Evaluation of high-fidelity and virtual reality simulation platforms for assessing fourth-year medical students' encounters with patients in need of urgent or emergent care.

BACKGROUND: Medical students in the U.S. must demonstrate urgent and emergent care competence before graduation. Urgent and emergent care competence involves recognizing, evaluating and initiating management of an unstable patient. High-fidelity (HF) simulation can improve urgent and emergent care skills, but because it is resource intense, alternative methods are needed. STUDY OBJECTIVE: Our primary purpose was to use program evaluations to compare medical student experiences with HF and virtual reality (VR) simulations as assessment platforms for urgent and emergent care skills. METHODS: During their emergency medicine clerkship, students at The Ohio State University College of Medicine must demonstrate on HF manikins, competence in recognizing and initiating care of a patient requiring urgent or emergent care. Students evaluated these simulations on a five-point quality scale and answered open-ended questions about simulation strengths and weaknesses. Faculty provided feedback on student competence in delivering urgent or emergent care. In 2022, we introduced VR as an alternative assessment platform. We used Wilcoxon Signed Ranks and Boxplots to compare ratings of HF to VR and McNemar Test to compare competence ratings. Comments were analyzed with summative content analysis or thematic coding. RESULTS: We received at least one evaluation survey from 160 of 216 (74.1%) emergency medicine clerkship students. We were able to match 125 of 216 (57.9%) evaluation surveys for students who completed both. Average ratings of HF simulations were 4.6 of 5, while ratings of VR simulations were slightly lower at 4.4. Comments suggested that feedback from both simulation platforms was valued. Students described VR as novel, immersive, and good preparation for clinical practice. Constructive criticism identified the need for additional practice in the VR environment. Student performance between platforms was significantly different with 91.7% of students achieving competence in HF, but only 65.5% in VR (p≤.001, odds-ratio = 5.75). CONCLUSION: VR simulation functions similarly to HF for formative assessment of urgent and emergent care competence. However, using VR simulation for summative assessment of urgent and emergent care competence must be considered with caution because students require considerable practice and acclimation to the virtual environment.

Medical students found value in using virtual reality simulation as a platform for practice and feedback in a formative assessment arrangement.Students described the virtual reality simulation as immersive and good preparation for clinical practice.Technical difficulties were common and the student learning curve for acclimating and learning how to function in the virtual environment was noteworthy.

Corporal punishment of children in Australia: The evidence-based case for legislative reform.

OBJECTIVE: Across all of Australia's states and territories, it is legal for a parent or carer to hit their child. In this paper, we outline the legal context for corporal punishment in Australia and the argument for its reform. METHODS: We review the laws that allow corporal punishment, the international agreements on children's rights, the evidence on the effects of corporal punishment, and outcomes of legislative reform in countries that have changed their laws to prohibit corporal punishment. RESULTS: Legislative reform typically precedes attitude changes and reductions in the use of corporal punishment. Countries with the most ideal outcomes have instigated public health campaigns educating the population about law reform while also providing access to alternative non-violent discipline strategies. CONCLUSIONS: Extensive evidence exists demonstrating the adverse effects of corporal punishment. When countries change legislation, educate the public about these effects, and provide alternative strategies for parents, rates of corporal punishment decrease. IMPLICATIONS FOR PUBLIC HEALTH: We recommend law reform in Australia to prohibit corporal punishment, a public health campaign to increase awareness of corporal punishment and its effects, provision of access for parents to alternative evidence-based strategies to assist in parenting, and a national parenting survey to monitor outcomes.

Positional MR imaging of normal and injured knees.

OBJECTIVES: This study uses a practical positional MRI protocol to evaluate tibiofemoral translation and rotation in normal and injured knees. METHODS: Following ethics approval, positional knee MRI of both knees was performed at 35° flexion, extension, and hyperextension in 34 normal subjects (mean age 31.1 ± 10 years) and 51 knee injury patients (mean age 36.4 ± 11.5 years, ACL tear n = 23, non-ACL injury n = 28). At each position, tibiofemoral translation and rotation were measured. RESULTS: Normal knees showed 8.1 ± 3.3° external tibial rotation (i.e., compatible with physiological screw home mechanism) in hyperextension. The unaffected knee of ACL tear patients showed increased tibial anterior translation laterally (p = 0.005) and decreased external rotation (p = 0.002) in hyperextension compared to normal knees. ACL-tear knees had increased tibial anterior translation laterally (p < 0.001) and decreased external rotation (p < 0.001) compared to normal knees. Applying normal thresholds, fifteen (65%) of 23 ACL knees had excessive tibial anterior translation laterally while 17 (74%) had limited external rotation. None (0%) of 28 non-ACL-injured knees had excessive tibial anterior translation laterally while 13 (46%) had limited external rotation. Multidirectional malalignment was much more common in ACL-tear knees. CONCLUSIONS: Positional MRI shows (a) physiological tibiofemoral movement in normal knees, (b) aberrant tibiofemoral alignment in the unaffected knee of ACL tear patients, and (c) a high frequency of abnormal tibiofemoral malalignment in injured knees which was more frequent, more pronounced, more multidirectional, and of a different pattern in ACL-tear knees than non-ACL-injured knees. KEY POINTS: • Positional MRI shows physiological tibiofemoral translation and rotation in normal knees. • Positional MRI shows a different pattern of tibiofemoral alignment in the unaffected knee of ACL tear patients compared to normal control knees. • Positional MRI shows a high prevalence of abnormal tibiofemoral alignment in injured knees, which is more frequent and pronounced in ACL-tear knees than in ACL-intact injured knees.

Effects of students' perception of teachers' ethnic-racial socialization on students' ethnic identity and mental health in rural China's schools.

Introduction: Using students in the Liangshan Yi autonomous prefectures of southwestern China (n = 585; 13-15 years old), we examined (i) the effects of students' perception of their teachers' ethnic-racial socialization on their ethnic identity and mental health outcomes of depressive and stress symptoms; (ii) the effects of students' ethnic identity on their depressive and stress symptoms; (iii) the differential associations among these factors in Yi ethnic minority versus Han cultural majority students. Methods: We conducted a cross-sectional survey and used multistage sampling to collect the information. Chinese-validated standardized measures were used: the Patient Health Questionaires-9, Children's Revised Impact of Event Scale-8, Multigroup Ethnic Identity Measure, Cultural Socialization Scale, and Teachers' Attitude on Adoption of Cultural Diversity Scale. Multigroup confirmatory factor analysis and multigroup structural equation modeling were employed. Results: Comparing the findings in Yi and Han students, their perception of teachers' ethnic-racial socialization had dissimilar effects on their ethnic identity and mental health outcomes. Three key findings comparing the differences between Yi and Han students were as follows: (i) students' perception of their teachers' multicultural socialization practices positively affected the ethnic identity of both Yi and Han young people; however, their perception of their teachers' socializing them to their own cultures did not exert any effect; (ii) students' perception of teachers' multicultural socialization practices had different mental health effects on Yi versus Han students; and (iii) ethnic identity affected the mental health of Yi ethnic minority students only. Conclusion: The findings underscore the importance of teachers' multicultural socialization in the ethnic identity development of both Yi ethnic minority and Han majority students. Ethnic identity serves as a linking variable bridging perceived teachers' multicultural socialization practices and mental health in Yi ethnic minority students but not among the Han cultural majority youths. Research, practice, and policy implications relevant to the global context are also discussed.

Enter and Discuss Orders and Prescriptions (EPA 4): A Curriculum for Fourth-Year Medical Students.

Introduction: Order entry, entrustable professional activity (EPA) 4, is one of several EPAs that residency program directors identify as a weakness for PGY 1 residents. A multispecialty survey of program directors indicated that only 69% of interns could be trusted to enter and discuss orders and prescriptions without supervision. To address this gap, we developed a formative workshop for fourth-year medical students. Methods: Prior to the start of their subinternships, 366 fourth-year medical students engaged in an order entry workshop. Students performed chart reviews on electronic standardized patients within an educational electronic health record (EHR), placed admission orders, customized order sets, responded to safety alerts, utilized decision support tools, and incorporated high-value care considerations. Students used expert-validated rubrics to assess the quality of their admission orders and participated in a facilitated group discussion on key learning points. Finally, students participated in order entry, with all orders requiring cosignature by a supervising physician, during their clinical rotations. Students reported their confidence with order entry before and after the workshop and after the clinical rotation. Results: One hundred seventeen students completed the pre- and postworkshop surveys, and 99 went on to complete the postcourse evaluation. Students showed a statistically significant increase in their confidence level following the workshop. Discussion: Order entry is a critical, complex skill that requires deliberate instruction. This curriculum, which leverages the features of an educational EHR, can facilitate instruction, practice, and confidence gains regarding order entry prior to further application of these skills in the clinical environment.

Effectiveness of a Multicomponent Parenting Intervention for Promoting Social-Emotional School Readiness Among Children From Low-Income Families in Hong Kong: A Cluster Randomized Clinical Trial.

IMPORTANCE: Most parenting programs target parents of children with severe behavioral problems. There is limited evidence on the effectiveness of universal parenting programs, especially for families with low income. OBJECTIVE: To evaluate the effectiveness of the KeySteps@JC Parent-Child Interaction Program for low-income families in Hong Kong. DESIGN, SETTING, AND PARTICIPANTS: A parallel, unblinded, cluster, randomized clinical trial was conducted from September 2018 to June 2019. Eight participating preschools in Hong Kong were randomly assigned (1:1) using an online randomization plan generator into intervention (immediate) and waiting list control (delayed) groups. Intervention participants included the parents of children in kindergarten grade 1. The results were processed by an intention-to-treat analysis. INTERVENTIONS: KeySteps@JC Parent-Child Interaction program. MAIN OUTCOMES AND MEASURES: The primary outcome was child behavioral problems, which were assessed using the Strength and Difficulties Questionnaire. Secondary outcomes were parental emotion coaching, involvement in child reading and play, and parent stress levels, which were assessed using Chinese-validated versions of the Parent Reading Belief Inventory, the Chinese Parent-Child Interaction Scale, the Emotion-Related Parenting Styles, and the Parental Stress Scale questionnaires. Parents in the intervention group participated in a training program consisting of 20 weekly 1.5-hour sessions on child behavior management, emotion coaching, dialogic reading, and interactive play. The primary hypothesis was that child behavior problems would be reduced after the intervention. The main analysis was a mixed-method regression with group status as the independent variable. RESULTS: A total of 267 parents (mean age, intervention group: 33.8 years; 95% CI, 32.9-34.7 years; waiting list group: 35.7 years; 95% CI, 34.5-36.9 years) participated in the program. The intervention group included 153 participants (57.3%), and the waiting list group included 114 participants (42.7%). Among the target children (mean age, intervention group: 3.5 years; 95% CI, 3.4-3.5 years; waiting list group: 3.4 years; 95% CI, 3.4-3.5 years), there were 88 boys (57.5%) in the intervention group and 59 boys (51.8%) in the waiting list group. At postintervention, the intervention group reported a statistically significant improvement in children's behavior (Cohen d, 0.29; 95% CI, 0.04-0.53); parents' use of emotion-coaching strategies, including feelings of uncertainty or ineffectiveness in emotion socialization (Cohen d, 0.26; 95% CI, 0.01-0.50) and parental rejection of negative emotion (Cohen d, 0.33; 95% CI, 0.08-0.57); and involvement in child reading (Cohen d, 0.17; 95% CI, -0.07 to 0.41). CONCLUSIONS AND RELEVANCE: The results of this randomized clinical trial provide promising evidence on the effectiveness of a multicomponent parenting intervention in preparing children from low-income families to be more socially and emotionally ready for school. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03615937.

Impact of clinical placement sites on general practice as a career preference for Australian medical students.

OBJECTIVE: This study investigates whether General Practice placement experience or locations (urban/metropolitan vs non-metropolitan) promote student interest in pursuing general practice. DESIGN: SurveyMonkey was used in the design of the survey. SETTING: The study was conducted online. PARTICIPANTS: A total of 520 and 705 clinical-year students were surveyed in 2009 and 2019, respectively. The study was conducted online, using SurveyMonkey, and the participants were mostly non-indigenous Australian medical students, between the ages of 18 and 30. INTERVENTIONS: Students were recruited from the General Practice Students' Network membership database to complete the survey online. Chi-squared testing, Pearson's correlation and a multivariate logistic regression analysis were used to investigate the correlation between general practice placements and intention to become a general practice. MAIN OUTCOME MEASURES: The association and causation between general practice placement location, student experience and students' intended career outcomes. RESULTS: In 2009, majority of students rated their general practice experience 'mostly positive' while most metropolitan participants and majority of non-metropolitan placement participants in the 2019 survey responded with 'mostly positive' in 2019. Based on 2009 and 2019 data, general practice placement location had no association with the likelihood of pursuing general practice as a career, while student experience had a stronger positive correlation with the likelihood of pursuing general practice as a career. CONCLUSION: Our study shows that students' overall experience with their general practice placements significantly encourages medical students to pursue the general practice pathway. As such, increasing both metropolitan and non-metropolitan placement experiences can potentially overcome general practice shortage.

Vulnerability and resilience in children during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is having a profound impact on the health and development of children worldwide. There is limited evidence on the impact of COVID-19 and its related school closures and disease-containment measures on the psychosocial wellbeing of children; little research has been done on the characteristics of vulnerable groups and factors that promote resilience. METHODS: We conducted a large-scale cross-sectional population study of Hong Kong families with children aged 2-12 years. Parents completed an online survey on family demographics, child psychosocial wellbeing, functioning and lifestyle habits, parent-child interactions, and parental stress during school closures due to COVID-19. We used simple and multiple linear regression analyses to explore factors associated with child psychosocial problems and parental stress during the pandemic. RESULTS: The study included 29,202 individual families; of which 12,163 had children aged 2-5 years and 17,029 had children aged 6-12 years. The risk of child psychosocial problems was higher in children with special educational needs, and/or acute or chronic disease, mothers with mental illness, single-parent families, and low-income families. Delayed bedtime and/or inadequate sleep or exercise duration, extended use of electronic devices were associated with significantly higher parental stress and more psychosocial problems among pre-schoolers. CONCLUSIONS: This study identifies vulnerable groups of children and highlights the importance of strengthening family coherence, adequate sleep and exercise, and responsible use of electronic devices in promoting psychosocial wellbeing during the COVID-19 pandemic.

Utility of PSA Density in Predicting Upgraded Gleason Score in Men on Active Surveillance With Negative MRI.

OBJECTIVES: To determine whether PSA density (PSAD), can sub-stratify risk of biopsy upgrade among men on active surveillance (AS) with normal baseline MRI. METHODS: We identified a cohort of patients with low and favorable intermediate-risk prostate cancer on AS at two large academic centers from February 2013 - December 2017. Analysis was restricted to patients with GG1 cancer on initial biopsy and a negative baseline or surveillance mpMRI, defined by the absence of PI-RADS 2 or greater lesions. We assessed ability of PSA, prostate volume and PSAD to predict upgrading on confirmatory biopsy. RESULTS: We identified 98 patients on AS with negative baseline or surveillance mpMRI. Median PSA at diagnosis was 5.8 ng/mL and median PSAD was 0.08 ng/mL/mL. Fourteen men (14.3%) experienced Gleason upgrade at confirmatory biopsy. Patients who were upgraded had higher PSA (7.9 vs 5.4 ng/mL, P = .04), PSAD (0.20 vs 0.07 ng/mL/mL, P < .001), and lower prostate volumes (42.5 vs 65.8 mL, P = .01). On multivariate analysis, PSAD was associated with pathologic upgrade (OR 2.23 per 0.1-increase, P = .007). A PSAD cutoff at 0.08 generated a NPV of 98% for detection of pathologic upgrade. CONCLUSION: PSAD reliably discriminated the risk of Gleason upgrade at confirmatory biopsy among men with low-grade prostate cancer with negative MRI. PSAD could be clinically implemented to reduce the intensity of surveillance for a subset of patients.

Erratum: Lee, R.L.T., et al. Effects of an Unstructured Free Play and Mindfulness Intervention on Wellbeing in Kindergarten Students. Int. J. Environ. Res. Public Health 2020, 17, 5382.

The authors wish to make the following corrections to their paper [...].

Preparing students for residency interviews in the age of COVID: Lessons learned from a standardized video interview preparation program.

Objectives: The COVID-19 pandemic has necessitated the widescale adoption of video-based interviewing for residency applications. Video interviews have previously been used in the residency application process through the pilot program of the American Association of Medical Colleges standardized video interview (SVI). We conducted an SVI preparation program with our students over 3 years that consisted of an instructional lecture, deliberate practice in video interviewing, and targeted feedback by emergency medicine faculty. The aim of this investigation was to summarize the feedback students received on their practice SVIs to provide the guidance they need for preparing for the video interviews that will replace in-person interviews with residency programs. Methods: A retrospective thematic analysis was conducted on faculty feedback provided to students who had completed SVI practice videos in preparation for their application to an EM residency between June 2017 and July 2019. Categorized comments were also sorted by type of faculty feedback: positive reinforcement, constructive criticism, or both. Results: Forty-six medical students received 334 feedback elements from three faculty. Feedback was balanced between positive reinforcement statements and constructive criticism. Students performed well on appearance and attire, creating a proper recording environment, and response content. They needed the most guidance with the delivery of content and the technical quality of the video. Conclusions: Our results demonstrate a need for formal instruction in how to communicate effectively through the video medium. Medical educators will need to formally prepare students for tele-interviews with residency programs, with an emphasis on communication skills and techniques for improving the quality of their video presentation, including lighting and camera placement.

A Chinese version of the young children's participation and environment measure: psychometric evaluation in a Hong Kong sample.

PURPOSE: To investigate the psychometric properties of a Chinese-translated version of the Young Children's Participation and Environment Measure. MATERIALS AND METHODS: The Young Children's Participation and Environment Measure was translated into Chinese using cultural adaptation by adding/replacing with activities relevant to Chinese culture. Parents of 53 children aged 2-5 years with developmental disabilities and of 50 typical developing children completed the questionnaires. Internal consistency, test-retest reliability, known-group validity, and discriminant validity were examined using Cronbach's alpha, intraclass correlation coefficient, Mann-Whitney U tests, and Spearman's rank correlation coefficients respectively. RESULTS: Internal consistency was acceptable for most scales (α = 0.42-0.89). Test-retest reliability of the summary scores was moderate to high for all scales (intraclass correlation coefficient = 0.65-0.90). Known-group validity was supported by demonstrating significant differences by disability status in all community participation scales, two daycare/preschool participation scales, and one home participation scale. Low or negative correlations between the scores of some scales and children's cognition (ρ = 0.27-0.32; -0.36-to-0.35) and parental stress (ρ = -0.42-to-0.31) supported discriminant validity. CONCLUSION: This study provided psychometric evidence supporting the use of the Young Children's Participation and Environment Measure to assess Chinese children's participation and environmental support.IMPLICATIONS FOR REHABILITATIONThe Young Children's Participation and Environment Measure is translated into Chinese using a cultural adaptation process.The Chinese version of the Young Children's Participation and Environment Measure demonstrates evidence for internal consistency, test-retest reliability (including the minimal detectable change).The Chinese version of the Young Children's Participation and Environment Measure demonstrates evidence for known-group validity and discriminant validity.The Chinese version of the Young Children's Participation and Environment Measure holds promise for use in children aged 2-5 years to assess their participation and identify environmental barriers warranting intervention.

Development and pilot evaluation of the Cognition domain of the Hong Kong Comprehensive Assessment Scales for Toddlers.

Purpose: To describe the development of the Cognition domain of the Hong Kong Comprehensive Assessment Scales for Toddlers (HKCAS-T).Methods: Participants included 345 toddlers aged 18-41 months, with 258 recruited from Maternal and Child Health Centers (MCHCs) and 87 with cognitive delay recruited from Child Assessment Centers (CACs). They were individually administered the 83-item pilot version by medical practitioners or educational psychologists between 2017 and 2019 in MCHCs and CACs in Hong Kong.Results: Rasch analysis results supported the unidimensionality of the pilot version, after removing six items. Analysis of covariance results indicated that both the 83-item version and the 77-item version could differentiate between children of different age groups, and children with typical development from children with cognitive delay. Internal consistency and interrater reliability were 0.90 or above.Conclusions: The Cognition domain of the HKCAS-T is a promising developmental assessment tool for the assessment of toddlers. Cognition assessment, preschool, Chinese.

Comparison of long-term outcomes in a 10-year experience of robotic cystectomy vs. open cystectomy.

To compare the outcomes of robotic-assisted (RARC) vs. open radical cystectomy (ORC) at a single academic institution. We retrospectively identified patients undergoing radical cystectomy for urothelial carcinoma of the bladder at our institution from 2007 to 2017. Data collected included age, sex, Body Mass Index (BMI), Charlson Age-Adjusted Comorbidity Index (CCI), final pathologic stage, surgical margins, lymph-node yield, estimated blood loss (EBL), 90-day complication rate, and length of stay (LOS). We evaluated overall survival (OS) and recurrence-free survival (RFS). Multivariable Cox proportional hazard models were used to adjust for covariates. We identified 232 patients (73 RARC, 159 ORC) who underwent radical cystectomy. Patients who underwent RARC were older (71.8 vs. 67.5, p < 0.05) and had higher CCI scores (6.2 vs. 5.3, p < 0.05). In comparing perioperative outcomes, RARC patients had lower EBL (500 vs. 850, p < 0.01), lower blood transfusion rate (p < 0.01), and lower lymph-node yield (12 vs. 20, p < 0.01), and higher ICU admission rate (29% vs. 16% p < 0.01). There was no difference in BMI (p = 0.93), sex (p = 0.28), final pathological stage (p = 0.35), positive surgical margins (p = 0.47), complications (p = 0.58), or LOS (p = 0.34). Kaplan-Meier analysis showed no difference in OS (p = 0.26) or RFS (p = 0.86). There was no difference in restricted mean survival time for OS (53 vs. 56 months, p = 0.81) or for RFS (65 vs. 64 months, p = 0.90). Cox multivariate regression models showed that surgical approach does not have a significant impact on OS (p = 0.46) or RFS (p = 0.35). Our study indicates that in our 10-year experience, patients undergoing there was no difference between RARC and ORC patients with respect to OS and RFS despite being older and having more comorbidities. Our work supports the importance of patient selection to optimize outcomes.

Development of Gross Motor Evaluation for Children Aged 18 to 42 Months.

PURPOSE: To test the reliability and validity of the gross motor items making up a new instrument, Hong Kong Comprehensive Assessment Scales for Toddlers (HKCAS-T) for quantifying gross motor development among children aged 18 to 42 months. METHODS: The 37 items were administered to 330 children, including 258 typically developing children and 72 children with gross motor delay. RESULTS: Rasch analyzes indicated that the fit statistics of the 37 items were within the acceptable range. The assessment was found able to differentiate between typically developing children and those with gross motor delay and among children of different ages. The raw score reliability (KR-20) was 0.94. CONCLUSION: The new instrument is a promising alternative for assessing young children's gross motor development.

Effects of an Unstructured Free Play and Mindfulness Intervention on Wellbeing in Kindergarten Students.

Play is known as the core occupation of young children as it lays a foundation for their early development and physical, emotional and social wellbeing. Literature suggests that unstructured free play and mindfulness interventions may independently promote wellbeing among preschoolers. However, there is no clear evidence of their combination in supporting wellness in early learning environments. We conducted a quasi-experimental study with 42 children aged four to six years, attending two kindergartens in Hong Kong. The intervention included unstructured play with non-directional loose parts (play materials), conducted outdoors for one hour daily followed by a mindfulness intervention for 10 min per day indoors. The intervention lasted for five consecutive days. We examined happiness and aspects of playfulness before and after the intervention, finding a significant increase in all areas. Given greater freedom in play choice, children showed more disruptive behaviors during unstructured play than the control group engaging in recess as usual. We conclude that unstructured play in addition to mindfulness intervention is effective in promoting students' happiness and playfulness, both of which may help maintain mental health and wellbeing amid stressors such as transition and separation. The increased disruptive behavior requires additional investigation.

Parent Technology Use, Parent-Child Interaction, Child Screen Time, and Child Psychosocial Problems among Disadvantaged Families.

OBJECTIVE: To disentangle the pathways of parent technology use, parent-child interactions, child screen time, and child psychosocial difficulties among disadvantaged families in Hong Kong. STUDY DESIGN: Parents of 1254 3-year-old children from the KeySteps@JC project reported on the number of hours their children used electronic devices every day and evaluated their children's psychosocial behaviors using the Strengths and Difficulties Questionnaire. These parents also reported on their own digital device usage patterns and the frequency of parent-child interactions and provided sociodemographic data. Structural models were tested with parent technology use (independent variable), parent technological distractions and parent-child interactions and child screen time (mediators), child psychosocial problems (dependent variable), and children's age and sex and family socioeconomic status index (confounding variables). RESULTS: Parent distraction with technology during parent-child interactions completely mediated the overall association between parent problematic digital technology use and child screen use duration. Parent problematic digital technology use was positively and directly associated with child psychosocial difficulties. In addition, it was indirectly related to child psychosocial difficulties through technological distractions and reductions in parent-child interactions and increased media use by children. CONCLUSION: Higher parent digital technology usage was associated with reduced parent-child interactions and increased child screen time and psychosocial difficulties in disadvantaged families. These results suggest that limiting parents' use of electronic devices in front of their young children could be beneficial for childhood psychosocial development.

Systematic review of the impact of unstructured play interventions to improve young children's physical, social, and emotional wellbeing.

This review aimed to examine the effectiveness of unstructured play interventions on young children's physical, emotional and social wellbeing in various community settings. Eligibility criteria of articles included (1) studies which included young children aged three to seven years; (2) intervention studies which involved unstructured, free or loose parts play; (3) experimental or randomized controlled trial designs, with or without random allocation to groups; and (4) target variables of the study should include measurable physical, social or psychological constructs as modifiable outcomes. Electronic searches were conducted from June 2018 to March 2019 in ERIC, MEDLINE, PubMed, ProQuest, Sage Publications, Web of Science, Scopus, and Sociological Abstracts. Data were extracted from the included studies independently by using a pilot form. The study outcome measures of unstructured play in the eight selected articles were categorized into three aspects of children's physical health, social skills and emotional wellbeing. All studies reported positive impacts on children's physical activity level, social engagement and emotional wellbeing. We conclude that our review with identified impacts would assist future research directions and policy implementation in this promising field..

A cluster randomized controlled trial of a simplified 5-step handwashing technique versus a conventional 7-step handwashing technique among Chinese students with intellectual disabilities.

OBJECTIVE: To compare the effects of the simplified 5-step and the conventional 7-Step hand hygiene programme in a cluster randomized controlled trial among students with intellectual disabilities. METHOD: A total of 472 Chinese students with intellectual disabilities were randomized to either simplified 5-step or conventional 7-step hand hygiene programme. Assessments included handwashing technique, cleanliness and sick leave days. RESULTS: Handwashing technique scores (g = 0.25, 95% CI [0.18, 0.32]) and hand cleanliness scores (g = 0.33, 95% CI [0.26, 0.4]) in intervention group were significantly higher than those scores in control group at 6th month post-intervention although there were significant increases in the scores within both groups. The mean number of sick leave days decreased between baseline and 10 month in both groups according to descriptive statistics. CONCLUSIONS: It is feasible and effective to adopt the simplified 5-step intervention as a standardized handwashing technique for the population group with intellectual disabilities.

Agitated Psychiatric Patient.

Audience: This scenario was developed to educate emergency medicine residents about the diagnosis and management of the agitated psychiatric patient. Introduction: The prevalence of agitation among patients in the emergency department is increasing, with an estimated 1.7 million events occurring annually in the United States.1 There are various methodologies for de-escalation, including verbal and chemical de-escalation and physical restraints. Chemical and/or physical restraints are sometimes necessary to ensure patient and staff safety when verbal de-escalation is ineffective, particularly since agitation is the leading cause of hospital staff injuries.2 Chemical restraints have been shown to be less physically traumatizing to patients.3 4 Adverse events associated with physical restraints include persistent psychological distress, blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest.5 In regards to chemical restraints, adverse event reporting has been heterogeneous among studies, but the most consistent reported events involve respiratory compromise such as desaturation, airway obstruction, and respiratory depression.3 A study measuring QTc (corrected QT interval) after high-dose intramuscular ziprasidone or haloperidol did not demonstrate any QTc longer than 480 msec.6 Other events linked to chemical restraints include uncommon cardiovascular events and extrapyramidal side effects from medications.3 The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), second-generation antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazipenes (eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine).7,8 It is important to exclude other medical causes of agitation, consider the differential diagnoses, and then select a medication that is tailored to address underlying etiologies while remaining cognizant of the side effect profiles of these chemical agents.Educational Objectives: At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history and physical examination on the agitated psychiatric patient. 2) Develop a differential for the agitated psychiatric patient, including primary psychiatric conditions and other organic pathologies. 3) Discuss the management of the agitated psychiatric patient, including the different options available for chemical sedation. 4) Prioritize safety of self and staff when caring for an agitated psychiatric patient. Educational Methods: This session was conducted using simulation with a standardized patient, followed by a debriefing session and lecture on the presentation, differential diagnosis, and management of the agitated psychiatric patient. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board examination case. Research Methods: The residents are provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. Results: Feedback from the residents was overwhelmingly positive, although many stated that they felt some degree of intimidation or stress from the standardized patient who did not break from their role throughout the scenario.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form9 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. This session received mostly 7 scores (extremely effective/outstanding). Discussion: This is a physically safe method for reviewing management of the agitated psychiatric patient. There are multiple potential presentations of the agitated psychiatric patient, as well as varying underlying etiologies. These scenarios may be tailored to the needs of the learner, including identifying agitation, pharmacologic review, and de-escalation techniques. Topics: Medical simulation, agitated psychiatric patient, chemical sedation, verbal de-escalation, emergency medicine, psychiatry.