Barriers and enablers to achieving clinical procedure competency-based outcomes in a national paediatric training/residency program-a multi-centered qualitative study.

BACKGROUND: In 2018, the Royal College of Physicians of Ireland revised its paediatric training program to a competency-based medical education (CBME) training/residency curriculum. This included a requirement to achieve competence in a number of core procedural skills to progress within the program. Internationally, simulation-based medical education (SBME) is gaining interest as an effective teaching pedagogy for training procedural skill competency. The objectives of this study were to (1) identify enablers and barriers for paediatric trainees to achieve their required procedural competencies, (2) gain insight on the feasibility of achieving the required procedural skills, and (3) explore what simulation-based resources are used as well as their role in achieving the required procedural skill competencies. METHODS: A multi-centered qualitative study using semi-structured interviews was performed. Twenty-four paediatric consultants and trainees were recruited from two academic tertiary hospitals using purposive and snowball sampling. Interviews were conducted between March and September 2021, audio recorded, transcribed, and analyzed using thematic analysis. RESULTS: Three main themes regarding enablers for achieving procedural competencies were reported and include having protected training time, routine assessments, and a standardized curriculum. Barriers to achieving procedural competencies focused mainly on limited clinical exposure. The use of SBME was recommended by all participants (n = 24, 100%) to assist in achieving procedural competencies and most (n = 15, 62.5%) reported it is feasible to attain the required procedural skills in the paediatric CBME program. CONCLUSION: It is feasible to achieve the required procedural competencies for most paediatric trainees, but this can be improved with protected training time, routine assessments, and a standardized curriculum. Barriers to achieving these skills mainly center on limited clinical exposure, which can be remedied by SBME. Further research is warranted to determine the costs and types of SBME tools available as well as teaching pedagogies to support paediatric trainees achieve their required procedural competencies.

Do deepfake videos undermine our epistemic trust? A thematic analysis of tweets that discuss deepfakes in the Russian invasion of Ukraine.

Deepfakes are a form of multi-modal media generated using deep-learning technology. Many academics have expressed fears that deepfakes present a severe threat to the veracity of news and political communication, and an epistemic crisis for video evidence. These commentaries have often been hypothetical, with few real-world cases of deepfake's political and epistemological harm. The Russo-Ukrainian war presents the first real-life example of deepfakes being used in warfare, with a number of incidents involving deepfakes of Russian and Ukrainian government officials being used for misinformation and entertainment. This study uses a thematic analysis on tweets relating to deepfakes and the Russo-Ukrainian war to explore how people react to deepfake content online, and to uncover evidence of previously theorised harms of deepfakes on trust. We extracted 4869 relevant tweets using the Twitter API over the first seven months of 2022. We found that much of the misinformation in our dataset came from labelling real media as deepfakes. Novel findings about deepfake scepticism emerged, including a connection between deepfakes and conspiratorial beliefs that world leaders were dead and/or replaced by deepfakes. This research has numerous implications for future research, societal media platforms, news media and governments. The lack of deepfake literacy in our dataset led to significant misunderstandings of what constitutes a deepfake, showing the need to encourage literacy in these new forms of media. However, our evidence demonstrates that efforts to raise awareness around deepfakes may undermine trust in legitimate videos. Consequentially, news media and governmental agencies need to weigh the benefits of educational deepfakes and pre-bunking against the risks of undermining truth. Similarly, news companies and media should be careful in how they label suspected deepfakes in case they cause suspicion for real media.

Face/Off: Changing the face of movies with deepfakes.

There are growing concerns about the potential for deepfake technology to spread misinformation and distort memories, though many also highlight creative applications such as recasting movies using other actors, or younger versions of the same actor. In the current mixed-methods study, we presented participants (N = 436) with deepfake videos of fictitious movie remakes (such as Will Smith staring as Neo in The Matrix). We observed an average false memory rate of 49%, with many participants remembering the fake remake as better than the original film. However, deepfakes were no more effective than simple text descriptions at distorting memory. Though our findings suggest that deepfake technology is not uniquely placed to distort movie memories, our qualitative data suggested most participants were uncomfortable with deepfake recasting. Common concerns were disrespecting artistic integrity, disrupting the shared social experience of films, and a discomfort at the control and options this technology would afford.

Guidelines for Thrombolytic Therapy for Frostbite.

The data are insufficient to support standardized treatment of all patients with frostbite with thrombolytic therapy. The following guidelines, however, should be applied to all patients with cyanosis persisting proximal to the distal phalanx (Grade 3 or 4 frostbite injury) and demonstrated loss of perfusion at or proximal to the middle phalanx immediately after rewarming.

Profiling emergency department presentations of 14-15-year-olds in modern Ireland.

BACKGROUND: Mid-adolescence, that twilight era when the human child transitions to adulthood, is an often overlooked developmental age yet harbours a subpopulation of patients with their own myriad of medical problems somewhat unique to their age group. AIMS: Our study is aimed at reviewing the typical presentations to a paediatric emergency department of modern Irish teenagers in mid-adolescence, the profile of which has changed significantly over the past 10 years. METHODS: Hospital electronic databases were used to conduct a retrospective review of the paediatric emergency department presentations of patients aged 14-15 years during the year of 2017. We collated data on the presenting complaint, background history, admission rate and medical specialities involved in each patient's care while in our Emergency Department. RESULTS: A total of 1485 presentations were made, with 1363 being eligible for inclusion in this study. The results highlight the varied and challenging presentations (Table 1) and the high number of specialities required within emergency medicine to care for this unique population (Table 2). CONCLUSION: The results highlight the most common presentations of this subgroup of patients, with trauma, in keeping with recent international data, being the most common presentation. The noted high frequency in the number of mental health/intoxication/self-harm presentations among the Irish teenagers in our region is consistent with trends reported in world literature and serves to emphasise one of the main challenges facing those working in paediatrics in Ireland over the next 10 years.

A case of peripheral ulcerative keratitis associated with neutrophilic dermatosis of the dorsal hand.

We report a case of peripheral ulcerative keratitis associated with neutrophilic dermatosis of the dorsal hand, a recently described clinical entity. A 68-year-old man presented with concurrent peripheral ulcerative keratitis of the right eye and neutrophilic dermatosis of the dorsal hand causing pustular skin eruptions on the dorsal surface of both hands. Systemic investigations suggested an underlying diagnosis of Wegener's granulomatosis. To our knowledge this is the first reported case of neutrophilic dermatosis of the dorsal hand associated with ocular complications.

Ethical, legal, psychosocial, and cultural implications of genomics for oncology nurses.

OBJECTIVES: To summarize the role of oncology nurses in the ethical, legal, psychosocial, and cultural issues inherent in genetic testing for hereditary cancer risk and to describe the recent trend and implications of direct-to-consumer genetic tests. DATA SOURCES: Published articles/books, legal rulings, professional organization statements. CONCLUSIONS: Ethical, legal, psychosocial, and cultural implications are inherent in the growing field of genetic science that is transforming modern health care. IMPLICATIONS FOR NURSING PRACTICE: Nurses have a duty to be knowledgeable about and advocate for the ethical integration of genetic/genomic information into their patient's health care.

Health care professionals' views of sharing information with families who have a child with a genetic condition.

The purpose of this study was to examine health care professionals' views and strategies for individualizing information sharing in families who have a child with a genetic condition. The sample consisted of 37 health professionals from three clinical sites in the greater metropolitan area of a large Midwestern city. Qualitative content thematic analysis was used to analyze data from the health professionals' semi-structured interviews. Four themes captured how health care professionals work with families around information management: Sharing Information with Parents, Taking into Account Parental Preferences, Understanding of the Condition, and Helping Parents Inform Others. These findings contribute to understanding the processes that health professionals use in sharing information with parents who have children with a genetic condition, and they provide guidance for clinical practice, professional training, and future research.

Evaluation of nanostructural, mechanical, and biological properties of collagen-nanotube composites.

Collagen I is an essential structural and mechanical building block of various tissues, and it is often used as tissue-engineering scaffolds. However, collagen-based constructs reconstituted in vitro often lacks robust fiber structure, mechanical stability, and molecule binding capability. To enhance these performances, the present study developed 3-D collagen-nanotube composite constructs with two types of functionalized carbon nanotubes, carboxylated nanotubes and covalently functionalized nanotubes (CFNTs). The influences of nanotube functionalization and loading concentration on the collagen fiber structure, mechanical property, biocompatibility, and molecule binding were examined. Results revealed that surface modification and loading concentration of nanotubes determined the interactions between nanotubes and collagen fibrils, thus altering the structure and property of nanotube-collagen composites. Scanning electron microscopy and confocal microscopy revealed that the incorporation of CFNT in collagen-based constructs was an effective means of restructuring collagen fibrils because CFNT strongly bound to collagen molecules inducing the formation of larger fibril bundles. However, increased nanotube loading concentration caused the formation of denser fibril network and larger aggregates. Static stress-strain tests under compression showed that the addition of nanotube into collagen-based constructs did not significantly increase static compressive moduli. Creep/recovery testing under compression revealed that CFNT-collagen constructs showed improved mechanical stability under continuous loading. Testing with endothelial cells showed that biocompatibility was highly dependent on nanotube loading concentration. At a low loading level, CFNT-collagen showed higher endothelial coverage than the other tested constructs or materials. Additionally, CFNT-collagen showed capability of binding to other biomolecules to enhance the construct functionality. In conclusion, functionalized nanotube-collagen composites, particularly CFNT-collagen composites, could be promising materials, which provide structural support showing bundled fibril structure, biocompatibility, multifunctionality, and mechanical stability, but rigorous control over chemical modification, loading concentration, and nanotube dispersion are needed.

Group C streptococcal subperiosteal abscess of the orbit.

Group C Streptococcus is a well recognised pathogen in acute pharyngitis and sinusitis. To our knowledge group c streptococcus has not been reported to cause orbital cellulitis or subperiosteal abscess. We wish to report a case of a child with orbital subperiosteal abscess caused by Group C streptococcus.

Presymptomatic genetic testing in children for neurofibromatosis 2.

Genetic testing in children, when there is a question of whether or not there is a clear medical benefit that will accrue to the child, is a controversial topic within the health care community. A convenience sample of 10 parents from nine families who had made the decision whether or not to test their children for the neurofibromatosis 2 gene mutation was asked in interviews to describe why they made their choice about presymptomatic testing for this late-onset disease. Findings from a narrative analysis revealed how the nine parents who tested or intended to test their young children saw the decision as a pathway to knowledge that would help the family unit. All parents interviewed noted that their decision was informed by their health team and was not difficult to make. Implications of these findings for bioethical analysis are presented.

Slightly hypertonic saline and dextran-40 in resuscitation of methamphetamine burn patients.

The inherent danger of illegal manufacture of methamphetamine is explosion and fire with the "cookers" presenting to burn centers for treatment. Recent studies have shown that methamphetamine burn patients required resuscitation volumes two to three times that of the standard Parkland formula and experienced a higher mortality rate. The purpose of this study was to compare the fluid resuscitation requirements and other characteristics of our methamphetamine-positive burn patients with a control group of methamphetamine-negative burn patients. A retrospective study of burn patients with methamphetamine-positive urine toxicology screens was conducted from August 1996 to April 2005. The data collected were age, sex, %total body surface area (%TBSA) burn, urine toxicology screen result, length of stay (LOS), ventilator days, weight, urine output, and fluid requirement during the first 24 hours along with fluid type, survival, and hospital charges. Methamphetamine-positive patients were matched to controls for %TBSA, age, and sex. Eleven methamphetamine-positive burn patients were well matched with 11 methamphetamine-negative controls. There was no difference in intubation rate, ventilator days, LOS, and there were no deaths in either group. There was no statistical difference between the two groups for the ratio of the 24-hour fluid resuscitation requirement divided by the estimate from the Parkland formula. Hospital charges were similar for the two groups. The largest volume of fluid infused was lactated Ringers (LR) and the slightly hypertonic fluid combination of LR + 50 mEq sodium bicarbonate + 3.4 mmol potassium phosphate. Both groups also received a dextran-40 (Rheomacrodex) infusion. In contrast to previous studies, our experience with methamphetamine-positive burn patients shows that they did not have an increased initial fluid requirement, a longer LOS, more days on the ventilator, higher hospitalization charges nor an increased mortality rate. The only apparent difference between our study and others is in the method of resuscitation. The slightly hypertonic fluid combination of LR + 50 mEq sodium bicarbonate +3.4 mM potassium phosphate was used for resuscitation along with Rheomacrodex. Prospective trials should be conducted on this fluid resuscitation strategy to determine wider applicability for all large burn patients.

Investigation into the multidimensional genetic basis of drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis.

OBJECTIVE: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe blistering skin diseases, which are mainly caused by drugs. The two idiosyncratic conditions are distinguished on the basis of the degree of blistering, possibly representing diseases at different ends of the same spectrum. A genetic predisposition has been postulated. METHOD: We have retrospectively identified a heterogeneous group of patients with SJS and TEN (n = 73 cases, 141 matched controls) induced by a number of marketed drugs and evaluated effector candidate genetic predisposition. We have used a multivariate genetic analysis method for the first time to handle the heterogeneity of clinical presentation, drug etiology, ethnicity and gender in these adverse events. RESULTS: Our results show that predisposition varied according to ethnicity. There was a correlation for SJS with HLA-B*44, DRB1*07 and with the MHC ancestral 57.1 haplotype (and its constituents) in subjects who self-reported as Caucasians, which did not differ with gender. The HLA-DRB and -DRQ genetic predisposition to SJS seemed to be distinct from that of TEN, but further work is needed for both conditions to identify the causal variants. No conclusion concerning correlations with different drugs could be made because of small numbers in each drug group. CONCLUSION: This study stresses the importance of accurate clinical phenotyping, exemplifies a novel analysis method to dissect complicated samples and calls for collaborative prospective studies.

Keratectasia as a presentation of surgically induced necrotizing sclerokeratitis (SINS).

PURPOSE: A case of keratectasia is reported as a severe presentation of surgically induced necrotizing sclerokeratitis (SINS). METHODS: A 72-year-old white woman had a painful, raised lesion on the superior cornea of her right eye 3 years after uncomplicated extracapsular cataract extraction with intraocular lens implantation. Examination showed a large ectatic area of the superior cornea with inflamed sclera adjacent to the surgical wound, which was diagnosed as SINS. RESULTS: No underlying systemic autoimmune condition or vasculitis was identified on investigation. Progressive painful keratectasia necessitated enucleation, which confirmed on histopathologic examination features of chronic nodular episcleritis and nongranulomatous scleritis with evidence of keratitis and fibrovascular scarring. CONCLUSION: The predominant inflammatory response in the cornea represents surgically induced necrotizing keratoscleritis (SINK) as a new variant presentation of SINS. Oral corticosteroids and immunosuppressive agents should not be delayed to prevent progressive tissue destruction and poor outcome.

Randomized clinical study of Hydrofiber dressing with silver or silver sulfadiazine in the management of partial-thickness burns.

This prospective, randomized study compared protocols of care using either AQUACEL Ag Hydrofiber (ConvaTec, a Bristol-Myers Squibb company, Skillman, NJ) dressing with silver (n = 42) or silver sulfadiazine (n = 42) for up to 21 days in the management of partial-thickness burns covering 5% to 40% body surface area (BSA). AQUACEL Ag dressing was associated with less pain and anxiety during dressing changes, less burning and stinging during wear, fewer dressing changes, less nursing time, and fewer procedural medications. Silver sulfadiazine was associated with greater flexibility and ease of movement. Adverse events, including infection, were comparable between treatment groups. The AQUACEL Ag dressing protocol tended to have lower total treatment costs (Dollars 1040 vs. Dollars 1180) and a greater rate of re-epithelialization (73.8% vs 60.0%), resulting in cost-effectiveness per burn healed of Dollars 1,409.06 for AQUACEL Ag dressing and Dollars 1,967.95 for silver sulfadiazine. A protocol of care with AQUACEL(R) Ag provided clinical and economic benefits compared with silver sulfadiazine in patients with partial-thickness burns.

Issues in genetic testing of children.

Commentary about the ethical issues involved in the genetic testing in children (GTIC) has centered around beliefs that early testing of children when no medical benefits are anticipated should be discouraged. This article discusses the types of GTIC and the contexts of possible testing scenarios, and provides a review of the current research into the effects of such testing on children and their families. As data cannot support either substantive benefits or harms accrued after GTIC, it is recommended that the traditional ethical analysis based on principled theory be augmented by theories that reflect a family-centered ethic.

An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite.

BACKGROUND: Severe frostbite can have devastating consequences with loss of limbs and digits. One of the mechanisms of cold injury to human tissue is vascular thrombosis. The effect of tissue plasminogen activator (tPA) and heparin in limb and digit preservation in severe frostbite patients has not been previously studied. METHODS: Intra-arterial (6 patients) or intravenous (i.v., 13 patients) tPA and IV heparin were used in patients with severe frostbite. All patients between January 1, 1989 and February 1, 2003 with severe frostbite not improved by rapid rewarming, with absent Doppler pulses in distal limb or digits, without perfusion by Technetium (Tc) 99m three-phase bone scan, and no contraindication to tPA use were eligible. Efficacy was assessed on the basis of predicted digit amputation before therapy, given the clinical and Tc-99m scan results, versus partial or complete digits removed. RESULTS: There were no complications with i.v. tPA. Two patients with intra-arterial TPA had bleeding complications. We know from historical Tc-99m scan data which digits were at risk for amputation. In this study, there were 174 digits at risk in 18 patients and only 33 were amputated. CONCLUSION: Intravenous tPA and heparin after rapid rewarming is safe and reduced predicted digit amputations considerably. Patients with no response to thrombolytic therapy were those with more than 24 hours of cold exposure, warm ischemia times greater than 6 hours, or evidence of multiple freeze-thaw cycles. Our algorithm for treatment of severe frostbite now includes use of i.v. tPA for patients without contraindications.

Genetic testing of children: confluence or collision between parents and professionals?

Nursing has been challenged to lead in all areas of knowledge development in genetics. In addition to participation in genetic counseling and research, the profession must be an advocate for the proper use of new clinical practices in genetic care. One of these areas is the largely unregulated practice of genetic testing of minor children. Psychological and bioethical concerns have been raised about testing children at parental request when no immediate benefit will result. Several professional bodies have urged the adoption of guidelines that would limit parental choice in the testing process. This article argues that little data exists to support the creation of strict regulations, and also notes that analysis of this issue through the use of alternative ethical theory can yield useful directions for nurses attempting to navigate this controversial topic.