Structural Competency in Simulation-Based Health Professions Education: A Call to Action and Pragmatic Guide.

SUMMARY STATEMENT: Simulation-based health professions educators can advance diversity, equity, and inclusion by cultivating structural competency, which is the trained ability to discern inequity not only at an individual level, but also at organizational, community, and societal levels. This commentary introduces Metzl and Hansen's Five-Step Model for structural competency and discusses its unique applicability to the metacognitive underpinnings of simulation-based health professions education. We offer a pragmatic guide for simulation-based health professions educators to collaboratively design learning objectives, simulation cases, character sketches, and debriefs in which structural competency is a simulation performance domain, alongside patient management, resource usage, leadership, situational awareness, teamwork, and/or communication. Our overall goal is to promote a paradigm shift in which educators are empowered to partner with patients, colleagues, and communities to recognize, learn about, and challenge the factors driving health inequities; a skill that may be applied to a broad range of health professions education within and outside of simulation.

WITHDRAWN: Comparison of Preadministered and Coadministered Lidocaine for Treating Pain and Distress Associated With Intranasal Midazolam Administration in Children: A Randomized Clinical Trial.

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Comparison of preadministered and coadministered lidocaine for treating pain and distress associated with intranasal midazolam administration in children: A randomized clinical trial.

OBJECTIVE: Pain and distress associated with intranasal midazolam administration can be decreased by administering lidocaine before intranasal midazolam (preadministered lidocaine) or combining lidocaine with midazolam in a single solution (coadministered lidocaine). We hypothesized coadministered lidocaine is non-inferior to preadministered lidocaine for decreasing pain and distress associated with intranasal midazolam administration. METHODS: Randomized, outcome assessor-blinded, noninferiority trial. Children aged 6 months to 7 years undergoing laceration repair received intranasal midazolam with preadministered or coadministered lidocaine. Pain and distress were evaluated with the Observational Scale of Behavioral Distress-Revised (OSBD-R) (primary outcome; non-inferiority margin 1.8 units) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Faces, Legs, Activity, Cry, Consolability (FLACC) scales and cry duration (secondary outcomes). Secondary outcomes also included adverse events, clinician and caregiver satisfaction, and pain and distress associated with intranasal lidocaine administration. RESULTS: Fifty-one patients were analyzed. Mean OSBD-R scores associated with intranasal midazolam administration were 6.4 (95% confidence interval [CI] 5, 7.8) and 7 (95% CI 5.2, 8.9) units for preadministered and coadministered lidocaine, respectively. The difference of 0.6 (95% CI -1.7, 2.8) units represented an inconclusive non-inferiority determination. CHEOPS and FLACC scores and cry duration were similar between groups. OSBD-R, CHEOPS, and FLACC scores and cry duration associated with intranasal lidocaine administration were 3.8, 9.9, and 6 units, and 56 seconds, respectively. Clinicians considered coadministered lidocaine easier to administer. CONCLUSION: Pain and distress associated with intranasal midazolam administration were similar when using coadministered or preadministered lidocaine, but our non-inferiority determination was inconclusive. Administration of intranasal lidocaine by itself was associated with a measurable degree of pain and distress.Keywords: intranasal, midazolam, anxiolysis, sedation, emergency department, emergency medicine, pain, distress, pediatric, lidocaine, laceration.

The "Facemask Blinder": A Technique for Optimizing Anxiolysis in Children Undergoing Facial Laceration Repair.

We present the case of a 7-year-old boy with a forehead laceration that required suture repair. The child was anxious and uncooperative, and the initial plan was to administer intranasal midazolam to facilitate the repair. However, a facemask blinder was first implemented as a visual barrier to block the child's view of any anxiety-provoking stimuli and appeared to improve the child's cooperation with the procedure. Intranasal midazolam was not administered, and the laceration was cleaned and repaired successfully. In conjunction with adequate local anesthesia and distraction techniques, the facemask blinder helped to facilitate the completion of the laceration repair without the need for any physical restraint or pharmacologic anxiolysis or sedation.

Enduring love? Attitudes to family and inheritance law in England and Wales.

This paper reports on the findings from a large-scale study of public attitudes to inheritance law, particularly the rules on intestacy. It argues that far from the assumption that the family' is in terminal decline, people in England and Wales still view their most important relationships, at least for the purposes of inheritance law, as centred on a narrow, nuclear family model. However, there is also widespread acceptance of re-partnering and cohabitation, producing generally high levels of support for including cohabitants in the intestacy rules and for ensuring that children from former relationships are protected. We argue that these views are underpinned by a continuing sense of responsibility to the members of one's nuclear family, arising from notions of sharing and commitment, dependency and support, and a sense of lineage.