Exploratory randomized controlled trial of hybrid obstetric simulation training for undergraduate students.

BACKGROUND: Introducing novel methods in undergraduate teaching of obstetrics and gynecology has been recommended. High-fidelity simulation of shoulder dystocia has been shown to improve skills of qualified maternity staff. We aimed to assess whether simulation is also useful for improving medical students' skills. METHODS: Twenty-four medical students were recruited. Training consisted of a high-fidelity simulation teaching session for all 24 students and a refresher session for which the same students were randomly allocated to two groups. Half attended a small-group tutorial (SGT) and half a simulation session with a patient-actor (hybrid simulation, HYB). Afterward, they were asked to deliver a baby with simulated shoulder dystocia. We assessed their practical skills and compared communication skills between SGT and HYB. Primary outcome measure was their communication score, using a validated scale. Secondary measure was the students' ability to deliver the baby appropriately. RESULTS: Posttraining, all students managed delivery appropriately. Group HYB had significantly higher median total patient perception scores (11 simulation versus 9 tutorial, P = 0.0239, Mann-Whitney) than SGT. CONCLUSION: High-fidelity simulation can be used to train and evaluate learning. The use of patient-actors during simulation improves students' communication skills. Future research should assess whether this translates into better communication with real patients.

Advanced physical assessment: the role of the district nurse.

This article describes an initiative by an NHS trust to support its district nurses in developing and using physical examination skills as part of patient assessment. The article outlines the process and suggests that the initiative is important to help meet the needs of older patients with long-term conditions.

Risk factors for human corneal graft failure within the Australian corneal graft registry.

BACKGROUND: Our aims were to examine graft survival and visual outcome after full-thickness corneal transplantation. METHODS: Records of 18,686 penetrating corneal grafts, 14,622 with archival follow-up from 1 to 22 years, were examined within a national database. Kaplan-Meier survival analysis indicated variables of interest for Cox proportional hazards regression analysis. A model clustered by patient to control intereye or intergraft dependence was constructed to identify variables best predicting penetrating corneal graft failure. Visual acuity in the grafted eye was measured by Snellen acuity. RESULTS: Probability of corneal graft survival was 0.87, 0.73, 0.60, and 0.46 at 1, 5, 10, and 15 years, respectively. Reasons for graft failure included irreversible rejection (34%), corneal endothelial cell failure including cases of glaucoma (24%), and infection (14%). Variables predicting graft failure in multivariate analysis included transplant center, location and volume of surgeon's case-load, graft era, indication for graft, number of previous ipsilateral grafts, lens status, corneal neovascularization at transplantation, a history of ocular inflammation or raised intraocular pressure, graft diameter, and postoperative events including graft neovascularization and rejection. Best-corrected Snellen acuity of 6/12 or better was achieved by 45%, and of less than 6/60 by 26%, of grafted eyes at last follow-up. CONCLUSIONS: The short-term survival of penetrating corneal transplants is excellent, but the eventual attrition rate appears inexorable and many factors that influence graft survival significantly are not amenable to change. Most penetrating grafts are performed for visual improvement, and excellent acuity will be achieved by approximately half of all grafts.

Management of shoulder dystocia: skill retention 6 and 12 months after training.

OBJECTIVE: To assess skill retention 6 and 12 months after shoulder dystocia training. METHODS: Midwives and doctors from six United Kingdom hospitals attended a 40-minute workshop on shoulder dystocia management. Participants managed a standardized simulation before and 3 weeks, 6 months, and 12 months afterward. Outcome measures were delivery, head-to-body delivery time, performance of appropriate actions, force applied, and quality of communication. RESULTS: A total of 122 participants were recruited. One hundred eighteen were evaluated 3 weeks posttraining, for whom follow-up was available for 95 (81%) at 6 months and 82 (70%) at 12 months. Before training, 60 of 122 (49%) achieved delivery, 97 of 118 (82%) were able to deliver after initial training, 80 of 95 (84%) were able to deliver at 6 months, and 75 of 82 (85%) were able to deliver at 12 months. Twenty-one (18%) who could not deliver 3 weeks after training were offered additional training; of these, 11 of 14 (79%) achieved delivery at 12 months. Among those who could deliver 3 weeks posttraining, there was no deterioration in the performance of basic actions, delivery interval, force application, and patient communication. Those who were proficient before initial training performed best at follow-up, but skill retention was also good in those who learned to deliver during initial training. Eighteen percent could not deliver after initial training and required additional individualized tuition; the large majority retained their newly acquired skills at 6 and 12 months. CONCLUSION: Overall, training resulted in a sustained improvement in performance. Annual training seems adequate for those already proficient before training, but more frequent rehearsal is advisable for those initially lacking competency until skill acquisition is achieved. LEVEL OF EVIDENCE: II.

Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins.

OBJECTIVE: To evaluate the effectiveness of simulation training for shoulder dystocia management and compare training using a high-fidelity mannequin with that using traditional devices. METHODS: Training was undertaken in six hospitals and a medical simulation center in the United Kingdom. Midwives and obstetricians working for participating hospitals were eligible for inclusion. One hundred forty participants (45 doctors, 95 midwives) were randomized to training with a high-fidelity training mannequin (incorporating force perception training) or traditional low-fidelity mannequins. Performance was assessed pre- and posttraining, using a videoed, standardized shoulder dystocia simulation. Outcome measures were delivery, head-to-body delivery time, use of appropriate and inappropriate actions, force applied, and communication. RESULTS: One hundred thirty-two participants completed the posttraining assessment. All training was associated with improved performance: use of basic maneuvers 114 of 140 (81.4%) to 125 of 132 (94.7%) (P=.002), successful deliveries 60 of 140 (42.9%) to 110 of 132 (83.3%) (P<.001), good communication with the patient 79 of 139 (56.8%) to 109 of 132 (82.6%) (P<.001), pre- and posttraining, respectively. Training with the high-fidelity mannequin was associated with a higher successful delivery rate than training with traditional devices: 94% compared with 72% (odds ratio 6.53, 95% confidence interval 2.05-20.81; P=.002). Total applied force was significantly lower for those who had undergone force training (2,030 Newton seconds versus 2,916 Newton seconds; P=.006) but there was no significant difference in the peak applied force 102 Newtons versus 112 Newtons (P=.242). CONCLUSION: This study verifies the need for shoulder dystocia training; before training only 43% participants could achieve delivery. All training with mannequins improved the management of simulated shoulder dystocia. Training on a high-fidelity mannequin, including force perception teaching, offered additional training benefits. LEVEL OF EVIDENCE: I.

How effective is penetrating corneal transplantation? Factors influencing long-term outcome in multivariate analysis.

BACKGROUND: In a large patient cohort, we investigated long-term corneal graft outcome, risk factors for graft failure, and whether corneal graft survival had improved over time. METHODS: Records of 10,952 full-thickness corneal grafts with associated archival follow-up were examined within a prospectively-maintained, national database of 13,831 records, with follow-up extending for up to 18 years. Kaplan-Meier survival analysis was used to indicate variables of interest for Cox proportional hazards regression analysis. A model clustered by individual patient to control for inter-eye or inter-graft dependence was constructed to identify variables best predicting penetrating corneal graft failure. RESULTS: Probability of corneal graft survival was 0.86 at 1 year, 0.73 at 5 years, 0.62 at 10 years, and 0.55 at 15 years. Graft survival did not improve over a 15-year timeframe. Variables predicting graft failure in multivariate analysis included transplant centre, donor age, preoperative diagnosis, number of previous ipsilateral grafts, lens status, history of corneal neovascularisation, ocular inflammation or raised intraocular pressure in the grafted eye, requirement for anterior vitrectomy, graft size, early suture removal, postoperative events including graft neovascularisation, rise in intraocular pressure, and rejection episodes, type of treatment for raised intraocular pressure, and arrangements for recipient follow-up. A further 11 variables showing a significant influence on graft survival in univariate analysis were not included in the final Cox model. CONCLUSION: The long-term results of corneal transplantation are no better than for other forms of transplantation and have shown no measurable improvement over the past 15 years.