Assessing dynamic violence risk: Common language risk levels and recidivism rates for the Violence Risk Scale.

The present study features the development of new risk categories and recidivism estimates for the Violence Risk Scale (VRS), a violence risk assessment and treatment planning tool. We employed a combined North American multisite sample (k = 6, N = 1,338) of adult mostly male offenders, many with violent criminal histories, from correctional or forensic mental health settings that had complete VRS scores from archival or field ratings and outcome data from police records (N = 1,100). There were two key objectives: (a) to identify the rates of violent recidivism associated with VRS scores and (b) to generate updated evidence-based VRS violence risk categories with external validation. To achieve the first objective, logistic regression was applied using VRS pretreatment and change scores on treated samples with a minimum 5-year follow-up (k = 5, N = 472) to model 2-, 3-, and 5-year violent and general recidivism estimates, with the resulting logistic regression algorithms retained to generate a VRS recidivism rates calculator. To achieve the second objective, the Council of State Governments' guidelines were applied to generate five risk levels using the common language framework using percentiles, risk ratios (from Cox regression), and absolute violent and general recidivism estimates (from logistic regression). Construct validity of the five risk levels was examined through group comparisons on measures of risk, need, protection, and psychopathy obtained from the constituent samples. VRS applications to enhance risk communication, treatment planning, and violence prevention in light of the updated recidivism estimates and risk categories are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Improving IBD Transition, Self-management, and Disease Outcomes With an In-clinic Transition Coordinator.

OBJECTIVES: Deficits in the preparation of patients with inflammatory bowel disease (IBD) who are transitioning to adult care are known yet studies presenting outcome data of transition interventions in IBD are lacking. We present data evaluating the impact of a transition coordinator on behavioral and clinical transition outcomes. METHODS: A retrospective chart review identified 135 patients who had met with our transition coordinator and completed the Transition Readiness Assessment Questionnaire before, and 1 year after, the intervention. Changes in transition readiness, self-management skill acquisition, and clinical outcomes (eg, number of patients transferred vs "bounced back" to pediatrics, percentage of patients over age 21, changes in disease remission) were examined and compared with patients who received no intervention. RESULTS: Intervention participants demonstrated a significant increase in transition readiness, F(1, 134) = 24.34, P < 0.001, and self-management skill acquisition, F(1, 134) = 5.61, P < 0.05. The percentage of patients in remission significantly increased from pre- to post-intervention, χ(134) = 9.03, P < 0.01. There were no significant changes in the comparison population (Ps > 0.05). Following implementation of our programming, the percentage of patients over age 21 decreased by 33.07%. CONCLUSIONS: A 1-time transition coordinator-led intervention improved adolescent transition readiness and acquisition of self-management skills. The proportion of young adult patients retained in pediatric care was reduced. Benefits of hiring a transition coordinator are discussed.

Multi-Site Comparison of Patient, Parent, and Pediatric Provider Perspectives on Transition to Adult Care in IBD.

PURPOSE: This multi-site study examines patient, parent, and pediatric provider perspectives on what is most important for successful transition. DESIGN AND METHODS: Using the Transition Readiness Assessment Questionnaire, 190 participants recruited from two pediatric IBD centers selected the top five skills they considered "most important for successful transition." Rankings were summarized and compared by group. RESULTS: While patients, parents, and clinicians all identified "calling the doctor about unusual changes in health" and "taking medications correctly and independently" as being important, each stakeholder group qualitatively and statistically differed in terms of transition readiness skills emphasized. Patients endorsed "calling the doctor about unusual changes in health" and "being knowledgeable about insurance coverage," as being most important to successful transition while parents emphasized health monitoring and problem solving. Pediatric providers emphasized adherence to treatment and reporting unusual changes in health. There were statistically significant differences in endorsement rates across participants for seven transition readiness skills. Patients agreed with providers 80% of the time and with their parents 40% of the time. Parent-provider agreement was 60%. CONCLUSIONS: Although there was some overlap across groups, areas of emphasis differed by informant. Patients emphasized skills they need to learn, parents emphasized skills they most likely manage for their children, and providers emphasized skills that directly impact their provision of care. PRACTICE IMPLICATIONS: Patient, parent, and provider beliefs all need to be considered when developing a comprehensive transition program. Failure to do so may result in programs that do not meet the needs of youth with IBD.

Concerns, Barriers, and Recommendations to Improve Transition from Pediatric to Adult IBD Care: Perspectives of Patients, Parents, and Health Professionals.

BACKGROUND: The current transition literature is a fragmented assortment of studies examining select subsections of transition stakeholders. METHODS: Adolescent/young adult patients with IBD (40% transferred to adult care), parents, and health providers (53.8% adult providers) participated in 1 of 6 focus group interviews focused on concerns and needs surrounding transition to adult care. Data were analyzed through directed content analysis. RESULTS: Transition needs/concerns focused on (1) losing relationships with pediatric providers, (2) perceptions of poorer quality care from adult providers, (3) high parent involvement preventing the development of youth self-management skills, and (4) finances and insurance. Suggestions to improve transition to adult care included the following: (1) meeting alone with adolescents during appointments, (2) providing concrete guidance on how/when to transition responsibility, and (3) increasing accountability for adolescents. Recommendations to improve transfer included the following: (1) providing more information about the transfer process and adult providers, (2) obtaining peer support and mentoring, and (3) setting goals and deadlines for transfer. CONCLUSIONS: Inclusion of several stakeholder groups allowed for the identification of commonalities across groups as well as their unique needs and concerns surrounding transition to adult care. Concerns and recommendations by participants should be targeted in future transition program efforts.

Transition readiness skills acquisition in adolescents and young adults with inflammatory bowel disease: findings from integrating assessment into clinical practice.

BACKGROUND: Almost 80% of adult gastroenterologists report inadequacies in the preparation of patients transferred from pediatrics. To improve transition to adult care, it is important to identify the specific deficits that patients are demonstrating before transfer. We present data from a clinic-wide assessment of transition readiness skill acquisition in adolescents/young adults with IBD. METHODS: A total of 195 patients (age, 16-25 yr) with IBD completed the Transition Readiness Assessment Questionnaire. Patient age, diagnosis, time since diagnosis, physician global assessment, and patient and parent disease management confidence ratings were extracted from the medical record. Transition Readiness Assessment Questionnaire scores were compared with a benchmark established by an interdisciplinary, multi-institutional Transition Task Force. RESULTS: Only 5.6% of older adolescents/young adults on the verge of transfer to adult care met our institutional benchmark (3.5% of adolescents, 7.3% of young adults). Patients reported mastery of 9.10 ± 4.68 out of 20 Transition Readiness Assessment Questionnaire items. Transition readiness was associated with older age (r = 0.27, P < 0.001) and female gender (F(1,192) = 13.81, P < 0.001) but not time since diagnosis, physician global assessment, or confidence ratings. Deficits in health care utilization/self-advocacy (e.g., understanding insurance, scheduling appointments/following up on referrals), and self-management (e.g., filling/reordering prescriptions) were observed. CONCLUSIONS: Most patients on the verge of transferring to adult care are not demonstrating transition readiness. Deficits observed represent modifiable behaviors. Using data-driven assessments to guide interventions to enhance transition readiness may minimize the retention of young adult patients in pediatrics and result in patients who are better prepared for adult care.

Comparing the DN4 tool with the IASP grading system for chronic neuropathic pain screening after breast tumor resection with and without paravertebral blocks: a prospective 6-month validation study.

Investigating protective strategies against chronic neuropathic pain (CNP) after breast cancer surgery entails using valid screening tools. The DN4 (Douleur Neuropathique en 4 questions) is 1 tool that offers important research advantages. This prospective 6-month follow-up study seeks to validate the DN4 and assess its responsiveness in screening for CNP that satisfies the International Association for the Study of Pain (IASP) definition and fulfills its grading system criteria after breast tumor resection with and without paravertebral blocks (PVBs). We randomized 66 females to standardized general anesthesia and sham subcutaneous injections, or PVB and total intravenous anesthesia. The 6-month CNP risk was assessed using the IASP grading system and the DN4 screening tools. We evaluated the DN4 sensitivity, specificity, and responsiveness in capturing the impact of PVB on the CNP risk relative to the IASP grading system. Data from 64 patients showed similar demographic characteristics in both groups. Twenty patients in both groups met the grading system CNP criteria; among these, 18 patients also met the DN4 CNP criteria. Furthermore, 15 patients in both groups did not meet the grading system CNP criteria; among these, 9 patients also did not meet the DN4 CNP criteria. Therefore, the sensitivity and specificity of the DN4 were estimated at 90% and 60%, respectively. Both screening tools suggested that PVB reduced the 6-month CNP risk. Our results suggest that the DN4 can reliably identify CNP at 6 months after breast tumor resection and detect the preincisional PVB effect on the risk of developing such pain.

Ultrasound-guided multilevel paravertebral blocks and total intravenous anesthesia improve the quality of recovery after ambulatory breast tumor resection.

BACKGROUND: Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection. METHODS: Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1-T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time. RESULTS: Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas-based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced. CONCLUSION: Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

Surgical safety checklist: implementation in an ambulatory surgical facility.

PURPOSE: In 2007, the World Health Organization created a Surgical Safety Checklist (SSC) that encompassed a simple set of surgical safety standards. The threefold purpose of this study was to add ambulatory-specific items to the SSC, to introduce the items into an ambulatory surgical facility, and to determine if patient outcomes regarding postoperative pain and nausea/vomiting improved following implementation. In addition, safety attitudes, antibiotic timing, regional anesthesia/nerve blocks, preemptive pain medications, prophylactic antiemetics, length of stay, and hospital admission were also assessed. METHODS: After Research Ethics Board approval, staff complete a Safety Attitudes Questionnaire. Seven items were added to the SSC. Data were then collected on 180 surgical cases before SSC implementation and 195 cases following implementation. Compliance with each section of the SSC was assessed. RESULTS: On postoperative day one, the median (97.5% confidence interval [CI]) difference between pre- and post-implementation pain scores was 0.5 (97.5% CI, 0 to 1; P = 0.13), and the median difference in the rate of post-discharge nausea/vomiting was -8.4% (97.5% CI, -17.9 to 1.1; P = 0.06). There was no improvement in safety attitudes or any of the secondary outcomes, with the exception of the use of preemptive pain medications. Compliance with the three sections of the checklist, i.e., briefing, time out, and debriefing was 99.49%, 97.95%, and 96.92%, respectively. There was low compliance in verbalization of the added "ambulatory-specific items". CONCLUSION: Potential reasons for lack of uptake and integration include poor "user" buy-in, an overly lengthy checklist, and lack of prioritization of ambulatory-specific items. A shortened SSC was developed based on the results of this study. This trial was registered at ClinicalTrials.gov ID: NCT00934310.

Determination of the psychometric properties of a behavioural marking system for obstetrical team training using high-fidelity simulation.

BACKGROUND: To determine the effectiveness of high-fidelity simulation for team training, a valid and reliable tool is required. This study investigated the internal consistency, inter-rater reliability and test-retest reliability of two newly developed tools to assess obstetrical team performance. METHODS: After research ethics board approval, multidisciplinary obstetrical teams participated in three sessions separated by 5-9 months and managed four high-fidelity simulation scenarios. Two tools, an 18-item Assessment of Obstetric Team Performance (AOTP) and a six-item Global Assessment of Obstetric Team Performance (GAOTP) were used.(5) Eight reviewers rated the DVDs of all teams' performances. RESULTS: Two AOTP items were consistently incomplete and omitted from the analyses. Cronbach's α for the 16-item AOTP was 0.96, and 0.91 for the six-item GAOTP. The eight-rater α for the GAOTP was 0.81 (single-rater intra-class correlation coefficient, 0.34) indicating acceptable inter-rater reliability. The 'four-scenario' α for the 12 teams was 0.79 for session 1, 0.88 for session 2, and 0.86 for session 3, suggesting that performance is not being strongly affected by the context specificity of the cases. Pearson's correlation of team performance scores for the four scenarios were 0.59, 0.35, 0.40 and 0.33, and for the total score across scenarios it was 0.47, indicating moderate test-retest reliability. CONCLUSIONS: The results from this study indicate that the GAOTP would be a sufficient assessment tool for obstetrical team performance using simulation provided that it is used to assess teams with at least eight raters to ensure a sufficiently stable score. This could allow the quantitative evaluation of an educational intervention.

Nontechnical skills assessment after simulation-based continuing medical education.

INTRODUCTION: Human factors have been identified as root causes of human error in medicine. The "Anesthetists' Non-Technical Skills (ANTS) system" evaluates the effect of simulation training and debriefing on nontechnical skills (NTS). Studies suggest that residents' NTS may improve after simulation training but the effect on NTS of practicing anesthesiologists is unclear. The purpose of this study was to determine whether high-fidelity simulation training and debriefing improved the NTS of practicing anesthesiologists using the ANTS tool. METHODS: In a previous study, 67 practicing anesthesiologists managed a 45-minute standardized anesthetic case using high-fidelity simulation and returned 5 to 9 months later to manage a second case. After Research Ethics Board approval, two blinded video reviewers, trained in the use of the ANTS system, evaluated archived videotapes of the 59 subjects who completed both sessions. Results were analyzed with a mixed-design analysis of variance. Interrater reliability was calculated using the intraclass correlation coefficient. RESULTS: Interrater reliability for the ANTS scoring was 0.436, P < 0.05. Overall, ANTS scores improved approximately 5% from session 1 to 2 (P < 0.01), but there was no effect due to debriefing. The situational awareness ANTS category showed a statistically significant effect of debriefing (P < 0.05). CONCLUSIONS: The relatively short simulation intervention, the length of time until the posttest was completed, well-developed NTS in practicing physicians, and a tool that might not be the optimal method of measurement may all account for the lack of improvement in NTS of practicing anesthesiologists as demonstrated in this study.

Simulation performance checklist generation using the Delphi technique.

PURPOSE: Performance assessment using high fidelity simulation is problematic, due to the difficulty in developing valid and reliable evaluation tools. The Delphi technique is a consensus based content generation method used for multiple purposes such as policy development, best-evidence practice guidelines and competency assessments. The purpose of this study was to develop checklists using a modified Delphi technique to evaluate the performance of practicing anesthesiologists managing two simulated scenarios. METHODS: The templates for two simulation scenarios were emailed to five anesthesiologists who were asked to generate performance items. Data were collated anonymously and returned. An a priori decision was made to delete items endorsed by

Evaluating teamwork in a simulated obstetric environment.

BACKGROUND: The National Confidential Enquiry into Maternal Deaths identified "lack of communication and teamwork" as a leading cause of substandard obstetric care. The authors used high-fidelity simulation to present obstetric scenarios for team assessment. METHODS: Obstetric nurses, physicians, and resident physicians were repeatedly assigned to teams of five or six, each team managing one of four scenarios. Each person participated in two or three scenarios with differently constructed teams. Participants and nine external raters rated the teams' performances using a Human Factors Rating Scale (HFRS) and a Global Rating Scale (GRS). Interrater reliability was determined using intraclass correlations and the Cronbach alpha. Analyses of variance were used to determine the reliability of the two measures, and effects of both scenario and rater profession (R.N. vs. M.D.) on scores. Pearson product-moment correlations were used to compare external with self-generated assessments. RESULTS: The average of nine external rater scores showed good reliability for both HFRS and GRS; however, the intraclass correlation coefficients for a single rater was low. There was some effect of rater profession on self-generated HFRS but not on GRS. An analysis of profession-specific subscores on the HFRS revealed no interaction between profession of rater and profession being rated. There was low correlation between externally and self-generated team assessments. CONCLUSIONS: This study does not support the use of the HFRS for assessment of obstetric teams. The GRS shows promise as a summative but not a formative assessment tool. It is necessary to develop a domain specific behavioral marking system for obstetric teams.

Applying theory to practice in undergraduate education using high fidelity simulation.

High-fidelity patient simulation allows students to apply their theoretical knowledge of pharmacology and physiology to practice. The purpose of this study was to determine if experiential education using high-fidelity simulation improves undergraduate performance scores on simulation-based and written examinations. After receiving research ethics board approval, students completed a consent form and then answered a ten question multiple-choice quiz to identify their knowledge regarding the management of cardiac arrhythmias. Four simulation scenarios were presented and students worked through each scenario as a team. Faculty facilitated the sessions and feedback was given using students' videotaped performances as a template for discussion. Performance evaluation scores using predetermined checklists and global rating scales were completed. Students then reviewed the American Heart Association guidelines for the management of unstable cardiac arrhythmias. The afternoon session involved repetition of the four case scenarios with the same teams involved but different team leaders. Students then repeated the quiz they received in the morning. Descriptive statistics, paired t-test and repeated measures analysis of variance (ANOVA) were used to analyse results. Two hundred and ninety-nine students completed the study. There was a statistically significant improvement in performance on the pharmacology written test. Simulation team performance also statistically improved and a good correlation between checklist and global rating scores were demonstrated in all but one scenario. Student evaluation of the experience was extremely positive. High-fidelity simulation can be used to allow students to apply theoretical knowledge to practice in a safe and realistic environment. Results of this study indicate that simulation is a valuable learning experience and bridges the gap between theory and practice. Simulation technology has the potential to provide an enriching venue to examine the role of communication and dynamics of novice learners in team environments.

Barriers to use of simulation-based education.

PURPOSE: Barriers to simulation-based education in postgraduate and continuing education for anesthesiologists have not been well studied. We hypothesized that the level of training may influence attitudes towards simulation-based education and impact on the use of simulation. This study investigated this issue at the University of Toronto which possesses two sites equipped with high-fidelity patient simulators. METHODS: A 40-question survey of experiences, perceptions, motivations and perceived barriers to simulation-based education, was distributed to 154 anesthesiologists attending a departmental conference. Data were analyzed using descriptive statistics and associations between responses were assessed using either the Chi-Square statistic or a one-way analysis of variance. RESULTS: The rate of response was 58%. Residents had experienced simulation-based education (96%) more often than staff (58%) and fellows (36%), (P < 0.001 respectively). Residents had also attended more simulation sessions than staff and fellows (mean 2.8 vs 1.05 and 1.04, P < 0.001 respectively). Residents and fellows found simulation-based education more relevant for their training than staff (88% vs 65%, P < 0.05). Eighty-one percent of the respondents identified at least one significant barrier that prevents or limits them from attending simulator sessions. Staff anesthesiologists perceived multiple barriers and identified 'time' and 'financial issues' as significant barriers. CONCLUSION: Anesthesiologists' level of training influences their attitudes towards and their perceptions of simulation-based education. This survey has identified perceived barriers that may limit a wider utilization of simulation. These results may be used to implement targeted actions such as course design, incentives, and information strategies, which could improve access and future use of simulation.

Simulation technology in training students, residents and faculty.

PURPOSE OF REVIEW: We provide an overview of the developments in medical education and assessment using high-fidelity simulation. Both descriptive and research papers recently published in the English language are included in this review. RECENT FINDINGS: The majority of articles reviewed are descriptive in nature, outlining the use of simulation for various educational purposes in undergraduate, postgraduate and continuing medical education. Some articles focus on the use of simulation for the acquisition of technical skills in different surgical disciplines using part-task simulation. Other disciplines such as emergency medicine, critical care, paediatrics and nursing have also contributed to the literature in this area. Very little research in the area of simulation is evident in the literature addressing the actual value or the reliability and validity of high-fidelity simulation as an evaluation tool during this time period. A strong interest in decreasing human error and the improvement in patient safety may indicate the future direction of high-fidelity simulation. SUMMARY: Simulation is receiving increasing support as an educational tool and in its use for evaluation purposes. Research into this area is still somewhat limited. As the research impetus increases in the future, we may see simulation as a major focus in all disciplines with respect to its use in the improvement of patient safety. Team training, including both personality and attitudinal issues similar to those performed in other high hazard industries, may become increasingly evident in the literature in the coming decade.

Identification of gaps in the achievement of undergraduate anesthesia educational objectives using high-fidelity patient simulation.

UNLABELLED: In this study we sought to identify educational gaps in medical students' knowledge using human patient simulation. The Undergraduate Committee developed 10 scenarios based on anesthesia curriculum objectives. Checklists were designed by asking 15 faculty members involved in undergraduate education to propose expected performance items at a level appropriate for medical students. These items consisted of essential performance items as well as critical management omissions. Checklists were used to score students' videotaped performances. Checklist items common to more than one scenario were grouped for data analysis and identification of gaps in achievement of educational objectives. Eighteen groupings of expected performance criteria and 8 groupings of critical management omissions were established. Performance data of 165 students were analyzed. Common management omissions were lack of adequate airway management, failure to check blood pressure, and failure to stop the anesthetic. Students reliably performed defibrillation, notation of vital signs, auscultation of lung fields, and administration of IV fluids. The most common critical omissions were failing to a). call for help, b). take a history/do physical examination, and c). prepare airway equipment. Management and critical omissions noted during performance assessments provide information regarding students' educational needs, enabling faculty to focus attention on demonstrated areas of weakness. IMPLICATIONS: This study involved the use of high-fidelity patient simulation that offers standardized clinical experiences that can detect gaps in medical students' knowledge base and clinical performance. This information can be used by faculty to focus their teaching efforts to ensure competency in important educational areas.

Misexpression of genes in mouse tooth germs using in vitro electroporation.

Mouse mandible primodia in vitro explant cultures are an excellent model for investigating tooth development. Mandibular arch epithelial-mesenchymal tissue recombinations and implantation of beads soaked in signaling proteins have revealed much about the early events of odontogenesis. These approaches do, however, suffer from several disadvantages, in particular the nonphysiological nature of beads soaked in very high concentrations of proteins and the inability to directly manipulate receptor and transcription factor gene expression. We have utilized the technique of DNA electroporation to deliver targeted gene expression to defined areas of mandibular arch epithelium or mesenchyme. This approach is being used to (a) ectopically express epithelial signals such as Shh and Bmp-4, (b) inhibit BMP and FGF signaling by expression of dominant negative receptors and antagonists, and (c) misexpress transcriptional factors in the mesenchyme. The technical aspects of electroporation are discussed, as well as preliminary findings.

A worldwide survey of the use of simulation in anesthesia.

PURPOSE: To gather information regarding the global use of simulation technology in education, evaluation and research in anesthesia. METHODS: The WorldWide Web was searched and located sites with simulation centres (n = 158) were mailed a 67-item questionnaire requesting information regarding demographics, personnel, education use and research involvement. Comments were solicited. Medical school data only are reported in this article. RESULTS: Two web sites were used to generate the list of simulation centres. Sixty responses were received (38%), with 41 emanating from medical schools. Seventy-seven percent of centres were involved in undergraduate education and 85% in postgraduate education. Few centres were involved in evaluation and/or competency assessments. Sixty-one percent of centres indicated ongoing research with a further 25% interested in international collaboration. University or university departmental-based funding largely supported simulation technology used in medical schools. The lack of financial and human resources was the single most common problem identified by respondents. CONCLUSIONS: From the survey responses received, opportunities for the simulator to be used for the assessment of performance appear to be under-utilized. This may be due to the lack of research in this area, lack of standardized, valid and reliable tests and the fact that most centres have only recently acquired this technology. Further research supporting the use of the simulator in education and evaluation is required.

Nitroglycerin as a uterine relaxant: a systematic review.

OBJECTIVE: To evaluate the effectiveness of nitroglycerin as a uterine relaxant for preterm labour, fetal extraction at Caesarean section, external version, embryo transfer, cervical dilation for first trimester pregnancy termination, and primary dysmenorrhea. DESIGN: A systematic review of randomized control trials (RCTs) of nitroglycerin in obstetrics and gynaecology. METHODS: We searched PubMed (1966-2001), the Cochrane Controlled Trials Register, and the International Journal of Obstetric Anesthesia using text terms quot:nitroglycerin," "glyceryl trinitrate," "uterus," "uterine," and "relaxation." The last search was conducted in January 2001. References from review articles and abstracts from major scientific meetings (1997-2000) were reviewed for relevant publications. RCTs comparing nitroglycerin to either placebo or another therapeutic intervention (ritodrine, magnesium sulphate, and prostaglandin) and whose quality score was equal to or greater than 2 were included (Class I evidence as described in the Report of the Canadian Task Force on the Periodic Health Exam). RESULTS: Sixty articles were retrieved of which 13 were RCTs. Nitroglycerin was more effective for arresting preterm labour than placebo but not more effective when compared to ritodrine or magnesium. Nitroglycerin was not superior to placebo for uterine relaxation for either fetal extraction at Caesarean section or for external version. There were no differences in ease of embryo transfers when nitroglycerin spray was compared to placebo. In first trimester pregnancy terminations, less force was required to dilate the cervix when nitroglycerin was compared to no treatment. The incidence of preeclampsia was not reduced by nitroglycerin but fewer complications were noted when compared to the placebo group. In patients with primary dysmenorrhea, nitroglycerin significantly decreased pain. CONCLUSION: Although nitroglycerin is widely used, its superiority over currently used tocolytic agents is unproven. (Class C recommendation) Nitroglycerin has been demonstrated to decrease pain associated with dysmenorrhea. (Class A recommendation)

Experiential learning in an anaesthesia simulation centre: analysis of students' comments.

The anesthesia computer-controlled patient simulator offers a valuable experiential learning experience for undergraduate medical students. The purpose of this study was to gather students' opinions of the simulator learning experiences and to study and analyze their comments regarding the nature of the learning. All fourth-year medical students were invited to participate in a simulator session during their anesthesia rotation. A satisfaction survey was administered and the qualitative data were analyzed. A total of 145 students completed the questionnaire (100% return rate). Most students (88%) reported the session to be a positive learning experience that provided opportunities for applying their knowledge in a realistic environment. Some students indicated a lack of comfort in the environment but this did not appear to inhibit performance. Student comments highlighted the value of the learning experience and provided insights into the nature of the learning. The computer-controlled patient simulator offers new and challenging opportunities for medical students to apply their knowledge and practice working through an Anesthesia case without endangering patient safety.