The Relationship Between Serious Mental Illness and Criminal Offending in Persons Experiencing Homelessness: The Role of Substance Use Disorder.

Individuals who live with mental illness are encumbered by related risk factors that increase the probability of legal involvement. The goal was to determine how homelessness and substance use disorder are intervening factors in the relationship between symptoms of serious mental illness (SMI) and criminal offending. A sample of 210 chronically homeless adults receiving SAMHSA-funded outreach and psychiatric rehabilitation services between 2014 and 2016 was recruited in a study of interventions to address housing in homeless persons with a SMI. Participants were interviewed and data collected were analyzed using structural equation modeling. Statistical analysis showed that homelessness severity mediated the relationship between SMI symptom severity and criminal offenses committed in the past 30 days in participants with a substance use disorder but not in those with no substance use diagnosis. Results show that homelessness and substance use are important to address to possibly alter trajectories for criminal justice involvement.

The Use of Therapeutic Inhaled Essential Oils (TIEO) as a Holistic Approach to Decrease Preoperative Anxiety in ERAS Gynecological Surgery.

INTRODUCTION: Preoperative anxiety is a negative symptom frequently experienced by surgical patients. This evidence-based-practice (EBP) project evaluated the effectiveness of therapeutic inhaled essential oils (TIEO) on anxiety levels during the preoperative phase of surgery in enhanced recovery after surgery (ERAS) gynecological patients ages 18 to 65 years old. METHODS: A prospective, preposttest, quasiexperimental design was used to evaluate preoperative anxiety scores. Patients (N = 53) scheduled for gynecological surgeries were enrolled at a level II trauma center. Upon arrival to the preoperative area on the day of surgery, patients were asked to score their anxiety level using the Visual Analog Scale for Anxiety (VAS-A). Patients were provided the TIEO intervention during their preoperative phase of surgery ranging from 15 to 60 minutes. Patients were encouraged to take mindful deep breaths and inhale the essential oil vapor. Before being transported into the operating room, patients were asked to re-evaluate their anxiety level using the VAS-A. RESULTS: A matched paired t-test revealed the post-VAS-A measurements were significantly lower (n = 52, M = 31.37, SD = 24.334) than the pre-VAS-A measurements (n = 52, M = 53.50, SD = 26.863), t51 = 8.756, P = .000). On average, postanxiety scores were 22.135 mm lower than pre-anxiety scores (95% CI [17.060, 27.209]). CONCLUSIONS: The use of TIEO demonstrated a statistically significant decrease in preoperative anxiety scores within the ERAS gynecological population. TIEO can be used as an adjunct intervention to manage preoperative anxiety. TIEO can be successfully administered in the preoperative area. Decreasing anxiety in the preoperative period may lead to many perioperative benefits such as improving surgical outcomes, patient satisfaction, and quality of care.

Happiness, well-being, and recovery: Experiences of adults receiving psychiatric rehabilitation services.

OBJECTIVES: Although recovery for people with serious mental illness (SMI) has received considerable attention, there is a research gap on the related topics of well-being and happiness-subjects that have been widely studied in the general population. The objective of this study was to explore the experiences of happiness, well-being, and recovery from the perspectives of persons with SMI, and to examine similarities and differences among these constructs. METHOD: This qualitative study used semistructured interviews with a purposive sample of 30 adults with SMI to explore experiences of happiness, well-being, and recovery. Reflexive thematic analysis was applied to generate themes related to each concept. RESULTS: Happiness was facilitated through relationships with natural and professional supports, engaging in meaningful activities that conferred a sense of accomplishment, using coping skills to reduce distress, engaging in recreational activities, and meeting basic material needs. Well-being was promoted through self-care activities and enhanced through relationships with professional supports. However, nearly one-fourth of participants expressed uncertainty about what well-being meant to them. Recovery was characterized as a process of overcoming illness or adversity through which personal control over symptoms and stressors is increased; recovery is also facilitated by supportive professional relationships. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Most factors relating to the happiness of people with SMI are also factors that have been identified in theory and research as facilitating the happiness of the general population. Findings suggest that happiness should be considered an important new area of research, policy, and practice in the fields of psychiatric rehabilitation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Optic Tract Shrinkage Limits Visual Restoration After Occipital Stroke.

Background and Purpose: Damage to the adult primary visual cortex (V1) causes vision loss in the contralateral visual hemifield, initiating a process of trans-synaptic retrograde degeneration. The present study examined functional implications of this process, asking if degeneration impacted the amount of visual recovery attainable from visual restoration training in chronic patients, and if restoration training impacted optic tract (OT) shrinkage. Methods: Magnetic resonance imaging was used to measure OT volumes bilaterally in 36 patients with unilateral occipital stroke. From OT volumes, we computed laterality indices (LI), estimating the stroke-induced OT shrinkage in each case. A subset of these chronic patients (n=14, 13±6 months poststroke) underwent an average of nearly 1 year of daily visual restoration training, which repeatedly stimulated vision in their blind field. The amount of visual field recovery was quantified using Humphrey perimetry, and post training magnetic resonance imaging was used to assess the impact of training on OT shrinkage. Results: OT LI was correlated with time since stroke: it was close to 0 (no measurable OT shrinkage) in subacute participants (<6 months poststroke) while chronic participants (>6 months poststroke) exhibited LI >0, but with significant variability. Visual training did not systematically alter LI, but chronic patients with baseline LI≈0 (no OT shrinkage) exhibited greater visual field recovery than those with LI>0. Conclusions: Unilateral OT shrinkage becomes detectable with magnetic resonance imaging by ≈7 months poststroke, albeit with significant interindividual variability. Although visual restoration training did not alter the amount of degeneration already sustained, OT shrinkage appeared to serve as a biomarker of the potential for training-induced visual recovery in chronic cortically blind patients.

Loss of P2Y12 Has Behavioral Effects in the Adult Mouse.

While microglia have been established as critical mediators of synaptic plasticity, the molecular signals underlying this process are still being uncovered. Increasing evidence suggests that microglia utilize these signals in a temporally and regionally heterogeneous manner. Subsequently, it is necessary to understand the conditions under which different molecular signals are employed by microglia to mediate the physiological process of synaptic remodeling in development and adulthood. While the microglial purinergic receptor P2Y12 is required for ocular dominance plasticity, an adolescent form of experience-dependent plasticity, it remains unknown whether P2Y12 functions in other forms of plasticity at different developmental time points or in different brain regions. Using a combination of ex vivo characterization and behavioral testing, we examined how the loss of P2Y12 affects developmental processes and behavioral performance in adulthood in mice. We found P2Y12 was not required for an early form of plasticity in the developing visual thalamus and did not affect microglial migration into barrels in the developing somatosensory cortex. In adult mice, however, the loss of P2Y12 resulted in alterations in recognition and social memory, as well as anxiety-like behaviors, suggesting that while P2Y12 is not a universal regulator of synaptic plasticity, the loss of P2Y12 is sufficient to cause functional defects.

Optogenetic activation of corticogeniculate feedback stabilizes response gain and increases information coding in LGN neurons.

In spite of their anatomical robustness, it has been difficult to establish the functional role of corticogeniculate circuits connecting primary visual cortex with the lateral geniculate nucleus of the thalamus (LGN) in the feedback direction. Growing evidence suggests that corticogeniculate feedback does not directly shape the spatial receptive field properties of LGN neurons, but rather regulates the timing and precision of LGN responses and the information coding capacity of LGN neurons. We propose that corticogeniculate feedback specifically stabilizes the response gain of LGN neurons, thereby increasing their information coding capacity. Inspired by early work by McClurkin et al. (1994), we manipulated the activity of corticogeniculate neurons to test this hypothesis. We used optogenetic methods to selectively and reversibly enhance the activity of corticogeniculate neurons in anesthetized ferrets while recording responses of LGN neurons to drifting gratings and white noise stimuli. We found that optogenetic activation of corticogeniculate feedback systematically reduced LGN gain variability and increased information coding capacity among LGN neurons. Optogenetic activation of corticogeniculate neurons generated similar increases in information encoded in LGN responses to drifting gratings and white noise stimuli. Together, these findings suggest that the influence of corticogeniculate feedback on LGN response precision and information coding capacity could be mediated through reductions in gain variability.

Direct and Indirect Associations Between Loneliness and Thoughts of Self-Harm Among a Clinical Sample of Older Adults With Serious Mental Illness.

This cross-sectional study examines the relationships of loneliness and depressive symptoms to thoughts of self-harm among a clinical sample (n = 150) of older adults (M = 58.42 years, SD = 5.86 years; male, 55.3%; African American, 61.3%) with serious mental illness (SMI) receiving publicly funded, community-based psychiatric rehabilitation services. Participants completed the De Jong Gierveld Loneliness Scale, Multidimensional Scale of Perceived Social Support, Patient Health Questionnaire 9, and Geriatric Depression Scale-Short Form. Mediation analyses tested the association of loneliness with thoughts of self-harm through depressive symptoms and were adjusted for social support and demographic variables. The direct association of loneliness with thoughts of self-harm was mediated by depressive symptoms; indirect associations of overall and emotional loneliness to thoughts of self-harm were significant. Findings suggest the need for clinicians to reduce feelings of loneliness among older adults with SMI as a means of partially ameliorating depressive symptoms and thoughts of self-harm.

Physiological characterization of a rare subpopulation of doublet-spiking neurons in the ferret lateral geniculate nucleus.

Interest in exploring homologies in the early visual pathways of rodents, carnivores, and primates has recently grown. Retinas of these species contain morphologically and physiologically heterogeneous retinal ganglion cells that form the basis for parallel visual information processing streams. Whether rare retinal ganglion cells with unusual visual response properties in carnivores and primates project to the visual thalamus and drive unusual visual responses among thalamic relay neurons is poorly understood. We surveyed neurophysiological responses among hundreds of lateral geniculate nucleus (LGN) neurons in ferrets and observed a novel subpopulation of LGN neurons displaying doublet-spiking waveforms. Some visual response properties of doublet-spiking LGN neurons, like contrast and temporal frequency tuning, were intermediate to those of X and Y LGN neurons. Interestingly, most doublet-spiking LGN neurons were tuned for orientation and displayed direction selectivity for horizontal motion. Spatiotemporal receptive fields of doublet-spiking neurons were diverse and included center/surround organization, On/Off responses, and elongated separate On and Off subregions. Optogenetic activation of corticogeniculate feedback did not alter the tuning or spatiotemporal receptive fields of doublet-spiking neurons, suggesting that their unusual tuning properties were inherited from retinal inputs. The doublet-spiking LGN neurons were found throughout the depth of LGN recording penetrations. Together these findings suggest that while extremely rare (<2% of recorded LGN neurons), unique subpopulations of LGN neurons in carnivores receive retinal inputs that confer them with nonstandard visual response properties like direction selectivity. These results suggest that neuronal circuits for nonstandard visual computations are common across a variety of species, even though their proportions vary.NEW & NOTEWORTHY Interest in visual system homologies across species has recently increased. Across species, retinas contain diverse retinal ganglion cells including cells with unusual visual response properties. It is unclear whether rare retinal ganglion cells in carnivores project to and drive similarly unique visual responses in the visual thalamus. We discovered a rare subpopulation of thalamic neurons defined by unique spike shape and visual response properties, suggesting that nonstandard visual computations are common to many species.

Loneliness and depressive symptoms in middle aged and older adults experiencing serious mental illness.

OBJECTIVE: To examine the relationship between loneliness and depressive symptoms among middle-aged and older adults diagnosed with serious mental illness (SMI). METHOD: Cross-sectional data from a community mental health center were used to understand the contribution of loneliness to depressive symptoms. Participants (n = 100) were aged 50 or older, diagnosed with SMI, and receiving intensive case management services. Hierarchical linear regression was conducted to explore the relationship of social and emotional loneliness to depressive symptoms when controlling for trauma symptom severity and self-rated health. RESULTS: The sample experienced high levels of loneliness, depressive symptoms, and trauma symptoms. Emotional loneliness explained a greater amount of unique variance in depressive symptoms compared with other significant predictors. Social loneliness did not significantly contribute to the model. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Among consumers of intensive case management services, emotional loneliness is uniquely associated with greater depressive symptoms. Loneliness and depression strongly covary but are distinct concepts that may be targeted conjointly to improve well-being among persons experiencing SMI. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Morphological heterogeneity among corticogeniculate neurons in ferrets: quantification and comparison with a previous report in macaque monkeys.

The corticogeniculate (CG) pathway links the visual cortex with the lateral geniculate nucleus (LGN) of the thalamus and is the first feedback connection in the mammalian visual system. Whether functional connections between CG neurons and LGN relay neurons obey or ignore the separation of feedforward visual signals into parallel processing streams is not known. Accordingly, there is some debate about whether CG neurons are morphologically heterogeneous or homogenous. Here we characterized the morphology of CG neurons in the ferret, a visual carnivore with distinct feedforward parallel processing streams, and compared the morphology of ferret CG neurons with CG neuronal morphology previously described in macaque monkeys [Briggs et al. (2016) Neuron, 90, 388]. We used a G-deleted rabies virus as a retrograde tracer to label CG neurons in adult ferrets. We then reconstructed complete dendritic morphologies for a large sample of virus-labeled CG neurons. Quantification of CG morphology revealed three distinct CG neuronal subtypes with striking similarities to the CG neuronal subtypes observed in macaques. These findings suggest that CG neurons may be morphologically diverse in a variety of highly visual mammals in which feedforward visual pathways are organized into parallel processing streams. Accordingly, these results provide support for the notion that CG feedback is functionally parallel stream-specific in ferrets and macaques.

The function of Drosophila larval class IV dendritic arborization sensory neurons in the larval-pupal transition is separable from their function in mechanical nociception responses.

The sensory and physiological inputs which govern the larval-pupal transition in Drosophila, and the neuronal circuity that integrates them, are complex. Previous work from our laboratory identified a dosage-sensitive genetic interaction between the genes encoding the Rho-GEF Trio and the zinc-finger transcription factor Sequoia that interfered with the larval-pupal transition. Specifically, we reported heterozygous mutations in sequoia (seq) dominantly exacerbated the trio mutant phenotype, and this seq-enhanced trio mutant genotype blocked the transition of third instar larvae from foragers to wanderers, a requisite behavioral transition prior to pupation. In this work, we use the GAL4-UAS system to rescue this phenotype by tissue-specific trio expression. We find that expressing trio in the class IV dendritic arborization (da) sensory neurons rescues the larval-pupal transition, demonstrating the reliance of the larval-pupal transition on the integrity of these sensory neurons. As nociceptive responses also rely on the functionality of the class IV da neurons, we test mechanical nociceptive responses in our mutant and rescued larvae and find that mechanical nociception is separable from the ability to undergo the larval-pupal transition. This demonstrates for the first time that the roles of the class IV da neurons in governing two critical larval behaviors, the larval-pupal transition and mechanical nociception, are functionally separable from each other.

Visual speed sensitivity in the drum corps color guard.

Drum corps color guard experts spend years developing skills in spinning rifles, sabers, and flags. Their expertise provides a unique window into factors that govern sensitivity to the speed of rotational and radial motion. Prior neurophysiological research demonstrates that rotational and radial motion register in the Medial Superior Temporal (MST) region of the primate visual system. To the extent that shared neural events govern rotational and radial speed sensitivity, one would expect expertise on either task to transfer to the other. One similarly would expect shared neural events to generate correlations between rotational and radial speed sensitivity. We evaluated these predictions via visual speed sensitivity tests on drum corps color guard experts, drum corps low brass experts, and other age-matched control participants. Displays comprised bilaterally presented plaid patterns that rotated, radiated, or both. Participants reported which side contained faster motion. The data revealed a modest but reliably reproducible and specific group-by-task interaction; color guard speed sensitivity exhibited a rotational motion advantage and radial motion disadvantage. Additionally, rotational and radial speed sensitivity failed to predict each other significantly. Overall, the findings match predictions that follow from a dissociation between the neural events governing rotational and radial speed sensitivity.

Quality Programs in Neurosurgery: The Memorial Hermann/University of Texas Experience.

The importance of outcome measures is steadily increasing due to the rise of "pay for performance" and the advent of population health. In 2007, a quality initiative was started due to poor performance on rankings such as the University Health Consortium (UHC) report card. Inherent to all such efforts are common challenges: how to engage the providers; how to gather and ensure the accuracy of the data; how to attribute results to individuals; how to ensure permanent improvements. After analysis, a strategy was developed that included an initial focus on 3 metrics (mortality, infection rates, and complications), leadership from practicing neurosurgeons, protocol development and adherence, and subspecialization. In addition, it was decided that the metrics would initially apply to attending physicians only, but that the entire team would need to be involved. Once the fundamental elements were established, the process could be extended to other measures and providers. To support this effort, special information system tools were developed and a support team formed. As the program matured, measured outcomes improved and more metrics were added (to a current total of 48). For example, UHC mortality ratios (observed over expected) decreased by 75%. Infection rates decreased 80%. The program now involves all trainee physicians, advanced practice providers, nurses, and other staff. This paper describes the design, implementation, and results of this effort, and provides a practical guide that may be useful to other groups undertaking similar initiatives.

HCC surveillance results in earlier HCC detection: results from an Indian cohort.

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death worldwide, with an increased incidence in South Asia. In order to describe the effect of surveillance for HCC with biannual ultrasound and alpha-fetoprotein (AFP) on diagnosis and survival in an Indian population a retrospective cohort-control study was performed at two liver clinics in India. The medical records of 3,258 patients with cirrhosis who received surveillance for HCC were reviewed, and 100 patients who developed HCC identified. Sixty-four cirrhotic patients diagnosed with HCC during the same time period without a history of surveillance were included and survival, BCLC stage at diagnosis, and treatment were compared. Patients who underwent surveillance were more likely to be diagnosed with potentially curable or treatable BCLC Stage 0/A disease and Stage B/C disease respectively, than late Stage D disease (χ2 = 0.0007). Patients diagnosed at an earlier stage of HCC lived significantly longer after diagnosis than patients diagnosed at a later stage (Stage 0/A: 15.6 ± 14.2 months vs. Stage B/C: 9.43 ± 19.7 months vs. Stage D: 5.59 ± 11.9 months; p = 0.0006). While treatment for HCC improved overall survival, only 28% of eligible patients received treatment, explaining the lack of survival benefit noted in the surveillance group. Surveillance for HCC led to detection of HCC at earlier stages. The impact of surveillance on improved mortality could not be evaluated given the limited number of patients who received treatment. HCC surveillance has the potential to improve survival in South Asian patients with cirrhosis only if improvements in access to appropriate treatment are made.

Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part I: methodologic and technologic innovations.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim. METHODS: A survey was conducted at the 19th Annual Children's National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program. RESULTS: Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training. CONCLUSION: Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.

Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part II: assessment of technical and behavioral skills.

BACKGROUND: Healthcare professionals are expected to make rapid, correct decisions in critical situations despite what may be a lack of real practical experience in a particular crisis situation. Successful resolution of a medical crisis depends upon demonstration not only of appropriate technical skills but also of key behavioral skills (eg, leadership, communication, and teamwork). We have developed a hands-on, high fidelity, simulation-based training program (ECMO Sim) to provide healthcare professionals with the opportunity to learn and practice the technical and behavioral skills necessary to manage ECMO emergencies. METHODS: Nine ECMO nurse specialists participated in two sequential randomly assigned simulated ECMO emergencies. The simulated emergencies were captured on videotape and reviewed with the subjects during facilitated debriefings that occurred immediately following each scenario. All videotapes were scored for key technical and behavioral skills by reviewers blinded to the sequence of the scenarios. The ratings of the subjects' technical and behavioral skills in each scenario were compared. RESULTS: Subjects performed key technical skills correctly more often in the second simulated ECMO emergency. In addition, their response times for three out of five specific technical tasks improved from the first to the second simulated emergency by an average of 27 seconds. Subjects' behavioral skills were rated more highly by masked reviewers in the second simulated ECMO emergency. The improvement in comprehensive behavioral scores from the first to the second scenario reached statistical significance in eight of nine subjects. CONCLUSION: After exposure to high-fidelity simulated ECMO emergencies, subjects demonstrated significant improvements in their technical and behavioral skills. ECMO Sim creates a learning environment that readily supports the acquisition of the technical and behavioral skills that are important in solving clinically significant, potentially life-threatening problems that can occur when patients are on ECMO.

Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios.

BACKGROUND: Access to resuscitation equipment is a critical component in delivering optimal care in pediatric arrest situations. Historically, children's hospitals and clinics have used a standard pediatric resuscitation cart ("standard cart") in which drawers are organized by intervention (eg, intubation module, intravenous module), requiring multiple drawers to be opened during a code. Many emergency departments, however, use a pediatric resuscitation cart based on the Broselow tape ("Broselow cart") in which each drawer is color coded and organized by patient length and weight ranges; each drawer contains all necessary equipment for resuscitation of a patient in that specific length/weight range. A literature review has revealed no studies examining the utility of either cart. OBJECTIVES: To compare which resuscitation cart organization (standard versus Broselow) allows for faster access to equipment, more accurate selection of appropriately sized equipment, and better user satisfaction. Methodology. We performed a prospective, randomized, controlled, crossover trial in which 21 pediatric health care providers were assigned the role of obtaining the appropriate equipment during 2 standardized, simulated codes alternately using either a standard or Broselow cart. Time to and accuracy of the selection of appropriate medical equipment along with posttesting satisfaction were measured. All simulations were performed in the Center for Advanced Pediatric Education at Stanford University Medical Center (Stanford, CA), a training facility designed to replicate the real medical environment with the technology to allow for videotaping of scenarios. RESULTS: Of the 21 subjects, 62% found the Broselow cart "easy" or "very easy" to use versus 33% for the standard cart. Of the 21 subjects, 67% preferred the Broselow cart, 10% preferred the standard cart, and 23% indicated no preference. Intubation supplies and nasogastric tubes were found significantly faster when using the Broselow cart (mean time: 29.1 and 20 seconds, respectively) versus the standard cart (mean time: 38.7 and 38.2 seconds, respectively). Correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart. Ten percent of the subjects had prior experience with the Broselow cart versus 62% having experience with the standard cart. CONCLUSIONS: Despite less prior experience with the Broselow cart, subjects in this study found it easier to use and preferred it over the standard cart. In addition, subjects located intubation equipment and nasogastric tubes significantly faster when using the Broselow cart, and correct equipment was provided significantly more often with the Broselow cart. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation carts after the Broselow cart to enhance provider confidence and patient safety.

High-fidelity simulation-based training in neonatal nursing.

Simulation-based training is a novel approach that facilitates the use of higher order thinking skills. Simulation-based training challenges medical professionals to develop cognitive, technical, and behavioral skills through the use of mannequins, working medical equipment, and human colleagues. During scenarios, trainees must make use of their knowledge base, analyze and synthesize factors contributing to the crises, and evaluate the effects of their actions. Feedback indicates that simulation-based training programs are more pertinent to and better accepted by adult learners than traditional programs. The instructional methodologies used in simulation-based training programs are more in line with the tenets of adult learning.