A review of the American College of Surgeons accredited education institutes' assessment practices for learners, faculty, and continuous program improvement.

Purpose: Simulation is an instructional modality that offers opportunities for assessment across many domains. The American College of Surgeons created the Accredited Education Institutes (AEIs) to build a community of high-quality simulation centers focused around improving surgical education and training. The goals of this project were to identify assessment methods used by AEIs, discuss how these methods align with established assessment frameworks, identify best practices, and provide guidance on best practice implementation. Methods: The authors analyzed responses regarding learner assessment, faculty assessment, and continuous program improvement from AEI accreditations surveys using deductive qualitative analysis. Results: Data from ninety-six centers were reviewed. Codes for each category were organized into formal and informal themes. For learner assessment, examinations and checklists identified as the most common types of formal assessment used and oral feedback as the most common type of informal assessment. For faculty assessment, written evaluations were the most common formal type and debriefs were the most common informal type. For continuous program improvement, written evaluations were the most common formal type and oral feedback was the most frequent informal type. Discussion: The goal of assessment should be to encourage learning through feedback and to ensure the attainment of educational competencies. The data revealed a variety of assessment modalities used to accomplish this goal with AEIs frequently utilizing some of the most reliable forms of assessment. We discuss how these forms of assessment can be integrated with best practices to develop assessment portfolios for learners and faculty, performance improvement reports for faculty, and assessments of clinical impact. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00132-6.

Recognizing the 2023 Fellows of the National Academy of School Nursing.

Membership as a Fellow in the National Academy of School Nursing (FNASN) is the NASN's highest recognition award. At the 2023 NASN Conference, five new Fellows were inducted and now add FNASN to their credentials. This group of exemplary school nurse professionals contributes to school nursing practice in many ways that crisscross NASN's Framework for 21st Century School Nursing Practice™. They each have chosen unique pathways to provide service. The 2023 NASN Fellows are: Eileen Gavin, New Jersey; Jenny Gormley, Massachusetts; Lynne Meadows, Georgia; Kathy Reiner, Colorado; and Sharonlee Trefry, Vermont. The following article outlines each Fellow's unique path to attaining FNASN.

Deciphering local and regional hydroclimate resolves contradicting evidence on the Asian monsoon evolution.

The winter and summer monsoons in Southeast Asia are important but highly variable sources of rainfall. Current understanding of the winter monsoon is limited by conflicting proxy observations, resulting from the decoupling of regional atmospheric circulation patterns and local rainfall dynamics. These signals are difficult to decipher in paleoclimate reconstructions. Here, we present a winter monsoon speleothem record from Southeast Asia covering the Holocene and find that winter and summer rainfall changed synchronously, forced by changes in the Pacific and Indian Oceans. In contrast, regional atmospheric circulation shows an inverse relation between winter and summer controlled by seasonal insolation over the Northern Hemisphere. We show that disentangling the local and regional signal in paleoclimate reconstructions is crucial in understanding and projecting winter and summer monsoon variability in Southeast Asia.

Meal-eating characteristics among patients with symptoms of gastroparesis: Relationships to delays in gastric emptying.

BACKGROUND: Patients with symptoms of gastroparesis (Gp) often modify their diets and consume small meals. However, the relationship between patients' eating behavior and their gastric emptying is not well understood. This study describes meal-eating characteristics of patients with Gp symptoms and relates them to severity of emptying delay. METHODS: Adult patients with Gp symptoms underwent 4-h gastric emptying scintigraphy and completed questionnaires including the Patient Assessment of GI Symptoms, a nutrition and diet questionnaire, and the Meal Patterns Questionnaire. KEY RESULTS: Of 119 patients with Gp symptoms, 35 had normal gastric emptying (≤10% gastric retention at 4 h), 26 mildly delayed (>10%-20%), 28 moderately delayed (>20%-35%), and 30 severely delayed (>35%). Most patients (85%) reported eating small meals with an average of 2.4 meals per day. The most common reasons for stopping eating a meal were feeling full (83%), nausea (46%), and abdominal pain (31%). As gastric emptying worsened, patients increasingly made diet modifications such as low-fat, low-fiber, Gp diet, oral supplements, and blenderized meals (r = 0.309, p = 0.0007). Postprandial fullness lasted for 351 ± 451 min for patients with severely delayed emptying versus 207 ± 173 min for patients with normal emptying (p = 0.19). CONCLUSIONS & INFERENCES: Meal-eating characteristics were found to vary with severity of gastric retention. Patients with severely delayed gastric emptying reported the longest duration of postprandial fullness. Dietary modification increased significantly with gastric retention. These meal-eating characteristics are important to understand as they impact on dietary education given to Gp patients for symptom management.

Trial of the MIND Diet for Prevention of Cognitive Decline in Older Persons.

BACKGROUND: Findings from observational studies suggest that dietary patterns may offer protective benefits against cognitive decline, but data from clinical trials are limited. The Mediterranean-DASH Intervention for Neurodegenerative Delay, known as the MIND diet, is a hybrid of the Mediterranean diet and the DASH (Dietary Approaches to Stop Hypertension) diet, with modifications to include foods that have been putatively associated with a decreased risk of dementia. METHODS: We performed a two-site, randomized, controlled trial involving older adults without cognitive impairment but with a family history of dementia, a body-mass index (the weight in kilograms divided by the square of the height in meters) greater than 25, and a suboptimal diet, as determined by means of a 14-item questionnaire, to test the cognitive effects of the MIND diet with mild caloric restriction as compared with a control diet with mild caloric restriction. We assigned the participants in a 1:1 ratio to follow the intervention or the control diet for 3 years. All the participants received counseling regarding adherence to their assigned diet plus support to promote weight loss. The primary end point was the change from baseline in a global cognition score and four cognitive domain scores, all of which were derived from a 12-test battery. The raw scores from each test were converted to z scores, which were averaged across all tests to create the global cognition score and across component tests to create the four domain scores; higher scores indicate better cognitive performance. The secondary outcome was the change from baseline in magnetic resonance imaging (MRI)-derived measures of brain characteristics in a nonrandom sample of participants. RESULTS: A total of 1929 persons underwent screening, and 604 were enrolled; 301 were assigned to the MIND-diet group and 303 to the control-diet group. The trial was completed by 93.4% of the participants. From baseline to year 3, improvements in global cognition scores were observed in both groups, with increases of 0.205 standardized units in the MIND-diet group and 0.170 standardized units in the control-diet group (mean difference, 0.035 standardized units; 95% confidence interval, -0.022 to 0.092; P = 0.23). Changes in white-matter hyperintensities, hippocampal volumes, and total gray- and white-matter volumes on MRI were similar in the two groups. CONCLUSIONS: Among cognitively unimpaired participants with a family history of dementia, changes in cognition and brain MRI outcomes from baseline to year 3 did not differ significantly between those who followed the MIND diet and those who followed the control diet with mild caloric restriction. (Funded by the National Institute on Aging; ClinicalTrials.gov number, NCT02817074.).

Glacial changes in sea level modulated millennial-scale variability of Southeast Asian autumn monsoon rainfall.

Most paleoclimate studies of Mainland Southeast Asia hydroclimate focus on the summer monsoon, with few studies investigating rainfall in other seasons. Here, we present a multiproxy stalagmite record (45,000 to 4,000 years) from central Vietnam, a region that receives most of its annual rainfall in autumn (September-November). We find evidence of a prolonged dry period spanning the last glacial maximum that is punctuated by an abrupt shift to wetter conditions during the deglaciation at ~14 ka. Paired with climate model simulations, we show that sea-level change drives autumn monsoon rainfall variability on glacial-orbital timescales. Consistent with the dry signal in the stalagmite record, climate model simulations reveal that lower glacial sea level exposes land in the Gulf of Tonkin and along the South China Shelf, reducing convection and moisture delivery to central Vietnam. When sea level rises and these landmasses flood at ~14 ka, moisture delivery to central Vietnam increases, causing an abrupt shift from dry to wet conditions. On millennial timescales, we find signatures of well-known Heinrich Stadials (HS) (dry conditions) and Dansgaard-Oeschger Events (wet conditions). Model simulations show that during the dry HS, changes in sea surface temperature related to meltwater forcing cause the formation of an anomalous anticyclone in the Western Pacific, which advects dry air across central Vietnam, decreasing autumn rainfall. Notably, sea level modulates the magnitude of millennial-scale dry and wet phases by muting dry events and enhancing wet events during periods of low sea level, highlighting the importance of this mechanism to autumn monsoon variability.

The National Academy of School Nursing Fellows (FNASN).

The National Association of School Nurses honors school nurses who have made extraordinary, unique, and enduring contributions to school nursing and the National Association of School Nurses with recognition in the National Academy of School Nursing Fellows (FNASN). The following article outlines the value of FNASNs, how they contribute, and how a school nurse can apply for Fellowship. The time is now for mid-career school nurses to prepare for the opportunity that an NASN Fellow represents!

Dynamic and thermodynamic influences on precipitation in Northeast Mexico on orbital to millennial timescales.

The timing and mechanisms of past hydroclimate change in northeast Mexico are poorly constrained, limiting our ability to evaluate climate model performance. To address this, we present a multiproxy speleothem record of past hydroclimate variability spanning 62.5 to 5.1 ka from Tamaulipas, Mexico. Here we show a strong influence of Atlantic and Pacific sea surface temperatures on orbital and millennial scale precipitation changes in the region. Multiple proxies show no clear response to insolation forcing, but strong evidence for dry conditions during Heinrich Stadials. While these trends are consistent with other records from across Mesoamerica and the Caribbean, the relative importance of thermodynamic and dynamic controls in driving this response is debated. An isotope-enabled climate model shows that cool Atlantic SSTs and stronger easterlies drive a strong inter-basin sea surface temperature gradient and a southward shift in moisture convergence, causing drying in this region.

The nonlinearity of regulation in biological networks.

The extent to which the components of a biological system are (non)linearly regulated determines how amenable they are to therapy and control. To better understand this property termed "regulatory nonlinearity", we analyzed a suite of 137 published Boolean network models, containing a variety of complex nonlinear regulatory interactions, using a probabilistic generalization of Boolean logic that George Boole himself had proposed. Leveraging the continuous-nature of this formulation, we used Taylor decomposition to approximate the models with various levels of regulatory nonlinearity. A comparison of the resulting series of approximations of the biological models with appropriate random ensembles revealed that biological regulation tends to be less nonlinear than expected, meaning that higher-order interactions among the regulatory inputs tend to be less pronounced. A further categorical analysis of the biological models revealed that the regulatory nonlinearity of cancer and disease networks could not only be sometimes higher than expected but also be relatively more variable. We show that this variation is caused by differences in the apportioning of information among the various orders of regulatory nonlinearity. Our results suggest that there may have been a weak but discernible selection pressure for biological systems to evolve linear regulation on average, but for certain systems such as cancer, on the other hand, to simultaneously evolve more nonlinear rules.

Impact of the COVID-19 pandemic on American College of Surgeons-Accredited Education Institutes & American Society of Anesthesiologists-Simulation Education Network: Opportunities for interdisciplinary collaboration.

BACKGROUND: The COVID-19 pandemic presented challenges for simulation programs including American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network. American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network leadership were surveyed to identify opportunities to enhance patient safety through simulation. METHODS: Between January and June 2021, surveys consisting of 3 targeted domains: (I) Changing practice; (II) Contributions and recognition; and (III) Moving ahead were distributed to 100 American College of Surgeons Accredited Education Institutes and 54 American Society of Anesthesiologists Simulation Education Network centers. Responses were combined and percent frequencies reported. RESULTS: Ninety-six respondents, representing 51 (51%) American College of Surgeons Accredited Education Institutes, 17 (31.5%) American Society of Anesthesiologists Simulation Education Network, and 28 dually accredited centers, completed the survey. Change of practice. Although 20.3% of centers stayed fully operational at the COVID-19 onset, 82% of all centers closed: 32% were closed less than 3 months, 28% were closed 3 to 6 months, 8% were closed 7 to 9 months, and 32% remained closed as of June 6, 2021. Most impacted activities were large-group instruction and team training. Sixty-nine percent of programs converted in-person to virtual programs. Contributions. The top reported innovative contributions included policies (80%), curricula (80%), and scholarly work (74%), Moving ahead. The respondents' top concerns were returning to high-quality training to best address learners' deficiencies and re-engagement of re-directed training programs. When asked "How the American College of Surgeons/American Society of Anesthesiologists Programs could best assist your simulation center goals?" the top responses were "facilitate collaboration" and "publish best practices from this work." CONCLUSION: The Pandemic presented multiple challenges and opportunities for simulation centers. Opportunities included collaboration between American College of Surgeons Accredited Education Institutes and the American Society of Anesthesiologists Simulation Education Network to identify best practices and resources needed to enhance patient safety through simulation.

A Prospective Observational Comparison of Two Approaches to Anesthetizing the Trachea for Awake Intubation.

BACKGROUND: Multiple techniques have been described for anesthetizing the lower glottis and trachea prior to awake fiberoptic intubation. The primary aim of this study is to evaluate whether direct application of local anesthetic to the lower airway via an epidural catheter under direct vision is equally efficacious when compared to use of a transtracheal block in adult patients with an anticipated difficult airway. METHODS: Patients age >18 years requiring awake fiberoptic intubation who underwent upper and lower airway topicalization were observed prospectively. Following topicalization of the upper airway, patients underwent either a transtracheal block or had their trachea and lower glottis anesthetized under direct vision via dispersion of local anesthetic through a multi-orifice epidural catheter. Choice of technique was at the discretion of the attending anesthesiologist. The primary outcome was defined as the degree of coughing observed at the time of intubation based on a 4-point ordinal scale. RESULTS: Awake intubations in 88 patients were observed with 44 patients undergoing transtracheal block and 44 patients undergoing the epidural catheter technique. Degree of coughing with intubation was similar for each approach with a coughing score of (0, IQR (0,1)) versus (0, IQR (0,1)) in the epidural catheter and transtracheal groups respectively (p = 0.385). Duration of procedure was less in the transtracheal group (1.35 ± 1.54 min) vs. epidural catheter approach (2.86 ± 2.20 min) (p< 0.001). CONCLUSION: The epidural catheter and transtracheal approach appear to be equally effective at preventing coughing with intubation during awake fiberoptic intubation.

What are the Top Research Priorities in Surgical Simulation and How Can They Be Best Addressed? Results From a Multidisciplinary Consensus Conference.

OBJECTIVES: To define the top priorities in simulation-based surgical education where additional research would have the highest potential to advance the field and develop proposals that would address the identified research priorities. SUMMARY AND BACKGROUND DATA: Simulation has become integral part of surgical training but there are a number of outstanding questions that have slowed advances in this field. METHODS: The Delphi methodology was used to define the top priorities in simulation-based surgical education. A research summit was held with multiple stakeholders under the auspices of the American College of Surgeons Division of Education to develop proposals to address these priorities. RESULTS: Consensus was achieved after the first round of voting on the following 3 most important topics: (1) impact of simulation training on patient safety and outcomes, (2) the value proposition of simulation, and (3) the use of simulation for physician certification and credentialing. Knowledge gaps, challenges and opportunities, and research questions to address these topics were defined by summit participants. CONCLUSIONS: The top 3 priorities in surgical simulation research were defined and project outlines were developed for impactful projects on these topics. Successful completion of such projects is expected to advance the field of simulation-based surgical education.

Meal Eating Characteristics of Patients with Gastroparesis.

BACKGROUND: Patients with gastroparesis often consume only small meals due to early satiety. AIMS: (1) Describe meal eating characteristics of patients with gastroparesis; (2) Relate meal eating characteristics to symptoms, gastric emptying (GE), and body weight. METHODS: Patients with gastroparesis filled out questionnaires including Patient Assessment of Upper GI Symptoms (PAGI-SYM), and questionnaire about meal habits and body weight. Patients underwent gastric emptying scintigraphy. RESULTS: Of 192 gastroparesis patients, 93% endorsed early satiety (ES) with severity of 3.7 ± 1.5 (scored from 0-5) and 93% endorsed postprandial fullness (PPF) with severity of 3.9 ± 1.3. Time spent consuming meals averaged 13.6 ± 17.7 min. Main reasons patients stopped eating were fullness (61%), nausea (48%), and abdominal pain (31%). Time spent eating correlated inversely with severity of nausea (r = -0.18, p < 0.05), stomach fullness (r = -0.21, p < 0.01), PPF (r = -0.23, p < 0.01), loss of appetite (r = -0.34, p < 0.01). Postprandial fullness lasted for 316 ± 344 min. Duration of PPF correlated with nausea (r = 0.30, p < 0.01), retching (r = 0.29, p < 0.01), vomiting (r = 0.28, p < 0.01), stomach fullness (r = 0.33, p < 0.01), loss of appetite (r = 0.35, p < 0.01), and constipation (r = 0.27, p < 0.01). Underweight patients had increased inability to finish a normal size meal (p < 0.01), loss of appetite (p < 0.01), and lower abdominal pain/discomfort (p < 0.05). Patients had lost 3.06 ± 10.60 kgs from their baseline weight. Weight loss correlated with nausea (r = 0.26, p < 0.01), ES (r = 0.30, p < 0.01), loss of appetite (r = 0.28, p < 0.01). CONCLUSIONS: Early satiety and postprandial fullness were common with high severity. The main reasons for meal cessation were early satiety, nausea, and abdominal pain. Body weight and change in body weight were associated with symptoms of gastroparesis.

A critical gap: Advanced practice nurses focused on the public's health.

BACKGROUND: The COVID-19 pandemic has highlighted the need for nurse leaders who "embrace the interconnection" between medicine and public health. The inequitable impact of COVID-19 on people of color demonstrates the importance of applying expertise from nursing practice and public health systems to work with communities and other professions on complex health issues. Yet, despite a clear need for improved population health, educational programs designed to produce Advanced Public Health Nurses, with skills to address complex system changes, have become increasingly scarce. PURPOSE: We put forward the perspective that the nation needs more advanced practice nurses prepared for leadership roles focused on the health of whole populations, marginalized communities, and the systems and policies that promote their health. DISCUSSION: We argue that opportunities should be expanded for nurses to attain education for these roles through increased investments in the Doctor of Nursing Practice model to prepare nurses for advanced public health specialty practice.

Patient Centered Medical Home Cooking: Community Culinary Workshops for Multidisciplinary Teams.

Ideal management of chronic disease includes team based primary care, however primary care medical staff face a lack of training when addressing nutritional counseling and lifestyle prevention. Interactive culinary medicine education has shown to improve knowledge and confidence among medical students. The aim of this study was to determine whether a culinary medicine curriculum delivered to a multidisciplinary team of primary care medical staff and medical students in a community setting would improve self-reported efficacy in nutritional counseling and whether efficacy differed between participant roles. A 4-h interactive workshop that took place within the neighborhood of a primary care medical home was delivered to medical staff and students. Participants completed a voluntary questionnaire before and after the workshop that addressed participants' attitudes and confidence in providing nutritional counseling to patients. Chi-square tests were run to determine statistically significant associations between role of participant and survey question responses. Sign Rank tests were run to determine if pre-workshop responses differed significantly from post-workshop responses. Thirteen of seventeen responses related to attitudes and efficacy demonstrated significant improvement after the workshop compared with prior to the workshop. Significant differences noted between roles prior to the workshop disappear when asking the same questions after the workshop. Delivery of culinary medicine curricula to a primary care medical home team in a community setting is an innovative opportunity to collaboratively improve nutritional education and counseling in chronic disease prevention.

A Randomized Comparison of Positional Stability: The EZ-Blocker Versus Left-Sided Double-Lumen Endobronchial Tubes in Adult Patients Undergoing Thoracic Surgery.

OBJECTIVE: To assess if there is a difference in the repositioning rate of the EZ-Blocker versus a left-sided double-lumen endobronchial tube (DLT) in patients undergoing thoracic surgery and one-lung ventilation. DESIGN: Prospective, randomized. SETTING: Single center, university hospital. PARTICIPANTS: One hundred sixty-three thoracic surgery patients. INTERVENTIONS: Patients were randomized to either EZ-Blocker or a DLT. MEASUREMENTS AND MAIN RESULTS: The primary outcome was positional stability of either the EZ-Blocker or a left-sided double-lumen endobronchial tube, defined as the number of repositionings per hour of surgery and one-lung ventilation. Secondary outcomes included an ordinal isolation score from 1 to 3, in which 1 was poor, up to 3, which represented excellent isolation, and a visual analog postoperative sore throat score (0-100) on postoperative days (POD) one and two. Rate of repositionings per hour during one-lung ventilation and surgical manipulation in left-sided cases was similar between the two devices: 0.08 ± 0.15 v 0.11 ± 0.3 (p = 0.72). In right-sided cases, the rate of repositioning was higher in the EZ-Blocker group compared with DLT: 0.38 ± 0.65 v 0.09 ± 0.21 (p = 0.03). Overall, mean isolation scores for the EZ-Blocker versus the DLT were 2.76 v 2.92 (p = 0.04) in left-sided cases and 2.70 v 2.83 (p = 0.22) in right-sided cases. Median sore throat scores for left sided cases were 0 v 5 (p = 0.13) POD one and 0 v 5 (p = 0.006) POD two for the EZ-Blocker and left-sided DLT, respectively. CONCLUSION: For right-sided procedures, the positional stability of the EZ-Blocker is inferior to a DLT. In left-sided cases, the rate of repositioning for the EZ-Blocker and DLT are not statistically different.

Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) study: Rationale, design and baseline characteristics of a randomized control trial of the MIND diet on cognitive decline.

Alzheimer's dementia (AD) is the sixth leading cause of death in the U.S., with an estimated $305 billion cost of care in 2020. Currently there are no cures or therapies to ameliorate the disease progression and symptoms. Growing evidence links a diet characterized by high antioxidant components with benefits to cognitive function, which is indicative of the preventative potential of dietary inteventions. The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) study is a 3-year, multicenter, randomized controlled trial to test the effects of the MIND diet on cognitive function in 604 individuals at risk for AD. Men and women ages 65 to 84 years were recruited. Eligible participants were randomized to either the MIND diet with mild caloric restriction or their usual diet with mild caloric restriction. Cognitive assessments, medical history, blood pressure, anthropometric measurements, and blood and urine sample collections will be taken at baseline and follow-up visits. MRI scans will be completed on approximately half of the enrolled participants at the start and end of the study. Unique features of the MIND study include: 1) a dietary pattern, rather than single nutrient or food, tested in an at-risk population; 2) foods featured as key components of the MIND diet (i.e. extra-virgin olive oil, blueberries, and nuts) provided for participants; and 3) MRI scans of brain structure and volume that may provide potential mechanistic evidence on the effects of the diet. Results from the study will be crucial to the development of dietary guidelines for the prevention of AD.

Show Me the Evidence: COVID-19 and School Nursing in the 21st Century.

The emergence of COVID-19 and how to control its spread has highlighted the importance of understanding and applying evidence-based decisions into school nursing practice. This is the fifth and final article in NASN's series on how the Framework for 21st Century School Nursing PracticeTM is a mind-set that can be applied to everyday school nursing practice and will focus on the principle of Standards of Practice, and particularly how evidence-based practice decisions are made during COVID-19.