Teaching Chest Tube Insertion by Blended Learning: A Multi-Dimensional Analysis.

BACKGROUND: Emerging technologies are being incorporated in surgical education. The use of such technology should be supported by evidence that the technology neither distracts nor overloads the learner and is easy to use. To teach chest tube insertion, we developed an e-learning module, as part of a blended learning program delivered prior to in-person hands-on simulation. This pilot study was aimed to assess learning effectiveness of this blended learning, and cognitive load and the usability of e-learning. METHODS: The interactive e-learning module with multimedia content was created following learning design principles. In advance of the standard simulation, 13 first-year surgical residents were randomized into two groups: 7 received the e-learning module and online reading materials (e-learning group); 6 received only the online reading materials (controls). Knowledge was evaluated by pre-and post-tests; technical performance was assessed using a Global Rating Scale by blinded assessors. Cognitive load and usability were evaluated using rating scales. RESULTS: The e-learning group showed significant improvement from baseline in knowledge (P = .047), while controls did not (P = .500). For technical skill, 100% of residents in the e-learning group reached a predetermined proficiency level vs 60% of controls (P = .06). The addition of e-learning was associated with lower extrinsic and greater germane cognitive load (P = .04, .03, respectively). Usability was evaluated highly by all participants in e-learning group. CONCLUSION: Interactive e-learning added to hands-on simulation led to improved learning and desired cognitive load and usability. This approach should be evaluated in teaching of other procedural skills.

Online learning in health professions education. Part 2: Tools and practical application: AMEE Guide No. 163.

Part 1 of the AMEE Guide Online learning in health professions education focused on foundational concepts such as theory, methods, and instructional design in online learning. Part 2 builds upon Part 1, introducing technology tools and applications of these foundational concepts by exploring the various levels (from beginner to advanced) of utilisation, while describing how their usage can transform Health Professions Education. This Part covers Learning Management Systems, infographics, podcasting, videos, websites, social media, online discussion forums, simulation, virtual patients, extended and virtual reality. Intertwined are other topics, such as online small group teaching, game-based learning, FOAM, online social and collaboration learning, and virtual care teaching. We end by discussing digital scholarship and emerging technologies. Combined with Part 1, the overall aim of Part 2 is to produce a comprehensive overview to help guide effective use online learning in Health Professions Education.

Measurement and Management of Cognitive Load in Surgical Education: A Narrative Review.

BACKGROUND: Cognitive load should be considered in designing optimal educational programs in health care. Despite the highly demanding nature of surgery and surgical education, a consensus on how to manage cognitive load has not been established. The objective of this review is to map out how recent surgical education research incorporates cognitive load. METHODS: A literature search was performed using keywords related to cognitive load and digital education up to December 2021. Studies published in English relevant to assessment and management of cognitive load in surgical education were included. Terminology, assessment tools, association with different surgical procedures and training modalities, and programs considering cognitive load were reported. RESULTS: We identified several terms to describe cognitive load. Cognitive load was measured by subjective, self-reported questionnaires and by objective measurements, such as physiological parameters or estimated by reaction time to secondary tasks. Subjective measurements reported cognitive load in one or multiple dimensions. Correlations between subjective and objective measurements were shown in multiple studies. Overall, higher cognitive load was observed in training for more complex tasks and high-fidelity modalities, and among less experienced trainees. Cognitive load theory has been lately incorporated into designing teaching programs. CONCLUSIONS: A broad range of terms and assessment tools were identified for cognitive load. To maximize the learning outcome, management of cognitive load is necessary in surgical education. This review summarizes the current knowledge in assessment and management of cognitive load in surgical education and provides suggestions for future studies.

Insights for Teaching During a Pandemic: Lessons From a Pre-COVID-19 International Synchronous Hybrid Learning Experience.

BACKGROUND AND OBJECTIVES: Medical educators and researchers have increasingly sought to embed online educational modalities into graduate medical education, albeit with limited empirical evidence of how trainees perceive the value and experience of online learning in this context. The purpose of this study was to explore the experiences of hybrid learning in a graduate research methods course in a family medicine and primary care research graduate program. METHODS: This qualitative description study recruited 28 graduate students during the fall 2016 academic term. Data sources included qualitative group discussions and a 76-item online survey collected between March and September 2017. We used thematic analysis and descriptive statistics to analyze each data set. RESULTS: Nine students took part in three group discussions, and completed an online survey. While students reported positive learning experiences overall, those attending virtually struggled with the synchronous elements of the hybrid model. Virtual students reported developing research skills not offered through courses at their home institution, and students attending the course in person benefited from the diverse perspectives of distance learners. All stressed the need to foster a sense of community. CONCLUSIONS: Quality delivery of online graduate education in family medicine research requires optimizing social exchanges among virtual and in-person learners, ensuring equitable engagement among all students, and leveraging the unique tools afforded by online platforms to create a shared sense of a learning community.

Embedding Identity and How Clinical Teachers Reconcile Their Multiple Professional Identities to Meet Overlapping Demands at Work.

PHENOMENON: Clinical teachers perform overlapping tasks in education and patient care. They are therefore expected to juggle many professional identities such as educator and clinician. Yet little is known about how clinical teachers negotiate their professional identities. The present research examined the lived experiences of clinical teachers as they manage and make sense of their professional identities in the context of a faculty development program. APPROACH: This study adopted interpretative phenomenological analysis, which is an idiographic and inductive methodological approach that enables an in-depth examination of how people conceptualize their personal and social worlds. In-depth semi-structured individual interviews were conducted with six purposively sampled Brazilian clinical teachers who were attending a faculty development program. Each participant's lived experience was analyzed independently. Then, these individual analyses were compared against each other to identify convergence and divergence. FINDINGS: Participants recognized one identity, which was labeled as embedding identity, containing other identities and roles. Participants integrated their professional identities in agreement with their personal identities, values, and beliefs, striving thus for identity consonance. Participants understood their craft as a relational process by which they wove themselves into their context and entangled their experience with that of others. They, however, diverged when recognizing who their peers were; whereas some named a single professional group (i.e., family physicians), others had a more comprehensive view and considered as peers healthcare professionals, students, and even patients. Finally, participants identified time constraints and lower prestige of family medicine as a medical discipline vis-à-vis other specialties as challenges posed by their contexts. INSIGHTS: Clinical teachers have multifaceted identities, to which they give a sense, manage, and integrate into their daily practice. Participants recognized an embedding identity and looked for common points between the identities it contained, which allowed them to meaningfully reconcile the different demands from their overlapping professional identities. Thus, this research introduces the notion of embedding identity as a strategy to make sense of many professional identities. Variability in the embedding identities depicted in this investigation suggests the fluid and contextualized character of professional identity development. How participants saw themselves also influenced how they behaved and interacted with others accordingly. Understanding clinical teacher identity development enriches current perspectives of what it is like to be one of these medical professionals. Faculty development programs ought to consider these perspectives to better support clinical teachers in meeting the overlapping demands in education and patient care.

Evaluating Usability in Blended Learning Programs Within Health Professions Education: a Scoping Review.

Knowledge was mapped about how usability has been applied in the evaluation of blended learning programs within health professions education. Across 80 studies, usability was explicitly mentioned once but always indirectly evaluated. A conceptual framework was developed, providing a foundation for future instruments to evaluate usability in this context. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01295-x.

What Role Can Trained Volunteers Add to Chronic Disease Care of Immigrants?

To help primary care teams improve patient-centered care, we elicited health and life goals of immigrants with a chronic disease. We conducted an exploratory study of the (1) acceptability of home visits by volunteers to collect health information and (2) content of health and life goals within a primary care program for immigrants with chronic disease. Pairs of trained community volunteers visited 23 patients in their homes and asked them to identify three life goals and three health goals. We conducted content analyses of written notes. Health goals were related to disease prevention and symptom control, family well-being, own quality of life, own or family members' work and/or financial situation. Life goals concerned family well-being, their own quality of life, work/financial situation and health. Given the limited time health professionals have with their patients, trained community volunteers could be important members of primary care teams caring for immigrants.

Sleep Duration and Timing in the Medium- to Long-Term Post-Bariatric Surgery.

Sleep duration improves short-term following bariatric surgery; however, little is known about its association with bodyweight medium- to long-term post-surgery. The purpose of this study was to describe sleep duration and its relationship with BMI and body composition. Forty-nine individuals, with a BMI of 36.6 ± 9.8 kg/m2, regained 26.4 ± 17.8% of their lost weight 9.5 ± 3.3 years post-surgery (range 3-16 years). Sleep logs and ActivPAL3 accelerometers were used to assess sleep duration. Participants averaged 7.9 ± 1.6 h/day and 8.5 ± 1.7 h/day of sleep for weekdays and weekends, respectively (P < 0.01). A positive association between delta weekend-weekday sleep timing midpoint with BMI (ß = 0.03, 95% CI = 0.01, 0.06; P = 0.01) was noted in the multivariable-adjusted model. On average, this sample achieved recommended sleep durations medium- to long-term post-surgery. Having an earlier sleep timing midpoint during the weekend may be associated with lower BMI.

Effect of Employment Status on Physical Activity and Sedentary Behavior Long-Term Post-Bariatric Surgery.

INTRODUCTION: Inactivity and weight regain are serious problems post-bariatric surgery. Nearly half of waking time is spent at work, representing an opportunity to accumulate physical activity and help avoid weight regain. PURPOSE: The purpose of this study is to evaluate potential differences in physical activity and sedentary time by employment status post-bariatric surgery. METHODS: A total of 48 adults (employed (n = 19), unemployed (n = 29)) aged 50.7 ± 9.4 years, BMI = 34.4 ± 10.1 kg/m2, and 10 ± 3 years post-surgery participated. ActivPAL accelerometers measured transitions, steps, and sedentary time for 7 days. RESULTS: Participants worked on average 8.7 ± 1.8 h/day. Twenty-one percent of employed met step/day guidelines on work-days compared to 10% of unemployed. Employed persons transitioned from sitting-to-standing more on work-days (58.6 ± 17.8) than unemployed (45.0 ± 15.4). Employment status did not influence activity or sedentarism on weekend/non-working-days. CONCLUSION: Employment status may be associated with meaningful improvements in activity post-bariatric surgery.

Eccentric Ergometer Training Promotes Locomotor Muscle Strength but Not Mitochondrial Adaptation in Patients with Severe Chronic Obstructive Pulmonary Disease.

Eccentric ergometer training (EET) is increasingly being proposed as a therapeutic strategy to improve skeletal muscle strength in various cardiorespiratory diseases, due to the principle that lengthening muscle actions lead to high force-generating capacity at low cardiopulmonary load. One clinical population that may particularly benefit from this strategy is chronic obstructive pulmonary disease (COPD), as ventilatory constraints and locomotor muscle dysfunction often limit efficacy of conventional exercise rehabilitation in patients with severe disease. While the feasibility of EET for COPD has been established, the nature and extent of adaptation within COPD muscle is unknown. The aim of this study was therefore to characterize the locomotor muscle adaptations to EET in patients with severe COPD, and compare them with adaptations gained through conventional concentric ergometer training (CET). Male patients were randomized to either EET (n = 8) or CET (n = 7) for 10 weeks and matched for heart rate intensity. EET patients trained on average at a workload that was three times that of CET, at a lower perception of leg fatigue and dyspnea. EET led to increases in isometric peak strength and relative thigh mass (p < 0.01) whereas CET had no such effect. However, EET did not result in fiber hypertrophy, as morphometric analysis of muscle biopsies showed no increase in mean fiber cross-sectional area (p = 0.82), with variability in the direction and magnitude of fiber-type responses (20% increase in Type 1, p = 0.18; 4% decrease in Type 2a, p = 0.37) compared to CET (26% increase in Type 1, p = 0.04; 15% increase in Type 2a, p = 0.09). EET had no impact on mitochondrial adaptation, as revealed by lack of change in markers of mitochondrial biogenesis, content and respiration, which contrasted to improvements (p < 0.05) within CET muscle. While future study is needed to more definitively determine the effects of EET on fiber hypertrophy and associated underlying molecular signaling pathways in COPD locomotor muscle, our findings promote the implementation of this strategy to improve muscle strength. Furthermore, contrasting mitochondrial adaptations suggest evaluation of a sequential paradigm of eccentric followed by concentric cycling as a means of augmenting the training response and attenuating skeletal muscle dysfunction in patients with advanced COPD.

Effects of Neighborhood Walkability on Physical Activity and Sedentary Behavior Long-Term Post-Bariatric Surgery.

ᅟ: Chronic inactivity and weight regain are serious health concerns following bariatric surgery. Neighborhood walkability is associated with higher physical activity and lower obesity rates in normal weight populations. PURPOSE: Explore the influence of neighborhood walkability on physical activity and sedentarism among long-term post-bariatric surgery patients. METHODS: Fifty-eight adults aged 50.5 ± 9.1 years, with a BMI of 34.6 ± 9.7 kg/m2 having undergone surgery 9.8 ± 3.15 years earlier participated in this study. Participants were asked to wear an ActivPAL™ tri-axial accelerometer attached to their mid-thigh for 7-consecutive days, 24 hours/day. The sample was separated into those that live in Car-Dependent (n = 23), Somewhat Walkable (n = 14), Very Walkable (n = 16), and Walker's Paradise (n = 5) neighborhoods as defined using Walk Score®. ANCOVA was performed comparing Walk Score® categories on steps and sedentary time controlling for age and sex. RESULTS: Neighborhood walkability did not influence either daily steps (F (3, 54) = 0.921, p = 0.437) or sedentary time (F (3, 54) = 0.465, p = 0.708), Car-Dependent (6359 ± 2712 steps, 9.54 ± 2.46 hrs), Somewhat Walkable (6563 ± 2989 steps, 9.07 ± 2.70 hrs), Very Walkable (5261 ± 2255 steps, 9.97 ± 2.06 hrs), and Walker's Paradise (6901 ± 1877 steps, 10.14 ± 0.815 hrs). CONCLUSION: Walkability does not appear to affect sedentary time or physical activity long-term post-surgery. As the built-environment does not seem to influence activity, sedentarism, or obesity as it does with a normal weight population, work needs to be done to tailor physical activity programming after bariatric surgery.

Validity and reliability of Fitbit activity monitors compared to ActiGraph GT3X+ with female adults in a free-living environment.

OBJECTIVES: Inexpensive activity monitors have recently gained popularity with the general public. Researchers have evaluated these consumer-based monitors in laboratory-conditions. Given the current wide-spread consumer use of these devices, it is important to ensure users are attaining accurate information compared to previously validated measures. This study investigates the accuracy of Fitbit One and Flex activity monitors in measuring steps, sedentary time, and time spent in light, moderate, and vigorous intensity activities with ActiGraph GT3X+ with female adults in free-living conditions. DESIGN: Cross-sectional study. METHODS: Twenty-two women, 21.23±1.63 years, BMI: 22.35±2.34kg/m2 wore two Fitbit Ones (bra and waist), one Fitbit Flex on the wrist, and one ActiGraph GT3X+ on the waist for seven-consecutive days. Repeated measures ANOVA was used to explore differences in steps, sedentary time, and time spent in light, moderate and vigorous intensity activities among the four devices. RESULTS: No differences were found in number of steps recorded across the four devices. Fitbit One, waist and bra, overestimated time spent in light intensity activities. Fitbit One (waist) and Fitbit Flex overestimated time spent in moderate intensity activities. Fitbit One, waist and bra, and Fitbit Flex overestimated time spent in vigorous intensity activities. All Fitbit activity monitors overestimated MVPA and underestimated sedentary time compared to the ActiGraph. CONCLUSIONS: Regardless of wear-location all Fitbit devices provide similar activity monitoring and users can wear the devices wherever best accommodates their lifestyle or needs. Users should not rely solely on these monitors when tracking vigorous and MVPA activities.

Physical activity and sedentary behavior in bariatric patients long-term post-surgery.

BACKGROUND: To measure sedentary behaviors and physical activity using accelerometry in participants who have undergone bariatric surgery 8.87 ± 3.78 years earlier and to compare these results with established guidelines. METHODS: Participants' weight and height were measured, an ActivPAL™3 accelerometer and sleeping journal were used to determine day sedentary time, transitions from sitting to standing, as well as steps/day, and participants were asked to indicate if they felt that they were currently less, the same, or more active than before surgery. RESULTS: Participants averaged 48 ± 15 transitions/day, 6375 ± 2690 steps/day, and 9.7 ± 2.3 h/day in sedentary positions. There was a negative correlation between steps/day and sedentary time (r = -.466, p ≤ .001), 11.27 % of participants achieved 10,000 steps/day. Participants who reported being more active prior to surgery averaged 6323.4 ± 2634.79 steps/day, which was not different from the other two groups of self-perceived change in level of physical activity (F (2, 68) = .941, p ≤ .05) from pre- to post-surgery. CONCLUSIONS: Participants were inadequately active and overly sedentary compared to established guidelines and norms. Healthcare workers should be taking physical activity and sedentary time into account when creating post-surgical guidelines for this population to ensure the best long-term weight loss maintenance and health outcomes.

Keeping the weight off: physical activity, sitting time, and weight loss maintenance in bariatric surgery patients 2 to 16 years postsurgery.

BACKGROUND: Bariatric surgery patients often exhibit low levels of physical activity (PA), despite the presumed importance of PA as an adjunct to surgery for successful weight loss. Little is known regarding the associations of PA and sedentary behaviors to weight loss outcomes in the long term following surgery. The objective of the study was to assess the associations of PA and sitting time with weight status, weight loss, and weight maintenance outcomes in bariatric patients 2-16 years postsurgery. METHODS: A total of 303 Roux-en-Y Gastric Bypass patients (73% female; mean age 47 ± 10 years, mean 7 ± 4 years since surgery) completed a telephone questionnaire. Patients reported moderate-to-vigorous PA (MVPA: # sessions/week ≥30 min) and average daily sitting time (h/day). Associations with various weight outcomes were assessed. RESULTS: Only 48% of patients reported ≥1 session/week MVPA, and mean reported sitting time was 7 ± 4 h/day. Neither MVPA nor sitting time was associated with weight loss outcomes at patients' lowest weight postsurgery. However, both MVPA and sitting time were independently positively and inversely, respectively, associated with total (kg) weight loss, % weight loss, and % excess weight loss at current weight, as well as weight loss maintained vs. regained, controlling for age, sex, surgery type, presurgery BMI, total initial weight loss, and time since surgery. CONCLUSIONS: Results demonstrate associations between MVPA and high sitting time and weight loss outcomes among bariatric patients in the long term. The implications for long-term weight management and concomitant health outcomes highlight the need for appropriate follow-up and interventions in this unique high-risk patient population.

Precision of the iDXA for visceral adipose tissue measurement in severely obese patients.

UNLABELLED: A new measurement tool, the automated software CoreScan, for the GE Lunar iDXA, has been validated for measuring visceral adipose tissue (VAT) against computed tomography in normal-weight populations. However, no study has evaluated the precision of CoreScan in measuring VAT among severely obese patients. PURPOSE: The purpose of the study was to evaluate the precision of CoreScan for VAT measurements in severely obese adults (body mass index > 40 kg·m(-2)). METHODS: A total of 55 obese participants with a mean age of 46 ± 11 yr, body mass index of 49 ± 6 kg·m(-2), and body mass of 137.3 ± 21.3 kg took part in this study. Two consecutive iDXA scans with repositioning of the total body were conducted for each participant. The coefficient of variation, the root-mean-square averages of SD of repeated measurements, the corresponding 95% least significant change, and intraclass correlations were calculated. RESULTS: Precision error was 8.77% (percent coefficient of variation), with a root-mean-square SD of 0.294 kg and an intraclass correlation of 0.96. Bland-Altman plots demonstrated a mean precision bias of -0.08 ± 0.41 kg, giving a coefficient of repeatability of 0.82 kg and a bias range of -0.890 to 0.725 kg. CONCLUSIONS: When interpreting VAT results with the iDXA in severely obese populations, clinicians should be aware of the precision error for this important clinical parameter.

In vivo precision of the GE lunar iDXA for the assessment of lumbar spine, total hip, femoral neck, and total body bone mineral density in severely obese patients.

No study has evaluated the precision of the GE Lunar iDXATM (GE Healthcare) in measuring bone mineral density (BMD) among severely obese patients. The purpose of the study was to evaluate the precision of the GE Lunar iDXATM for assessing BMD, including the lumbar spine L1-L4, L2-L4, the total hip, femoral neck, and total body in a severely obese population (body mass index [BMI]>40 kg/m(2)). Sixty-four severely obese participants with a mean age of 46 ± 11 yr, BMI of 49 ± 6 kg/m(2), and a mean body mass of 136.8 ± 20.4 kg took part in this investigation. Two consecutive iDXA scans (with repositioning) of the total body (total body BMD [TBBMD]), lumbar spine (L1-L4 and L2-L4), total hip (total hip BMD [THBMD]), and femoral neck (femoral neck BMD [FNBMD]) were conducted for each participant. The coefficient of variation (CV), the root mean square (RMS) averages of standard deviations of repeated measurements, the corresponding 95% least significant change, and intraclass correlations (ICCs) were calculated. In addition, analysis of bias and coefficients of repeatability were calculated. The results showed a high level of precision for total body (TBBMD), lumbar spine (L1-L4), and total hip (THBMD) with values of RMS: 0.013, 0.014, and 0.011 g/cm(2); CV: 0.97%, 1.05%, and 0.99%, respectively. Precision error for the femoral neck was 2.34% (RMS: 0.025 g/cm(2)) but still represented high reproducibility. ICCs in all dual-energy X-ray absorptiometry measurements were 0.99 with FNBMD having the lowest at 0.98. Coefficients of repeatability for THBMD, FNBMD, L1-L4, L2-L4, and TBBMD were 0.0312, 0.0688, 0.0383, 0.0493, and 0.0312 g/cm(2), respectively. The Lunar iDXA demonstrated excellent precision for BMD measurements and is the first study to assess reproducibility of the GE Lunar iDXA with severely obese adults.

In vivo precision of the GE iDXA for the assessment of total body composition and fat distribution in severely obese patients.

OBJECTIVE: To evaluate the precision of the iDXA for total body composition and fat distribution measurements in severely obese patients. DESIGN AND METHODS: Sixty-five severely obese participants with a mean age of 46 ± 11 years, BMI of 49 ± 6 kg/m(2) , and a mean body mass of 137.3 ± 20.9 kg took part in this investigation. Two consecutive iDXA scans with repositioning of the total body were conducted for each participant. The coefficient of variation (CV), the root-mean-square (RMS) averages of standard deviations of repeated measurements, the corresponding 95% least significant change, and Intraclass Correlations (ICC) were calculated. RESULTS: Precision expressed as % CV, for total body bone mineral content, fat free mass, total body fat, total body lean, and % total body fat were 1.08%, 0.94%, 0.90%, 1.00%, 0.79%, respectively. Precision was 1.44% for gynoid fat distribution and 1.64% for android fat (AF) distribution. The ICCs in all DXA measurements were 0.99 with % AF having the lowest at 0.96. CONCLUSIONS: The GE Lunar iDXA™ demonstrated excellent precision for total body composition assessments and is the first study to assess reproducibility in severely obese individuals.

Relation between physical exertion and postural stability in hemiparetic participants secondary to stroke.

INTRODUCTION: Chronic hemiparetic stroke individuals are at a higher risk of falling. This may be due to balance impairments, cardiovascular deconditioning, and muscle weakness associated with stroke effects. Postural instability associated with fatigue would likely be attained more rapidly for stroke individuals than for healthy individuals. OBJECTIVE: To determine the effects of physical exertion induced by walking on postural stability in hemiparetic stroke participants. METHODS: Twelve hemiparetic participants and 12 control participants walked over-ground for a duration of 6 min and 18 min at their comfortable speed. Postural stability was assessed using centre of pressure related parameters during double-legged stance and tasks before the walk, immediately after the walk, 15 min post-walk, and 30 min post-walk. Measures of physical exertion during walking were also obtained from cardiorespiratory parameters, time-distance parameters, and subjective scales. Variables on postural stability and on physical exertion were analyzed using two-way repeated measures ANOVA and Generalized Estimating Equations. RESULTS: Physical exertion measures significantly increased when the duration of walk was increased from 6 min to 18 min in both control and hemiparetic participants. For postural stability measures, increasing the duration of walking led to a significant increase of postural sway in double-legged stance and sit-to-stand for the hemiparetic participants only. This effect on balance of hemiparetic participants was observed immediately after the end of the walk. CONCLUSION: This study demonstrated that physical exertion can increase postural sway in hemiparetic participants which could possibly lead to an increased risk of falling in these individuals.