E-Learning Experiences Among Nursing Students: A Scoping Review.

Background: Electronic learning (e-learning) is a broader approach to learning that opens up new avenues for studying and teaching in many sectors of education outside of the standard classroom setting. This paper might enhance cultural competence among nursing students and the perspective of the lecturer. Methods: Literature databases of Cinahl "Ebsco", Pubmed, and Science Direct were searched, and 326 potentially relevant nursing research articles were reviewed between 2017 and 2022. Fourteen papers were found to meet the inclusion criteria. Results: Fourteen articles were included for scoping review, themes include blended E-learning, nursing students' e-learning readiness, and The challenges with the E-learning system. First: Blended learning may be a beneficial educational strategy in nursing education but it also requires a cautious and carefully planned approach with sufficient time for each student. Second: E-readiness is an important component of academic success, and prospective e-learning users' capacity to use a new learning environment, as well as alternative technologies, is referred to as e-learning readiness. In addition, continuous readiness assessment is required to ensure the successful deployment of e-learning. Thirdly, Accessibility is the most significant challenge students experience; many other issues also challenge e-learning, such as Infrastructure, Ineffective Time Management, and a lack of Instant Communication. Conclusion: E-learning, on the other hand, can provide an alternate mode of education, blended learning Proven to be effective as a modern learning method, students' e-learning readiness was a significant predictor of their satisfaction and motivation in the classroom, there are still concerns about the instructional veracity of e-Learning, as well as how to analyze and overcome hurdles and fears in e-Learning. Implications: Specialized implications for practical ramifications include strategic management planning, curriculum enhancement, and raising standards at the lecturer level in several specific areas.

Blended learning has a significant impact on enhancing the learning process by combining instructional strategies to boost student outcomes and motivation.Success requires strategic planning, faculty development, and embracing digital resources. Access to the Internet, hardware, and regular training facilitate effective e-learning.The study emphasizes the significance of taking learning styles and student requirements into account during the course development process. Future research should investigate the cost-effectiveness of integrated nursing courses and broaden their application to all levels of nursing education.This review will contribute to the incorporation of blended learning, which facilitates the transition of nursing students to competency-based education and continuous learning, while technological proficiency becomes essential for maximizing the benefits of e-learning.

Antimicrobial Activities of Rhopalaea-Associated Fungus Aspergillus flavus strain MFABU9.

BACKGROUND AND OBJECTIVE: Rhopalaea is a genus of ascidian belonging to the family Diazonidae. Ascidians provide niches for various microorganisms including fungi. This present study describes the potential new source for natural bioactive compounds from Rhopalaea-associated fungi obtained from Bunaken marine park. MATERIALS AND METHODS: As part of an on-going research program to explore the chemical diversity of marine derived fungi, we performed an antimicrobial bioactivity-guided screening of EtOAc extracts of the fungi isolated from ascidian Rhopalaea sp. RESULTS: The study confirms that the ascidian obtained from Bunaken marine park was Rhopalaea sp. The fungus isolated from the ascidian was Aspergillus flavus which showed antimicrobial activity against bacteria Escherichia coli, Staphylococcus aereus, Aeromonas hydrophila and antifungal against the human pathogenic fungus Candida albicans. CONCLUSION: Aspergillus flavus isolated from ascidian Rhopalaea sp. has the potential as antibacterial and antifungal.

ON THE PRIVACY AND UTILITY PROPERTIES OF TRIPLE MATRIX-MASKING.

Privacy protection is an important requirement in many statistical studies. A recently proposed data collection method, triple matrix-masking, retains exact summary statistics without exposing the raw data at any point in the process. In this paper, we provide theoretical formulation and proofs showing that a modified version of the procedure is strong collection obfuscating: no party in the data collection process is able to gain knowledge of the individual level data, even with some partially masked data information in addition to the publicly published data. This provides a theoretical foundation for the usage of such a procedure to collect masked data that allows exact statistical inference for linear models, while preserving a well-defined notion of privacy protection for each individual participant in the study. This paper fits into a line of work tackling the problem of how to create useful synthetic data without having a trustworthy data aggregator. We achieve this by splitting the trust between two parties, the "masking service provider" and the "data collector."

Two-stage adaptive enrichment design for testing an active factor.

We propose an adaptive enrichment approach to test an active factor, which is a factor whose effect is non-zero in at least one subpopulation. We implement a two-stage play-the-winner design where all subjects in the second stage are enrolled from the subpopulation that has the highest observed effect in the first stage. We recommend a weighted Fisher's combination of the most powerful test for each stage, respectively: the first stage Hotelling's test and the second stage noncentral chi-square test. The test is further extended to cover binary outcomes and time-to-event outcomes.

The feasibility of an interactive voice response system (IVRS) for monitoring patient safety after discharge from the ED.

BACKGROUND: Return ED visits are frequent and may be due to adverse events: adverse outcomes related to healthcare received. An interactive voice response system (IVRS) is a technology that translates human telephone input into digital data. Use of IVRS has been explored in many healthcare settings but to a limited extent in the ED. We determined the feasibility of using an IVRS to assess for adverse events after ED discharge. METHODS: This before and after study assessed detection of adverse events among consecutive high-acuity patients discharged from a tertiary care ED pre-IVRS and post-IVRS over two 2-week periods. The IVRS asked if the patient was having a health problem and if they wanted to speak to a nurse. Patients responding yes received a telephone interview. We searched health records for deaths, admissions to hospital and return ED visits. Three trained emergency physicians independently determined adverse event occurrence. We analysed the data using descriptive statistics. RESULTS: Of 968 patients studied, patients' age, sex, acuity and presenting complaint were comparable pre-IVRS and post-IVRS. Postimplementation, 393 (81.7%) of 481 patients had successful IVRS contact. Of these, 89 (22.6%) wanted to speak to a nurse. A total of 37 adverse events were detected over the two periods: 10 patients with 10 (6.5%) adverse events pre-IVRS and 16 patients with 27 (16.9%) adverse events post-IVRS. In the postimplementation period, the adverse events of seven patients were detected by the IVRS and five patients spontaneously requested assistance navigating post-ED care. CONCLUSIONS: This was a successful proof-of-concept study for applying IVRS technology to assess patient safety issues for discharged high-acuity ED patients.

Healthcare providers' perceptions of a situational awareness display for emergency department resuscitation: a simulation qualitative study.

IMPORTANCE: Emergency resuscitation of critically ill patients can challenge team communication and situational awareness. Tools facilitating team performance may enhance patient safety. OBJECTIVES: To determine resuscitation team members' perceptions of the Situational Awareness Display's utility. DESIGN: We conducted focus groups with healthcare providers during Situational Awareness Display development. After simulations assessing the display, we conducted debriefs with participants. SETTING: Dual site tertiary care level 1 trauma centre in Ottawa, Canada. PARTICIPANTS: We recruited by email physicians, nurses and respiratory therapist. INTERVENTION: Situational Awareness Display, a visual cognitive aid that provides key clinical information to enhance resuscitation team communication and situational awareness. MAIN OUTCOMES AND MEASURES: Themes emerging from focus groups and simulation debriefs. Three reviewers independently coded and analysed transcripts using content qualitative analysis. RESULTS: We recruited a total of 33 participants in two focus groups (n = 20) and six simulation debriefs with three 4-5 member teams (n = 13). Majority of participants (10/13) strongly endorsed the Situational Awareness Display's utility in simulation (very or extremely useful). Focus groups and debrief themes included improved perception of patient data, comprehension of context and ability to project to future decisions. Participants described potentially positive and negative impacts on patient safety and positive impacts on provider performance and team communication. Participants expressed a need for easy data entry incorporated into clinical workflow and training on how to use the display. CONCLUSION: Emergency resuscitation team participants felt the Situational Awareness Display has potential to improve provider performance, team communication and situational awareness, ultimately enhancing quality of care.

Team communication patterns in emergency resuscitation: a mixed methods qualitative analysis.

BACKGROUND: In order to enhance patient safety during resuscitation of critically ill patients, we need to optimize team communication and enhance team situational awareness but little is known about resuscitation team communication patterns. The objective of this study is to understand how teams communicate during resuscitation; specifically to assess for a shared mental model (organized understanding of a team's relationships) and information needs. METHODS: We triangulated 3 methods to evaluate resuscitation team communication at a tertiary care academic trauma center: (1) interviews; (2) simulated resuscitation observations; (3) live resuscitation observations. We interviewed 18 resuscitation team members about shared mental models, roles and goals of team members and procedural expectations. We observed 30 simulated resuscitation video recordings and documented the timing, source and destination of communication and the information category. We observed 12 live resuscitations in the emergency department and recorded baseline characteristics of the type of resuscitations, nature of teams present and type and content of information exchanges. The data were analyzed using a qualitative communication analysis method. RESULTS: We found that resuscitation team members described a shared mental model. Respondents understood the roles and goals of each team member in order to provide rapid, efficient and life-saving care with an overall need for situational awareness. The information flow described in the interviews was reflected during the simulated and live resuscitations with the most responsible physician and charting nurse being central to team communication. We consolidated communicated information into six categories: (1) time; (2) patient status; (3) patient history; (4) interventions; (5) assistance and consultations; 6) team members present. CONCLUSIONS: Resuscitation team members expressed a shared mental model and prioritized situational awareness. Our findings support a need for cognitive aids to enhance team communication during resuscitations.

An Innovative Approach to Retention: Thermoplastic Retainer.

AIM: The aim of this study was to design and introduce a retainer that overcomes the common shortcomings seen in other retainers. MATERIALS AND METHODS: Hard thermoplastic sheet of 0.5 mm thickness is vacuum or pressure-molded onto the patient cast. Lingual portion of the retainer is trimmed according to the contours of the anterior teeth. Contact points between the maxillary and mandibular anterior teeth are marked on the retainer and reduced. Punch cut holes are placed on the retainer for the exit of flash and air bubbles while fixation. The retainer is bonded onto the lingual surface of the anterior teeth using composite. RESULTS: A 1-month review of the retainer showed no patient discomfort, occlusal interference, or bond failure. The aim of the article was found to have been achieved. CONCLUSION: Initial evaluation has shown positive findings. Long-term clinical findings will determine the overall success of this new retainer. CLINICAL SIGNIFICANCE: As compared with other retainers, thermoplastic retainer has shown reduced tendency to debond from occlusal forces, decreased patient discomfort, and occlusal interference.

Implementation of a structured hospital-wide morbidity and mortality rounds model.

IMPORTANCE: There is a paucity of literature on the quality and effectiveness of institutional morbidity & mortality (M&M) rounds processes. OBJECTIVE: We sought to implement and evaluate the effectiveness of a hospital-wide structured M&M rounds model at improving the quality of M&M rounds across multiple specialties. DESIGN, SETTING, PARTICIPANTS: We conducted a prospective interventional study involving 24 clinical groups (1584 physicians) at a tertiary care teaching hospital from January 2013 to June 2015. INTERVENTION: We implemented the published Ottowa M&M Model (OM3): appropriate case selection, cognitive/system issues analyses, interprofessional participation, dissemination of lessons and effector mechanisms. MAIN OUTCOMES AND MEASURES: We created an OM3 scoring index reflecting these elements to measure the quality of M&M rounds. Secondary outcomes include explicit discussions of cognitive/system issues and resultant action items. RESULTS: OM3 scores for all participating groups improved significantly from a median of 12.0/24 (95% CI 10 to 14) to 20.0/24 (95% CI 18 to 21). An increased frequency of in-rounds discussion around cognitive biases (pre 154/417 (37%), post 256/466 (55%); p<0.05) and system issues (pre 175/417 (42%), post 259/466 (62%); p<0.05) were reported by participants via online surveys postintervention, while in-person surveys throughout the intervention period demonstrated even higher frequencies (cognitive biases 1222/1437 (85%); system issues 1250/1437 (87%)). We found 45 action items resulting directly from M&M rounds postintervention, compared with none preintervention. CONCLUSIONS AND RELEVANCE: Implementation of a structured model enhanced the quality of M&M rounds with demonstrable policy improvements hospital wide. The OM3 can be feasibly implemented at other hospitals to effectively improve quality of M&M rounds across different specialties.

Teaching M&M rounds skills: enhancing and assessing patient safety competencies using the Ottawa M&M model.

BACKGROUND: Postgraduate medical education bodies and national patient safety institutes recommend that trainees develop patient safety competencies such as those for Morbidity and Mortality (M&M) rounds, yet there exists no model for their educational delivery. OBJECTIVE: We studied the effect of a single educational intervention on emergency medicine residents' aptitudes in selecting and analysing M&M rounds cases. METHODS: In this before-and-after study, participants attended an 1 h educational session based on the previously described Ottawa Morbidity and Mortality Model (OM3). Residents were asked to submit a case suitable for M&M rounds both preintervention and postintervention. A novel M&M rounds case critique tool was developed based on OM3 and used to assign a numerical score to each submitted case. Our primary outcome was an increase in mean scores between phases using the case critique tool. An a priori score increase of 1 was defined as educationally significant. Data were analysed using a paired Student's t test. RESULTS: A total of 19 residents were recruited for our pre-intervention and 15 residents for the post-intervention analysis. Mean M&M rounds case critique scores increased from 5.53 to 8.67 (p<0.01) between phases. Residents reported higher comfort with structured case selection and analysis, with an increase in five-point Likert scale means of 2.32 and 3.69 (p<0.01). CONCLUSIONS: We found that residents were more effective at M&M rounds case selection and analysis after our focused 1 h educational intervention. Training programmes should consider an M&M rounds training model to ensure future physicians have these skills for 21st-century practice.

Estimation of Ordinary Differential Equation Parameters Using Constrained Local Polynomial Regression.

We propose a new method to use a constrained local polynomial regression to estimate the unknown parameters in ordinary differential equation models with a goal of improving the smoothing-based two-stage pseudo-least squares estimate. The equation constraints are derived from the differential equation model and are incorporated into the local polynomial regression in order to estimate the unknown parameters in the differential equation model. We also derive the asymptotic bias and variance of the proposed estimator. Our simulation studies show that our new estimator is clearly better than the pseudo-least squares estimator in estimation accuracy with a small price of computational cost. An application example on immune cell kinetics and trafficking for influenza infection further illustrates the benefits of the proposed new method.

Stroke prenotification is associated with shorter treatment times for warfarin-associated intracerebral hemorrhage.

BACKGROUND: Warfarin-associated intracerebral hemorrhage (WAICH) is a devastating disease with increasing incidence. In this setting, treatment with prothrombin complex concentrates (PCC) is essential to correct coagulopathy. Yet despite the availability of coagulopathy correction strategies, significant treatment delays can occur in emergency departments (EDs), which may be overcome using stroke prenotification strategies. To explore this, we compared arrival-to-treatment times with PCC for WAICH between two different stroke response systems that used the same international normalized ratio (INR) correction protocol. METHODS: We established a registry of consecutive patients presenting with WAICH and treated with PCC presenting to two Canadian tertiary-care academic stroke centers: one with a stroke prenotification system, and one with a traditional ED assessment, treatment and referral system. In this comparative cohort design, we defined the WAICH diagnosis time as the earliest time point where both INR and CT were available. We compared median times from arrival to treatment, as well as arrival to diagnosis, and diagnosis to treatment. RESULTS: Between 2008 and 2010, we collected data from 123 consecutive patients with intracranial hemorrhage who received PCC for INR correction (79 from ED referral, and 44 prenotification). Onset-to-arrival times, demographics, Glasgow Coma Scale scores, and baseline INR were similar between the two systems. Arrival-to-treatment times were significantly shorter in the prenotification system as compared to the traditional ED referral system (135 vs. 267 min; p = 0.001), which was driven by both decreased arrival-to-diagnosis time (49 vs. 117 min; p = 0.006), as well as decreased diagnosis-to-treatment time (56 vs. 112 min; p < 0.001). Arrival-to-scan times and arrival-to-INR times were similarly shorter in the prenotification system (68 vs. 118 min and 20.5 vs. 47 min, respectively). CONCLUSION: Stroke prenotification was associated with shorter arrival-to-treatment times for emergent INR correction in patients with WAICH, which was driven by both faster diagnosis and treatment. Our results are consistent with those seen in ischemic stroke, suggesting that prenotification systems present an opportunity to optimize acute intracerebral hemorrhage therapy.

Differences in activity level between cownose rays (Rhinoptera bonasus) and Atlantic stingrays (Dasyatis sabina) are related to differences in heart mass, hemoglobin concentration, and gill surface area.

Aquatic animals are faced with the challenge of extracting oxygen from water, a medium that is metabolically expensive to ventilate and that contains just a fraction of the oxygen concentration relative to air, yet the physiologies of fishes have evolved to support a wide range of activity levels in nature. Oxygen delivery components, including gill surface area (oxygen uptake), blood chemistry (oxygen transport), and the heart (system pump), have been positively correlated to activity level in teleost fishes, yet relatively little is known about how these components are related to activity in elasmobranches. The current study addresses this question by examining heart mass, hemoglobin concentration, hematocrit level, and gill surface area in wild-caught representatives of the benthic Atlantic stingray (Dasyatis sabina) and active cownose ray (Rhinoptera bonasus). Allometric scaling exponents are similar for all four measures between the study species. Heart mass, gill surfaces areas, and hemoglobin concentrations were 2.1 times, approximately 7.1 times, and 2.0 times higher, respectively, in active cownose rays, when compared to benthic Atlantic stingrays, after correcting for differences in body mass. When considered in the context of functional plasticity within the oxygen delivery systems of benthic and active species, data from the current study indicate that higher activity levels in cownose rays are supported by modifications that, at least in part, are likely to enhance oxygen uptake.

Copula identifiability conditions for dependent truncated data model.

We provide a copula identifiability condition for dependent truncated data model. The identifiability is characterized by the strong lower-left tail identifiability of the copula family. We show that the commonly used Archimedean copula families with analytic generator functions satisfy this condition.

Hospital Emergency Readiness Overview study.

In 2001, a survey of Canadian emergency departments indicated significant deficiencies in disaster preparedness. Since then, there have been efforts on the part of Provincial governments to remedy this situation. This survey repeats the original study with minor modifications to determine if there has been improvement. The Hospital Emergency Readiness Overview study demonstrates that despite improvements, there remain gaps in Canadian healthcare facility readiness for disaster, specifically one involving contaminated patients. It also highlights the lack of any standardized assessment of healthcare facilities' chemical, biological, radiological, or nuclear readiness.

Regression analysis for recurrent events data under dependent censoring.

Recurrent events data are commonly seen in longitudinal follow-up studies. Dependent censoring often occurs due to death or exclusion from the study related to the disease process. In this article, we assume flexible marginal regression models on the recurrence process and the dependent censoring time without specifying their dependence structure. The proposed model generalizes the approach by Ghosh and Lin (2003, Biometrics 59, 877-885). The technique of artificial censoring provides a way to maintain the homogeneity of the hypothetical error variables under dependent censoring. Here we propose to apply this technique to two Gehan-type statistics. One considers only order information for pairs whereas the other utilizes additional information of observed censoring times available for recurrence data. A model-checking procedure is also proposed to assess the adequacy of the fitted model. The proposed estimators have good asymptotic properties. Their finite-sample performances are examined via simulations. Finally, the proposed methods are applied to analyze the AIDS linked to the intravenous experiences cohort data.

Comparison of CT head interpretation between emergency physicians and neuroradiologists.

Cranial computed tomography (CT) of the head is widely used in the emergency department 24 h a day. We compared the accuracy of CT head interpretation between staff emergency physicians (EPs) and neuroradiologists. We conducted a health records review of patients who required head CT in the emergency department. Two independent reviewers rated disagreement as clinically normal, significant, or clinically insignificant findings using published definition criteria. We calculated concordance and prepared descriptive and kappa statistics with 95% confidence intervals using SAS 9.1 software. We included 442 for this study. CT heads were classified as: normal or nonacute 81.5% (360 cases), insignificant 3.8% (17 cases), and significant 14.7% (65 cases). The weighted kappa for agreement was 0.83 (95% confidence interval 0.76-0.90). None of these patients had adverse outcomes related to EP misinterpretation of the CT head. In conclusion, clinically important findings on CT head are not commonly missed by our EPs and patients rarely have inappropriate disposition.

Prevalence of information gaps for seniors transferred from nursing homes to the emergency department.

OBJECTIVE: Information gaps, defined as previously collected information that is not available to the treating physician, have implications for patient safety and system efficiency. For patients transferred to an emergency department (ED) from a nursing home or seniors residence, we determined the frequency and type of clinically important information gaps and the impact of a regional transfer form. METHODS: During a 6-month period, we studied consecutive patients who were identified through the National Ambulatory Care Reporting System database. Patients were over 60 years of age, lived in a nursing home or seniors residence, and arrived by ambulance to a tertiary care ED. We abstracted data from original transfer and ED records using a structured data collection tool. We measured the frequency of prespecified information gaps, which we defined as the failure to communicate information usually required by an emergency physician (EP). We also determined the use of the standardized patient transfer form that is used in Ontario and its impact on the rate of information gaps that occur in our community. RESULTS: We studied 457 transfers for 384 patients. Baseline dementia was present in 34.1% of patients. Important information gaps occurred in 85.5% (95% confidence interval [CI] 82.0%-88.0%) of cases. Specific information gaps along with their relative frequency included the following: the reason for transfer (12.9%), the baseline cognitive function and communication ability (36.5%), vital signs (37.6%), advanced directives (46.4%), medication (20.4%), activities of daily living (53.0%) and mobility (47.7%). A standardized transfer form was used in 42.7% of transfers. When the form was used, information gaps were present in 74.9% of transfers compared with 93.5% of the transfers when the form was not used (p < 0.001). descriptors of the patient's chief complaint were frequently absent (81.0% for head injury [any information about loss of consciousness], 42.4% for abdominal pain and 47.1% for chest pain [any information on location, severity and duration]). CONCLUSION: Information gaps occur commonly when elderly patients are transferred from a nursing home or seniors residence to the ED. A standardized transfer form was associated with a limited reduction in the prevalence of information gaps; even when the form was used, a large percentage of the transfers were missing information. We also determined that the lack of descriptive detail regarding the presenting problem was common. We believe this represents a previously unidentified information gap in the literature about nursing home transfers. Future research should focus on the clinical impact of information gaps. System improvements should focus on educational and regulatory interventions, as well as adjustments to the transfer form.

Irreducible lateral patellar dislocation: the importance of impaction fracture recognition.

Irreducible lateral patellar dislocation may occur in the older patient with a previous history of patellofemoral arthritis. The only subtle finding on physical examination to suggest this diagnosis will be positioning of the knee in less flexion than a typical lateral patellar dislocation, anterolateral position of the patella and internal rotation of the patella from the coronal plane. That is, the patella is dislocated laterally but the lateral border comes to lie in a position of variable degrees of anterior displacement relative to the medial patellar border. Plain x-rays may reveal the rotation of the patella along the vertical axis and an anterolateral rather than lateral positioning of the patella. Computed tomographic scanning is of benefit if the diagnosis is suspected or if an initial attempt at closed reduction is unsuccessful. Open reduction is recommended, if a single closed reduction attempt is not successful, to prevent any potential worsening of the patellar impaction fracture. A laterally dislocated patella that displays internal rotation about the vertical axis or the "flipped patella" sign is pathognomonic of an irreducible patellar dislocation and suggests patellar impaction on a lateral femoral condylar ridge osteophyte. Open reduction is easily achieved through a vertically oriented quadriceps tenotomy without the need for medial repair.