FAIMER Global Faculty Development: A Sustainable Partnership Model to Advance Health Professions Education.

The Foundation for Advancement of International Medical Education and Research (FAIMER), a member of Intealth, offers longitudinal faculty development programs (LFDPs) in health professions education (HPE) and leadership through its International FAIMER Institute (IFI) in the United States and FAIMER Regional Institutes (FRIs) globally. FAIMER fosters mutual collaboration and delineates shared responsibilities for FRI development in partnership with local institutions, using an adapted hub-and-spoke organizational design. This paper describes FAIMER's model, its sustainability, and its impacts at individual, institutional, and national levels. IFI was launched in 2001 in Philadelphia, Pennsylvania, as a 2-year part-time hybrid LFDP; with the COVID-19 pandemic onset, IFI transitioned to a fully online program. Since FAIMER's launch, 11 FRIs developed in Brazil, Chile, China, Egypt, India, Indonesia, and South Africa, each modeled on the IFI curriculum and adapted to local context. The more than 1,600 IFI and FRI graduates (fellows) from over 55 countries now form a global community of health professions educators who have shared exposure to HPE methods and assessment, leadership and management, educational scholarship and research, and project management and evaluation. Across all global locations and program formats, fellows self-reported a similar increase in knowledge and skills in HPE. All programs center on the fellows' institutional projects as experiential learning; these projects have focused primarily on educational methods and curriculum revisions. An increased quality of education was reported as the top impact resulting from fellows' projects. As a result of these programs, fellows have influenced education policy in their countries and established academic societies for HPE, thus contributing to recognition of the HPE academic specialty. FAIMER has successfully developed a sustainable model for advancing HPE globally, creating a vibrant network of health professions educators who have influenced country-specific educational policy and practice. FAIMER's model offers one approach to building global capacity in HPE.

Framework to Incorporate Leadership Training in Competency-Based Undergraduate Curriculum for the Indian Medical Graduate.

The new competency-based curriculum recognized the importance of leadership skills in physicians and has outlined competencies that would lead to attaining this goal. To prepare the Indian medical graduates as effective healthcare leader, there is no universal approach; it is desirable that the institutes organize the leadership competencies into an institutional framework and integrate these vertically and horizontally in their curriculum in a longitudinal manner. We describe the rationale for incorporating formal leadership training in the new competency-based undergraduate curriculum and propose a longitudinal curricular template utilizing a mixed/multi-modality approach to teach and apply leadership competencies.

Leptospirosis following heavy rains in 2017 in Mumbai: Report of large-scale community chemoprophylaxis.

Background: Globally, cities get flooded due to heavy rains. As the incidence of leptospirosis increases after such flooding in Mumbai, community chemoprophylaxis to selected individuals was a consensus recommendation by experts. Methods: We surveyed a total of 1 499 293 houses in severely affected areas of Mumbai (where there was waterlogging or high incidence of leptospirosis in the past) as well as in all slum areas. A total of 6 714 210 people (>50% of the population) were screened. A total of 156 934 adults, 4465 children, 359 pregnant women and 4957 high-risk adults were given prophylaxis with doxycycline or azithromycin by paramedical staff (n = 9526) under the supervision of medical staff. Social media and newspaper advertisements were used to create public awareness. Results: Compared with previous floods, there were reduced number of cases of leptospirosis due to community chemoprophylaxis (432 confirmed cases in 2005 v. 128 [59 confirmed] in 2017). Conclusions: Selective, time-bound chemoprophylaxis following floods is likely to reduce the incidence of leptospirosis, as well as associated morbidity and mortality.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos).

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis.

Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis.

Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these bundles facilitates the adaptation of guidelines and helps improve the prognosis of target diseases. In Tokyo Guidelines 2013 (TG13), we proposed management bundles for acute cholangitis and cholecystitis. Here, in Tokyo Guidelines 2018 (TG18), we redefine the management bundles for acute cholangitis and cholecystitis. Critical parts of the bundles in TG18 include the diagnostic process, severity assessment, transfer of patients if necessary, and therapeutic approach at each time point. Observance of these items and procedures should improve the prognosis of acute cholangitis and cholecystitis. Studies are now needed to evaluate the dissemination of these TG18 bundles and their effectiveness. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos).

Since the publication of the Tokyo Guidelines in 2007 and their revision in 2013, appropriate management for acute cholecystitis has been more clearly established. Since the last revision, several manuscripts, especially for alternative endoscopic techniques, have been reported; therefore, additional evaluation and refinement of the 2013 Guidelines is required. We describe a standard drainage method for surgically high-risk patients with acute cholecystitis and the latest developed endoscopic gallbladder drainage techniques described in the updated Tokyo Guidelines 2018 (TG18). Our study confirmed that percutaneous transhepatic gallbladder drainage should be considered the first alternative to surgical intervention in surgically high-risk patients with acute cholecystitis. Also, endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage can be considered in high-volume institutes by skilled endoscopists. In the endoscopic transpapillary approach, either endoscopic naso-gallbladder drainage or gallbladder stenting can be considered for gallbladder drainage. We also introduce special techniques and the latest outcomes of endoscopic ultrasound-guided gallbladder drainage studies. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis.

We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?

Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.

Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018.

The Tokyo Guidelines 2013 (TG13) include new topics in the biliary drainage section. From these topics, we describe the indications and new techniques of biliary drainage for acute cholangitis with videos. Recently, many novel studies and case series have been published across the world, thus TG13 need to be updated regarding the indications and selection of biliary drainage based on published data. Herein, we describe the latest updated TG13 on biliary drainage in acute cholangitis with meta-analysis. The present study showed that endoscopic transpapillary biliary drainage regardless of the use of nasobiliary drainage or biliary stenting, should be selected as the first-line therapy for acute cholangitis. In acute cholangitis, endoscopic sphincterotomy (EST) is not routinely required for biliary drainage alone because of the concern of post-EST bleeding. In case of concomitant bile duct stones, stone removal following EST at a single session may be considered in patients with mild or moderate acute cholangitis except in patients under anticoagulant therapy or with coagulopathy. We recommend the removal of difficult stones at two sessions after drainage in patients with a large stone or multiple stones. In patients with potential coagulopathy, endoscopic papillary dilation can be a better technique than EST for stone removal. Presently, balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is used as the first-line therapy for biliary drainage in patients with surgically altered anatomy where BE-ERCP expertise is present. However, the technical success rate is not always high. Thus, several studies have revealed that endoscopic ultrasonography-guided biliary drainage (EUS-BD) can be one of the second-line therapies in failed BE-ERCP as an alternative to percutaneous transhepatic biliary drainage where EUS-BD expertise is present.

Producing Competent Doctors - The Art and Science of Teaching Clinical Skills.

For a doctor to provide medical care with competence, he must not only have knowledge but must also be able to translate that knowledge into action. It is his competence in clinical skills that will enable him to practice safely and effectively in the real world. To ensure acquisition of clinical skills, medical teachers must adopt teaching methods that prioritise observation, practice, feedback; and more practice. We try to elucidate the meaning of clinical skills, the challenges inherent in clinical skills training in India, training models that have shown success in practice and can be adopted in the Indian context, and various techniques to enhance skill-training, including the giving of feedback, which is a critically important component of skills development.

Morphological and functional changes in colon after coloplasty for management of corrosive esophageal strictures.

BACKGROUND: The etiology of corrosive esophageal strictures is different from that reported in Western literature, with acid ingestion being a major cause. This study evaluated functional and morphological changes in the colon used as neoesophagus. METHODS: Functional changes in the neoesophagus were evaluated by symptom score of dysphagia and manometry. Barium study and fluoroscopy were done to evaluate the flow patterns and endoscopy with histopathological examination to study the adaptive changes in the colon. RESULTS: Thirty-five patients with corrosive injury presented between 2007 and 2010. Isolated esophageal involvement was seen in 22 patients; 11 of them underwent colonic replacement. The passage of barium was smooth, without any hold up at the upper or lower anastomotic line. Endoscopic biopsy at 6 months and 1 year did not show any change in the mucosal pattern or in the muscularis layer of the transposed colon. Functional evaluation showed relief of dysphagia in all 11 patients after surgery. The mean preoperative dysphagia score was 7.81 (range 5-10), at 1 month was 0.73 (range 0-2), and at 3 months post-surgery was 0.45 (range 0-2). Manometric study at 3 months after the surgery in all 11 patients and in five patients at the end of 6 months showed no evidence of peristalsis in the neoesophagus. Three of the latter five patients demonstrated a 4-5-cm zone with a high pressure in the intraabdominal part of the transposed colon compared with that in the intrathoracic part of the colon. On barium studies, reflux from the stomach into the neoesophagus was not seen in any of the 11 patients. CONCLUSIONS: Esophagocoloplasty was associated with symptom relief, and the reflux of gastric content was low because of 4-5 cm of the colon being intraabdominal in a positive pressure environment.

Impact of a fellowship program for faculty development on the self-efficacy beliefs of health professions teachers: a longitudinal study.

BACKGROUND: Teachers' belief in their ability to teach influences how much of the new knowledge and skills gained during faculty development (FD) programs are actually implemented at the workplace. AIM: To study the effect of a longitudinal FD program on the self-efficacy beliefs (SEB) of teachers of health professions using quasi-experimental methodology. METHODS: The SEB of 70 teachers of health professions enrolling for a longitudinal FD program at three sites in India and one site in South Africa and an equal number of comparable controls were measured using the "teacher efficacy belief systems-self" (TEBS-self) scale. The scale was re-administered at 6 and 12 months to both the groups. RESULTS: Teachers enrolled in the program had lower scores than controls at the beginning of the program but demonstrated a significant increase at 6 months with an effect size of 0.56. The 12-month scores demonstrated a further rise in the participating teachers. The control group maintained the scores but did not show any significant change either at 6 or at 12 months. CONCLUSION: Longitudinal FD program has positive effect on SEB of teachers.

TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos).

Since its publication in 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) have been widely adopted. The validation of TG07 conducted in terms of clinical practice has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. Discussion by the Tokyo Guidelines Revision Committee concluded that acute cholecystitis should be suspected when Murphy's sign, local inflammatory findings in the gallbladder such as right upper quadrant abdominal pain and tenderness, and fever and systemic inflammatory reaction findings detected by blood tests are present but that definite diagnosis of acute cholecystitis can be made only on the basis of the imaging of ultrasonography, computed tomography or scintigraphy (HIDA scan). These proposed diagnostic criteria provided better specificity and accuracy rates than the TG07 diagnostic criteria. As for the severity assessment criteria in TG07, there is evidence that TG07 resulted in clarification of the concept of severe acute cholecystitis. Furthermore, there is evidence that severity assessment in TG07 has led to a reduction in the mean duration of hospital stay. As for the factors used to establish a moderate grade of acute cholecystitis, such as leukocytosis, ALP, old age, diabetes, being male, and delay in admission, no new strong evidence has been detected indicating that a change in the criteria used in TG07 is needed. Therefore, it was judged that the severity assessment criteria of TG07 could be applied in the updated Tokyo Guidelines (TG13) with minor changes. TG13 presents new standards for the diagnosis, severity grading and management of acute cholecystitis. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.