network infliximab reduced the proinflammatory response by suppressing M1 monocytes and CD1a expressing monocytes and macrophages and decreased levels of IFNγ, TARC and HGF mRNA. As predicted by the disease network inflammation aggravated in the presence of pitrakinra as indicated by the clinical and histological score, elevated frequencies of CD1a expressing macrophages and TNFα and IFNγ mRNA levels. CONCLUSIONS: The combination of the disease network and the NSG-UC animal model might be developed into a powerful tool to predict efficacy or in-efficacy and potential mechanistic side effects.

Quality of life in Ethiopia's street youth at a rehabilitation center and the association with trauma.

Quality of life (QOL) tends to be lower among the homeless than the general population, and traumatic events experienced on the streets have a negative impact on QOL. Low-income countries face a high number of street youth, yet little research has been performed so far on QOL, trauma, and posttraumatic stress disorder (PTSD) among this group. This study aimed at examining the QOL of a sample of Ethiopian street youth within a rehabilitation program and at exploring whether the street youth have experienced traumatic events and show posttraumatic stress symptoms. We interviewed 84 street youths with the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF) and the Diagnostic Interview for Children and Adolescents (DICA). Mean QOL scores differed significantly between the groups assessed at the beginning and at the end of the program (Cohen's d = 0.48). Eighty-three percent of the Ethiopian street youths had experienced traumatic events, and 25.0% met criteria for PTSD according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. QOL did not differ between those with and without PTSD symptoms. These findings show the high rate of traumatic events among Ethiopian street youth and the importance for rehabilitation programs that focus on improving QOL. The results of the study may have cultural limitations.

Promoting medical competencies through international exchange programs: benefits on communication and effective doctor-patient relationships.

BACKGROUND: Universities are increasingly organizing international exchange programs to meet the requirements of growing globalisation in the field of health care. Analyses based on the programs' fundamental theoretical background are needed to confirm the learning value for participants. This study investigated the extent of sociocultural learning in an exchange program and how sociocultural learning affects the acquisition of domain-specific competencies. METHODS: Sociocultural learning theories were applied to study the learning effect for German medical students from the LMU Munich, Munich, Germany, of participation in the medical exchange program with Jimma University, Jimma, Ethiopia. First, we performed a qualitative study consisting of interviews with five of the first program participants. The results were used to develop a questionnaire for the subsequent, quantitative study, in which 29 program participants and 23 matched controls performed self-assessments of competencies as defined in the Tuning Project for Health Professionals. The two interrelated studies were combined to answer three different research questions. RESULTS: The participants rated their competence significantly higher than the control group in the fields of doctor-patient relationships and communication in a medical context. Participant responses in the two interrelated studies supported the link between the findings and the suggested theoretical background. CONCLUSION: Overall, we found that the exchange program affected the areas of doctor-patient relationships and effective communication in a medical context. Vygotsky's sociocultural learning theory contributed to explaining the learning mechanisms of the exchange program.

Perception of Pain Expression Among Surgical Patients and Families from Three Ethnic Groups of a Nation: A Multicenter Qualitative Study.

Background: Despite its universal nature; perception, coping, responses, treatment options, and overall experiences of pain are influenced by biopsychosocial factors to various extents. Pain perception, expression, and control are progressively learned behaviors among members of a society and are culture-specific. Effects of ethnicity-related culture (ethnoculture) on pain experience in a broader context have increasingly been reported. However, evidence from ethnoculturally diverse groups of a nation, particularly based on surgical patients, is limited. Therefore, as a qualitative research effort of a broader project aimed at assessing ethnocultural determinants of surgical pain management, this study explored the perception of ethnoculturally diverse patients and families about expressing surgical disease-related pain. Methods: This study follows subjectivist-interpretivist philosophical assumptions as an underpinning research paradigm. We purposively selected 11 patients for in-depth interviews and 12 patients' family members for focus group discussions in three hospitals of ethnic-based regions of Ethiopia. In the phenomenological frame, thematic analysis was employed. Finding: Ethnocultural background influences how individuals express and respond to pain according to emergent themes of finding- Pain and overlooked cultural influence, Pain expressiveness in cultural context, Stereotypes of pain expressiveness, and Bravehood through stoic response. Pain feelings are commonly hidden where the domestic culture values stoic response to pain compared to ethnoculture where pain expressiveness is encouraged. Conclusion: Individuals can express and respond to pain differently due to ethnocultural diversity within a nation. Researchers and clinicians should consider cultural context while applying the prevailing one-size-fits-all pain assessment tools among surgical patients of a nation with ethnocultural diversity.

NOD/Scid IL2Rγnull Mice Reconstituted with PBMCs from Patients with Atopic Dermatitis or Psoriasis Vulgaris Reflect the Respective Phenotype.

NSG (NOD/Scid IL2Rγnull) mice reconstituted with PBMCs donated by patients with ulcerative colitis or Crohn's disease highly reflect the respective pathological phenotype. To determine whether these findings could be applicable to atopic dermatitis (AD) and psoriasis vulgaris (PV), PBMCs isolated from patients with AD and PV were first subjected to immunological profiling. Subsequently, NSG mice were reconstituted with these PBMCs. Hierarchical clustering and network analysis revealed a distinct profile of patients with AD and PV with activated CD4+ T cells (CD69, CD25) occupying a central position in the AD network and CD4+ CD134+ cells acting as the main hub in the PV network. After dermal application of DMSO, both NSG mice reconstituted with PBMCs from donors with AD (ie, NSG-AD mice) and NSG mice reconstituted with PBMCs from donors with PV (ie, NSG-PV mice) exhibited increased clinical, skin, and histological scores. Immunohistochemical analysis, frequencies of splenic human leukocytes, and cytokine expression levels indicated that CD4+ CD69+ cells, M1 and TSLP receptor-expressing monocytes, switched B cells, and monocyte chemoattractant protein 3 were the driving factors of inflammation in NSG-AD mice. In contrast, inflammation in NSG-PV mice was characterized by an increase in fibroblasts in the epidermis, frequencies of CD1a-expressing monocytes, and IL-17 levels. Therefore, the pathological phenotypes of NSG-AD mice and NSG-PV mice differ and partially reflect the respective human diseases.

NOD-scid IL2R γnull mice engrafted with human peripheral blood mononuclear cells as a model to test therapeutics targeting human signaling pathways.

BACKGROUND: Animal models of human inflammatory diseases have limited predictive quality for human clinical trials for various reasons including species specific activation mechanisms and the immunological background of the animals which markedly differs from the genetically heterogeneous and often aged patient population. OBJECTIVE: Development of an animal model allowing for testing therapeutics targeting pathways involved in the development of Atopic Dermatitis (AD) with better translatability to the patient. METHODS: NOD-scid IL2R γnull mice engrafted with human peripheral blood mononuclear cells (hPBMC) derived from patients suffering from AD and healthy volunteers were treated with IL-4 and the antagonistic IL-4 variant R121/Y124D (Pitrakinra). Levels of human (h)IgE, amount of B-, T- and plasma- cells and ratio of CD4 : CD8 positive cells served as read out for induction and inhibition of cell proliferation and hIgE secretion. Results were compared to in vitro analysis. RESULTS: hIgE secretion was induced by IL-4 and inhibited by the IL-4 antagonist Pitrakinra in vivo when formulated with methylcellulose. B-cells proliferated in response to IL-4 in vivo; the effect was abrogated by Pitrakinra. IL-4 shifted CD4 : CD8 ratios in vitro and in vivo when hPBMC derived from healthy volunteers were used. Pitrakinra reversed the effect. Human PBMC derived from patients with AD remained inert and engrafted mice reflected the individual responses observed in vitro. CONCLUSION: NOD-scid IL2R γnull mice engrafted with human PBMC reflect the immunological history of the donors and provide a complementary tool to in vitro studies. Thus, studies in this model might provide data with better translatability from bench to bedside.

Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality.

BACKGROUND: Nepal has made substantial progress in reducing under-five mortality and is on track to achieve Millennium Development Goal 4, but advances in neonatal health are less encouraging. The objectives of this study were to assess relative and absolute inequalities in neonatal mortality over time, and to review experience with major programs to promote neonatal health. METHODS: Using four nationally representative surveys conducted in 1996, 2001, 2006 and 2011, we calculated neonatal mortality rates for Nepal and for population groups based on child sex, geographical and socio-economic variables using a true cohort log probability approach. Inequalities based on different variables and years were assessed using rate differences (rd) and rate ratios (rr); time trends in neonatal mortality were measured using the annual rate of reduction. Through literature searches and expert consultation, information on Nepalese policies and programs implemented since 1990 and directly or indirectly attempting to reduce neonatal mortality was compiled. Data on timeline, coverage and effectiveness were extracted for major programs. RESULTS: The annual rate of reduction for neonatal mortality between 1996 and 2011 (2.8 percent per annum) greatly lags behind the achievements in under-five and infant mortality, and varies across population groups. For the year 2011, stark absolute and relative inequalities in neonatal mortality exist in relation to wealth status (rd = 21.4, rr = 2.2); these are less pronounced for other measures of socio-economic status, child sex and urban-rural residence, ecological and development region. Among many efforts to promote child and maternal health, three established programs and two pilot programs emerged as particularly relevant to reducing neonatal mortality. While these were designed based on national and international evidence, information about coverage of different population groups and effectiveness is limited. CONCLUSION: Neonatal mortality varies greatly by socio-demographic variables. This study clearly shows that much remains to be achieved in terms of reducing neonatal mortality across different socio-economic, ethnic and geographical population groups in Nepal. In moving forward it will be important to scale up programs of proven effectiveness, conduct in-depth evaluation of promising new approaches, target unreached and hard-to-reach populations, and maximize use of financial and personnel resources through integration across programs.

Differences in perceptions of capability, autonomy, and expectations between residents and surgical team members in executing EPAs in Ethiopian medical education.

Background: Entrustable Professional Activities (EPAs) are units of professional practice that are defined as tasks or responsibilities that are entrusted to an unsupervised execution by a trainee. In 2021, a framework of 29 EPAs was developed for surgical residency training programs in Ethiopia, with the goal of residents being able to perform independently by the time they graduate. However, studies show that surgical residents lack confidence and are unable to execute EPAs autonomously upon graduation, and concerns have been raised about graduate competencies in EPA execution. The goal of this research is to assess how surgical team members judge/perceive residents' performance in executing these EPAs autonomously at the time of graduation and how residents rate their own capability and autonomy in executing EPAs in order to systematically introduce and implement EPAs in Ethiopian medical education. Methods: A survey was conducted in the Departments of Surgery at four residency training institutions in Ethiopia. All eligible surgical team members and final-year general surgery residents were invited to participate. Surgical team members were asked to rate the observed performance of a group of graduating surgical residents in each of the 29 EPAs, and residents were asked to rate their own capability in executing EPAs. The analysis focused on variations in performance ratings between surgical team members and residents, as well as across surgical team members. Results: A total of 125 surgical team members and 49 residents participated in this study. Residents rate their competence in performing these EPAs higher than surgical team members, mean 4.2 (SD = 0.63) vs. 3.7 (SD = 0.9). A statistically significant difference in perceptions of capability, autonomy, and expectations in executing EPAs was observed between the two groups of study (p = 0.03, CI: 0.51-0.95), as well as within surgical team members (p < 0.001). Conclusions: Differences in perceptions of capability, autonomy, and expectations between residents and surgical team members, as well as within faculty members, were seen in executing EPAs. There were concerns about graduate surgical residents' competence to execute EPAs autonomously at the time of graduation. Surgical team members perceived that a set of graduating surgical residents are not yet safe to perform these EPAs independently (without supervision) and still requires distant supervision.

Vicarious learning during simulations: is it more effective than hands-on training?

CONTEXT: Doctor-patient communication skills are often fostered by using simulations with standardised patients (SPs). The efficiency of such experiences is greater if student observers learn at least as much from the simulation as do students who actually interact with the patient. OBJECTIVES: This study aimed to investigate whether the type of simulation-based learning (learning by doing versus vicarious learning) and the order in which these activities are carried out (learning by doing → vicarious learning versus vicarious learning → learning by doing) have any effect on the acquisition of knowledge on effective doctor-patient communication strategies. In addition, we wished to examine the extent to which an observation script and a feedback formulation script affect knowledge acquisition in this domain. METHODS: The sample consisted of 200 undergraduate medical students (126 female, 74 male). They participated in two separate simulation sessions, each of which was 30 minutes long and was followed by a collaborative peer feedback phase. Half of the students first performed (learning by doing) and then observed (vicarious learning) the simulation, and the other half participated in the reverse order. Knowledge of doctor-patient communication was measured before, between and after the simulations. RESULTS: Vicarious learning led to greater knowledge of doctor-patient communication scores than learning by doing. The order in which vicarious learning was experienced had no influence. The inclusion of an observation script also enabled significantly greater learning in students to whom this script was given compared with students who were not supported in this way, but the presence of a feedback script had no effect. CONCLUSIONS: Students appear to learn at least as much, if not more, about doctor-patient communication by observing their peers interact with SPs as they do from interacting with SPs themselves. Instructional support for observing simulations in the form of observation scripts facilitates both vicarious learning and learning by doing. An observation script may focus learners' attention on the important aspects of doctor-patient communication and increase the content-related accuracy of peer feedback.

Comparative cross-sectional study of empathy among first year and final year medical students in Jimma University, Ethiopia: steady state of the heart and opening of the eyes.

BACKGROUND: There is general consent that empathy is crucial for the physician-patient relationship and thus an important issue in medical education. This comparative study was designed to examine the differences in empathy between first year and final year medical students in Jimma University, Ethiopia. METHODS: A comparative cross-sectional study among 131 first year and 106 final year medical students was conducted in Jimma University, Ethiopia on academic year 2010/11. The study subjects were selected using simple random sampling technique from the list of the students. Study participation was voluntary. The Balanced Emotional Empathy Scale (BEES) was used for the detection of "heart-reading", i.e. emotional empathy and the Reading the Mind in the Eyes test (RME-R test) to evaluate "mind-reading", i.e. cognitive empathy. We performed t-test to compare the mean difference in empathy and RME-R scores between the two groups of students. A linear regression was computed to identify potential factors influencing the BEES and RME-R. RESULTS: Out of the total 237 students, 207 (87.3%) were males. The mean age of first year and final year students was 19.3 ± 1.1 and 24.0 ± 1.4 years respectively. First year students have scored 40.6 ± 23.8 while final year students scored 41.5 ± 20.8 mean in the BEES measuring emotional empathy score. However, this difference was not statistically significant (t = -0.30, df = 231, P-value >0.05). Final year students had significantly higher mean cognitive empathy score (17.8 ± 4.5) than first year students (14.4 ± 4.8) [ß = 2.7, 95%CI (1.20, 4.13)]. Males had scored lower cognitive [ß = -2.5, 95%CI (-4.37, -0.66)] and emotional empathy [ß = -12.0, 95%CI (-21.66, -5.46)]. CONCLUSIONS: Low emotional (BEES) and cognitive empathy sores were found in first year and final year students of Jimma University could have implications on the medical education curricula. Medical education targeted at enhancing emotional empathy and increasing cognitive empathy is required by segmenting with gender for effective physician-patient interaction. The influence of empathy on clinical competence should be studied using more rigorous design.

Development of an Entrustable Professional Activities (EPA) Framework to Inform Surgical Residency Training Programs in Ethiopia: A Three-round National Delphi Method Study.

BACKGROUND: Entrustable Professional Activities (EPAs) have been proposed as a means to translate competencies into clinical practice. Although EPAs for residency training have become available, 1 set of core EPAs cannot automatically be transferred from one context to another due to cultural variability. Further, there is a lack of African- and Asian-based EPA development and implementation studies. We developed an end-of-training EPAs framework to inform surgical residency training programs in the local context of Ethiopian medical education. METHODS: A three-round Delphi method was used to establish consensus about important surgical EPAs among experts. A total of 136 experts representing all surgical residency training institutions in Ethiopia were invited to participate. Round 1 & 2 consisted of senior expert panelists (n = 8) to identify potential EPAs and determine the content validity. Round 3 consisted of a survey (n = 128) to further validate the identified EPAs by attending surgeons who work with them. Each EPA had to achieve at least 80% or higher agreement among experts to be considered having acceptable content validity. RESULTS: In round 1, a total of 272 EPAs were proposed, reduced, and grouped to 39 consented EPAs. In round 2, the same experts rated each EPA's relevance, resulting in 32 EPAs with a satisfactory item-level content validity index (I-CVI > 0.83). Overall, in the survey in round 3, 29 EPAs met the standard criterion for acceptability (S-CVI/Ave = 0.90) and achieved a high degree of final consensus (ICC = 0.998, 95% CI [0.996, 0.999]; (F = 439.2, p < 0.0001). CONCLUSIONS: The framework of 29 validated and accepted EPAs can guide future surgical residency training programs in the Ethiopian medical education context. The framework allows programs to move from a time-dependent to an outcome-based model and transforms traditional assessment into entrustment decisions. Thus, the use of the framework can improve the quality of training and patient care in Ehtiopia.