Evaluating the efficacy of self-study videos for the surgery clerkship rotation: an innovative project in undergraduate surgical education.

Background: Educational videos have become valuable resources and can address some of the pitfalls of traditional learning. To ensure clerkship students have adequate exposure to curriculum objectives, a series of objective-aligned self-directed learning video podcasts covering core surgical concepts were developed by medical students and surgical residents. The objective of the study was to evaluate the efficacy of the video podcasts in the surgery clerkship rotation. Methods: Nineteen video podcasts were created, housed at www.surgicaleducationportal.com, and distributed to third-year medical students completing their surgical clerkship. A 10-question multiple-choice quiz was administered before and after students viewed each video, and they were also asked to complete a satisfaction survey. Results: A total of 302 paired pretests and posttests were completed. There was a mean increase of 2.7 points in posttest scores compared with pretest scores (p < 0.001). On a Likert scale from 1 to 5, with 5 being excellent, students rated the usefulness of the videos as 4.3, the quality of the content as 4.3 and the quality of the video as 4.2. Ninety-eight percent of students would recommend these videos to their classmates. Conclusion: Video podcasts are an effective modality for engaging medical students and may improve standardization of learning during their surgical clerkship.

Contexte: Les vidéos de formation sont devenues d'inestimables ressources et elles peuvent combler certaines des lacunes de l'enseignement traditionnel. Pour que les résidents bénéficient d'une exposition adéquate aux objectifs curriculaires, une série de balados vidéo d'autoapprentissage centrés sur des objectifs reliés aux principaux concepts de chirurgie a été réalisée par des étudiants en médecine et des résidents en chirurgie. L'objectif de l'étude était d'évaluer l'efficacité des balados pour les stages de chirurgie. Méthodes: Dix-neuf balados vidéo ont été réalisés (accessibles en anglais au www.surgicaleducationportal.com) et distribués à des étudiants de troisième année de médecine qui effectuent leur stage de chirurgie. Un questionnaire en 10 points à choix multiples leur a été administré avant et après le visionnement de chaque vidéo; ils ont ensuite été invités à répondre à un questionnaire d'évaluation. Résultats: En tout 302 pré- et post-tests appariés ont été effectués. On a observé une augmentation de 2,7 points aux scores post-test, comparativement aux scores pré-test (p < 0,001). Sur une échelle de Likert allant de 1 à 5, 5 correspondant à excellent, les étudiants ont accordé un score de 4,3 pour l'utilité des balados vidéo et de 4,2 pour leur qualité. Quatre-vingt-dix-huit pour cent des étudiants recommanderaient ces balados vidéo à leurs camarades. Conclusion: Les balados vidéo sont une modalité efficace pour mobiliser les étudiants en médecine et pourraient faciliter l'uniformisation de l'apprentissage lors des stages de chirurgie.

Oxygenation Instability Assessed by Oxygen Saturation Histograms during Supine vs Prone Position in Very Low Birthweight Infants Receiving Noninvasive Respiratory Support.

OBJECTIVE: To evaluate the effect of prone vs supine position on the oxygenation instability among very low birth weight (VLBW) infants receiving noninvasive respiratory support, as assessed by the average oxygen saturation (SpO2) histograms. STUDY DESIGN: Sixty-nine histograms from 23 VLBW infants were studied prospectively. Each infant was studied during 3 consecutive 3-hour periods of alternating positions; 12 infants started the study while prone and 11 infants started supine, by random order. Histogram classification system was used to quantify oxygenation stability and time spent in different SpO2 ranges. RESULTS: The fraction of inspired oxygen values were similar in both positions. Unstable histograms were more common in supine vs prone position (20/34 [59%] vs 10/35 [29%]; P = .02, respectively). Analyzing oxygenation stability as per position change revealed that a change from prone to supine increased oxygenation instability, and supine to prone decreased instability (P = .02). In the supine vs prone position, percent of time spent in SpO2 ≤80% and <90% was higher (5.0 ± 4.2 vs 2.4 ± 3.4 [P < .001] and 24.1 ± 13.7 vs 13.2 ± 10.0 [P < .001], respectively), and percent of time in SpO2 >94% was lower (39.7 ± 26.0 vs 52.4 ± 23.4 [P = .04]). CONCLUSIONS: Prone positioning decreased oxygenation instability and resulted in higher oxygenation among VLBW premature infants on noninvasive respiratory support. SpO2 histograms allow easy bedside assessment of oxygenation instability, and quantification of the time spent at different SpO2 ranges.

Cardiopulmonary Exercise Testing in Childhood in Late Preterms: Comparison to Early Preterms and Term-Born Controls.

Background: Late preterm (340−366 weeks gestational age [GA]) infants may have abnormal pulmonary development and possible exercise physiology parameters. We aim to assess the effect of late prematurity on exercise capacity in childhood and to compare it to early preterm (EP) (born < 300 GA), and to term healthy control (TC) (>370 week GA). Methods: Late preterm and early preterm (7−10 years) completed a cardiopulmonary exercise test (CPET) and spirometry and were compared to EP and to TC. Results: Eighty-four children (age 9.6 ± 1.0 years, 48% girls) participated. Twenty-one former LP were compared to 38 EP (15 with Bronchopulmonary dysplasia (BPD) [EP+], 23 without BPD [EP−]) and to 25 TC children. Peak oxygen uptake (peakV̇O2) was statistically lower than in the TC, but within the normal range, and without difference from the EP (LP 90.2 ± 15.1%, TC 112.4 ± 16.9%, p < 0.001; EP+ 97.3 ± 25.5%, EP− 85.4 ± 20.8%, p = 0.016 and p < 0.001, respectively, when compared with TC). Lung function (FEV1) was lower than normal only in the EP+ (75.6 ± 14.9% predicted, compared with 12.5 ± 87.8 in EP−, 87.5 ± 16.9 in LP and 91.0 ± 11.7 in TC). Respiratory and cardiac limitations were similar between all four study groups. Conclusions: This study demonstrated lower exercise capacity (peakV̇O2) in former LP children compared with healthy term children. Exercise capacity in LP was comparable to that of EP, with and without BPD. However, the exercise test parameters, specifically peakV̇O2, were within the normal range, and no significant physiological exercise limitations were found.

Cannula With Long and Narrow Tubing vs Short Binasal Prongs for Noninvasive Ventilation in Preterm Infants: Noninferiority Randomized Clinical Trial.

Importance: Use of cannulas with long and narrow tubing (CLNT) has gained increasing popularity for applying noninvasive respiratory support for newborn infants thanks to ease of use, perceived patient comfort, and reduced nasal trauma. However, there is concern that this interface delivers reduced and suboptimal support. Objective: To determine whether CLNT is noninferior to short binasal prongs and masks (SPM) when providing nasal intermittent positive pressure ventilation (NIPPV) in preterm infants. Design, Setting, and Participants: This randomized controlled, unblinded, prospective noninferiority trial was conducted between December 2017 and December 2019 at 2 tertiary neonatal intensive care units. Preterm infants born between 24 weeks' and 33 weeks and 6 days' gestation were eligible if presented with respiratory distress syndrome with the need for noninvasive ventilatory support either as initial treatment after birth or after first extubation. Analysis was performed by intention to treat. Interventions: Randomization to NIPPV with either CLNT or SPM interface. Main Outcomes and Measures: The primary outcome was the need for intubation within 72 hours after NIPPV treatment began. Noninferiority margin was defined as 15% or less absolute difference. Results: Overall, 166 infants were included in this analysis, and infant characteristics and clinical condition (including fraction of inspired oxygen, Pco2, and pH level) were comparable at recruitment in the CLNT group (n = 83) and SPM group (n = 83). The mean (SD) gestational age was 29.3 (2.2) weeks vs 29.2 (2.5) weeks, and the mean (SD) birth weight was 1237 (414) g vs 1254 (448) g in the CLNT and SPM groups, respectively. Intubation within 72 hours occurred in 12 of 83 infants (14%) in the CLNT group and in 15 of 83 infants (18%) in the SPM group (risk difference, -3.6%; 95% CI, -14.8 to 7.6 [within the noninferiority margin], χ2 P = .53). Moderate to severe nasal trauma was significantly less common in the CLNT group compared with the SPM group (4 [5%] vs 14 [17%]; P = .01). There were no differences in other adverse events or in the course during hospitalization. Conclusions and Relevance: In this study, CLNT was noninferior to SPM in providing NIPPV for preterm infants, while causing significantly less nasal trauma. Trial Registration: ClinicalTrials.gov Identifier: NCT03081611.

Long term follow-up of Palivizumab administration in children born at 29-32 weeks of gestation.

BACKGROUND: Severe respiratory syncytial virus (RSV) bronchiolitis requiring hospitalization induces long term immunological and respiratory abnormalities. The long-term immunomodulation effect of Palivizumab (RSV monoclonal antibody) prophylaxis and its impact on the development of asthma remain controversial. Our aim was to evaluate airway hyper-reactivity, systemic inflammatory markers, allergic parameters and respiratory morbidity, 5-7 years following Palivizumab administration to children born at 29-32 weeks of gestation (WGA). METHODS: Children born at 29-32 WGA were evaluated at age 5-7 years. Methacholine challenge test (MCT), serum inflammatory cytokines, fractional exhaled nitric oxide (FeNO), blood tests for eosinophil count, IgE and assessment of respiratory morbidity by questionnaire were compared between those born before Palivizumab prophylaxis was extended to 29-32 WGA and those who received Palivizumab prophylaxis. RESULTS: Of 42 children recruited, 27 received Palivizumab and 15 did not. The mean gestational age and weight were lower in the Palivizumab group. Similar values of spirometry, MCT, FeNO and allergic parameters were observed in the two groups. The Palivizumab group had higher IL4, IL5 and IL13 (Th2 cytokines), IL6, IL17α, and G-CSF (Th17 activation), and lower IL12 and higher INF-γ (Th1 cytokines). CONCLUSION: Compared to children who did not receive immunoprophylaxis, among children who received Palivizumab, no beneficial effects on long-term respiratory morbidity, airway reactivity or allergic parameters were observed, and levels of Th2 and Th17 cytokines implicated in the pathogenesis of asthma were higher. These findings cast doubt on the potential long-term beneficial effect of Palivizumab on asthma inception.

Less is More: Modern Neonatology.

Iatrogenesis is more common in neonatal intensive care units (NICUs) because the infants are vulnerable and exposed to prolonged intensive care. Sixty percent of extremely low-birth-weight infants are exposed to iatrogenesis. The risk factors for iatrogenesis in NICUs include prematurity, mechanical or non-invasive ventilation, central lines, and prolonged length of stay. This led to the notion that "less is more." In the delivery room delayed cord clamping is recommended for term and preterm infants, and suction for the airways in newborns with meconium-stained fluid is not performed anymore. As a symbol for a less aggressive attitude we use the term neonatal stabilization rather than resuscitation. Lower levels of oxygen saturations are accepted as normal during the first 10 minutes of life, and if respiratory assistance is needed, we no longer use 100% oxygen but 0.21-0.3 FiO2, depending on gestational age and the level of oxygen saturation. We try to avoid endotracheal ventilation by using non-invasive respiratory support and administering continuous positive airway pressure early on, starting in the delivery room. If surfactant is needed, non-invasive methods of surfactant administration are utilized. Use of central lines is shortened, and early feeding of human milk is the routine. Permissive hypercapnia is allowed, and continuous non-invasive monitoring not only of the O2 but also of CO2 is warranted. "Kangaroo care" and Newborn Individualized Developmental Care and Assessment Program (NIDCAP) together with a calm atmosphere with parental involvement are encouraged. Whether "less is more," or not enough, is to be seen in future studies.

"If I ever did have a daughter, I wouldn't raise her in New Brunswick:" exploring women's experiences obtaining abortion care before and after policy reform.

INTRODUCTION: New Brunswick (NB)'s Regulation 84-20 has historically restricted funded abortion care to procedures deemed medically necessary by two physicians and performed in a hospital by an obstetrician-gynecologist. However, on January 1, 2015, the provincial government amended the regulation and abolished the "two physician rule." OBJECTIVES: We aimed to document women's experiences obtaining abortion care in NB before and after the Regulation 84-20 amendment; identify the economic and personal costs associated with obtaining abortion care; and examine the ways in which geography, age and language-minority status condition access to care. METHODS: We conducted 33 semistructured telephone interviews with NB residents who had abortions between 2009 and 2014 (n=27) and after January 1, 2015 (n=6), in English and French. We audiorecorded and transcribed all interviews and conducted content and thematic analyses using ATLAS.ti software to manage our data. RESULTS: The cost of travel is significant for NB residents trying to access abortion services. Women reported significant wait times which impacted the disclosure of their pregnancy and the gestational age at the time of the abortion. Further, many women reported that physicians refused to provide referrals for abortion care. Even after the amendment to 84-20, all participants reported that they were required to have two physicians approve their procedure. CONCLUSIONS: The funding restrictions for abortion care in NB represent a profound inequity. Amending Regulation 84-20 was an important step but failed to address the fundamental issue that clinic-based abortion care is not funded and significant barriers to access persist. IMPLICATIONS: NB's policies create unnecessary barriers to accessing timely and affordable abortion care and produce a significant health inequity for women in the province. Further policy reforms are required to ensure that women are able to get the abortion care to which they are entitled.

Preinjury ASA score as an independent predictor of readmission after major traumatic injury.

BACKGROUND: Patients with trauma have a high predisposition for readmission after discharge. Unplanned solicitation of medical services is a validated quality of care indicator and is associated with considerable economic costs. While the existing literature emphasizes the severity of the injury, there is heterogeneity in defining preinjury health status. We evaluate the validity of the American Society of Anesthesiologists (ASA) Physical Status score as an independent predictor of readmission and compare it to the Charlson Comorbidity Index (CCI). METHODS: This is a single center, retrospective cohort study based on adult patients (>18 years of age) with trauma admitted to the Ottawa Hospital from January 1, 2004 to November 1, 2014. A multivariate logistic regression model is used to control for confounding and assess individual predictors. Outcome is readmission to hospital within 30 days, 3 months and 6 months. RESULTS: A total of 4732 adult patients were included in this analysis. Readmission rates were 6.5%, 9.6% and 11.8% for 30 days, 3 months and 6 months, respectively. Higher preinjury ASA scores demonstrated significantly increased risk of readmission across all levels in a dose-dependent manner for all time frames. The effect of preinjury ASA scores on readmission is most striking at 30 days, with patients demonstrating a 2.81 (1.88-4.22, P<0.0001), 3.59 (2.43-5.32, P<0.0001) and 7.52 (4.72-11.99, P<0.0001) fold odds of readmission for ASA class 2, 3 and 4, respectively, as compared with healthy ASA class 1 patients. The ASA scores outperformed the CCI at 30 days and 3 months. CONCLUSIONS: The preinjury ASA score is a strong independent predictor of readmission after traumatic injury. In comparison to the CCI, the preinjury ASA score was a better predictor of readmission at 3 and 6 months after a major traumatic injury. LEVEL OF EVIDENCE: Prognostic and Epidemiological Study, Level III.

Assessing abortion coverage in nurse practitioner programs in Canada: a national survey of program directors.

OBJECTIVES: Although nurse practitioners (NPs) play a critical role in the delivery of reproductive health services in Canada, there is a paucity of published information regarding the reproductive health education provided in their training programs. Our study aimed to understand better the didactic and curricular coverage of abortion in Canadian NP programs. STUDY DESIGN: In 2014, we conducted a 3-contact, bilingual (English-French) mailed survey to assess the coverage of, time dedicated to and barriers to inclusion of 17 different areas of reproductive health, including abortion. We also asked respondents to speculate on whether or not mifepristone would be incorporated into the curriculum if approved by Health Canada for early abortion. We analyzed our results with descriptive statistics and used inductive techniques to analyze the open-ended questions for content and themes. RESULTS: Sixteen of 23 (70%) program directors or their designees returned our survey. In general, abortion-related topics received less coverage than contraception, ectopic pregnancy management and miscarriage management. Fifty-six percent of respondents reported that their program did not offer information about first-trimester abortion procedures and/or post-abortion care in the didactic curriculum. Respondents expressed interest in incorporating mifepristone/misoprostol into NP education and training. CONCLUSION: Reproductive health issues receive uneven and often inadequate curricular coverage in Canadian NP programs. Identifying avenues to expand education and training on abortion appears warranted. Embarking on curricular reform efforts is especially important given the upcoming introduction of mifepristone into the Canadian health system for early abortion. IMPLICATIONS: Our findings draw attention to the need to integrate abortion-related content into NP education and training programs. The approval of Mifegymiso® may provide a window of opportunity to engage in curriculum reform efforts across the health professions in Canada.

Exploring Canadian women's knowledge of and interest in mifepristone: results from a national qualitative study with abortion patients.

INTRODUCTION: Although Canada decriminalized abortion in 1988, significant disparities in access to services and an uneven geographic distribution of providers persists. Health Canada registered mifepristone, the gold standard of medication abortion, in July 2015. Our study explored Canadian women's knowledge of, interest in, and perspectives on mifepristone prior to registration. METHODS: From November 2012 through July 2015 we conducted in-depth interviews with 174 Anglophone and Francophone women from Alberta, Manitoba, New Brunswick, Ontario, and Quebec about their abortion experiences and their opinions about medication abortion. We purposively recruited participants from different age cohorts and different regions within each study province to explore a range of perspectives. We analyzed these interviews for content and themes related to mifepristone using both deductive and inductive analytic techniques. RESULTS: The overwhelming majority of participants had no knowledge of mifepristone at the time of the interview. However, after providing a brief description of an evidence-based mifepristone/misoprostol regimen, more than half of the participants reported that they would have considered this method had it been available at the time of their abortion and most would have been comfortable receiving medication abortion care from a family physician or nurse practitioner. Most women supported the approval of mifepristone and felt Canadian women would benefit from having more options for early pregnancy termination. CONCLUSION: Although knowledge of mifepristone among recent abortion patients was low, considerable interest in medication abortion exists. Expanding awareness-raising efforts and supporting the approval of evidence-based regimens and provision of mifepristone appears warranted. IMPLICATIONS: The approval and introduction of mifepristone for early abortion in Canada promises to increase options and access. Creating tailored and culturally and contextually resonant messages about mifepristone is of high priority. Promoting evidence-based protocols and the inclusion of a full range of qualified professionals in service provision is also warranted.