Simulation-Based Nurse Mentoring To Promote Preeclampsia Care: What Is The Impact In Bihar, India?

Background: Inadequately treated, severe preeclampsia and eclampsia (PE/E) may rapidly lead to severe complications in both mothers and neonates and are estimated to cause 60,000 maternal deaths globally each year. Simulation-based training where health providers review basic emergency obstetric and newborn care through highly realistic cases have demonstrated promising results in low- and middle-income countries (LMIC). Two international simulation training programs, Helping Mothers Survive and PRONTO International, have demonstrated improved overall use of evidence-based practices (EBPs) in active management of third stage of labor and hemorrhage management, though individual skills varied. However, the impact of simulation training on use of EBPs for PE/E diagnosis and management in such settings has not been reported. Methods: PRONTO International’s simulation-based training was embedded within a statewide maternal and newborn health quality improvement project in Bihar, India. This mixed methods study evaluated change in the use of evidence-based clinical skills by nurse mentees during simulated cases at primary health clinics (PHC). We compared the proportion of skills completed during mentees’ first and last participation in simulated severe preeclampsia and eclampsia cases. Semi-structured interviews were conducted with nurse mentors to explore barriers and enablers to high quality preeclampsia care in Bihar. Qualitative data were analyzed using the thematic content approach. Results: A total of 39 matched pre- and post-training simulation video pairs, including 94 nurse mentees from 33 PHCs, were analyzed. Results demonstrated a significant increase in the number of ‘key history questions asked’ from 1 to 2 (p=0.03), which demonstrates improvement in nurse mentees’ ability to gather histories and make preeclampsia diagnoses. Additionally, ‘key management steps completed’ increased from 2 to 3 (p=0.03), reflecting mentees increased rates of antihypertensive administration and foley catheter and intravenous catheter insertion. Key barriers to preeclampsia care included knowledge gaps, resource shortages, hierarchy between nurses and physicians, poor relationships between nurses and patients, and fear of retaliation from patients’ families. Strategies that facilitated high quality care included case-based and participatory learning, promotion of teamwork and communication, and effective leadership. Conclusion: Simulation-based training increased the use of clinical skills by nurse mentees in simulated severe preeclampsia and eclampsia cases. Barriers affect all aspects of clinical management, and must be addressed in order to improve care. Teamwork, communication, and leadership are key mechanisms to facilitate high quality preeclampsia care in LMICs

The Association Between Adverse Childhood Experiences (ACEs), Bullying Victimization, and Internalizing and Externalizing Problems Among Early Adolescents: Examining Cumulative and Interactive Associations

Both adverse childhood experiences (ACEs) and bullying victimization are linked with mental health problems in adolescents. However, little is known about the overlap between the two factors and how this impacts adolescent mental health problems (i.e., internalizing and externalizing problems). The current study analyzed data from 8,085 participants (47.7% female; 44.1% racial/ethnic minority) in the Adolescent Brain Cognitive Development (ABCD) study, baseline (2016–2018, ages 9–10 years) to Year 2. Regression analyses were used to estimate associations between ACEs, bullying victimization and mental health problems, respectively, adjusting for sex, race/ethnicity, country of birth, household income, parental education, and study site. The findings showed that both ACEs and bullying victimization were independently associated with higher internalizing and higher externalizing problems. However, no significant interaction was found between ACEs and bullying victimization. Overall, the results align with the cumulative risk model of adversity, linking cumulative ACEs and bullying victimization to internalizing and externalizing problems in early adolescents

Training and evaluating simulation debriefers in low-resource settings: lessons learned from Bihar, India.

BACKGROUND: To develop effective and sustainable simulation training programs in low-resource settings, it is critical that facilitators are thoroughly trained in debriefing, a critical component of simulation learning. However, large knowledge gaps exist regarding the best way to train and evaluate debrief facilitators in low-resource settings. METHODS: Using a mixed methods approach, this study explored the feasibility of evaluating the debriefing skills of nurse mentors in Bihar, India. Videos of obstetric and neonatal post-simulation debriefs were assessed using two known tools: the Center for Advanced Pediatric and Perinatal Education (CAPE) tool and Debriefing Assessment for Simulation in Healthcare (DASH). Video data was used to evaluate interrater reliability and changes in debriefing performance over time. Additionally, twenty semi-structured interviews with nurse mentors explored perceived barriers and enablers of debriefing in Bihar. RESULTS: A total of 73 debriefing videos, averaging 18 min each, were analyzed by two raters. The CAPE tool demonstrated higher interrater reliability than the DASH; 13 of 16 CAPE indicators and two of six DASH indicators were judged reliable (ICC > 0.6 or kappa > 0.40). All indicators remained stable or improved over time. The number of 'instructors questions,' the amount of 'trainee responses,' and the ability to 'organize the debrief' improved significantly over time (p < 0.01, p < 0.01, p = 0.04). Barriers included fear of making mistakes, time constraints, and technical challenges. Enablers included creating a safe learning environment, using contextually appropriate debriefing strategies, and team building. Overall, nurse mentors believed that debriefing was a vital aspect of simulation-based training. CONCLUSION: Simulation debriefing and evaluation was feasible among nurse mentors in Bihar. Results demonstrated that the CAPE demonstrated higher interrater reliability than the DASH and that nurse mentors were able to maintain or improve their debriefing skills overtime. Further, debriefing was considered to be critical to the success of the simulation training. However, fear of making mistakes and logistical challenges must be addressed to maximize learning. Teamwork, adaptability, and building a safe learning environment enhanced the quality enhanced the quality of simulation-based training, which could ultimately help to improve maternal and neonatal health outcomes in Bihar

Ineffective penicillin treatment and absence of partner treatment may drive the congenital syphilis epidemic in Brazil

BACKGROUND: Reducing congenital syphilis has been the focus of Brazilian health programs for decades, yet the cases continue to increase. Although health interventions have targeted HIV screening and treatment, syphilis management continues to be challenging. Syphilis during pregnancy may enhance the HIV maternal seroconversion risk. The potential factors fueling the syphilis epidemic were evaluated in south Brazil, an area of high HIV or syphilis endemicity. OBJECTIVE: We hypothesized that ineffective treatment because of a lack of partner treatment, late presentation to care, and reinfection of previously treated mothers were potential drivers of syphilis mother-to-child transmission. STUDY DESIGN: Data on women diagnosed with syphilis during pregnancy between January 1, 2008 and December 31, 2018 were obtained from a large urban hospital in Porto Alegre, Brazil. The patients were stratified into effective vs ineffective treatment groups according to the World Health Organization guidelines. Crude and adjusted risk ratios for the prediction of congenital syphilis and adverse fetal or neonatal outcomes were computed using Poisson regression. RESULTS: Nearly 56,000 pregnant women delivered over the 11-year period; 1541 (2.8%) had confirmed syphilis during pregnancy, with 934 (61%) receiving ineffective syphilis treatment because of late presentation and diagnosis, delayed treatment initiation, and loss to follow-up with no treatment recorded. Ineffective treatment was associated with maternal education, prenatal care, timing of syphilis diagnosis, venereal diseases research laboratory titers, and maternal HIV coinfection. On multivariate regression analysis, ineffective treatment (adjusted risk ratio, 4.52; 95% confidence interval, 2.35–8.69), absence of prenatal care (adjusted risk ratio, 9.31; 95% confidence interval, 3.77–23.0), syphilis diagnosis at delivery (adjusted risk ratio, 3.08; 95% confidence interval, 2.07–4.58), and maternal nontreponemal titers ≥1:64 (1.09–1.93) were associated with an increased risk of fetal loss. Ineffective treatment (adjusted risk ratio, 1.71; 95% confidence interval, 1.59–1.84), year of diagnosis 2014 to 2016 (adjusted risk ratio, 1.07; 95% confidence interval, 1.02–1.13), absence of prenatal care (adjusted risk ratio, 1.44; 95% confidence interval, 1.17–1.76), and maternal nontreponemal titers >1:4 were associated with an increased risk of congenital syphilis. Although partner treatment reduced the congenital syphilis risk (adjusted risk ratio, 0.60; 95% confidence interval, 0.55–0.66), only 31.8% of partners received treatment. Maternal HIV coinfection was not associated with an increased risk of fetal loss, low birthweight, preterm birth, congenital syphilis, or symptomatic neonatal infection. CONCLUSION: Public health initiatives promoting effective syphilis treatment in pregnancy, increased access to high-quality prenatal care, and partner treatment should be considered to reduce congenital syphilis.Revisión por pare

Simulation-enhanced nurse mentoring to improve preeclampsia and eclampsia care: an education intervention study in Bihar, India.

BACKGROUND: Inadequately treated, preeclampsia and eclampsia (PE/E) may rapidly lead to severe complications in both mothers and neonates, and are estimated to cause 60,000 global maternal deaths annually. Simulation-based training on obstetric and neonatal emergency management has demonstrated promising results in low- and middle-income countries. However, the impact of simulation training on use of evidence-based practices for PE/E diagnosis and management in low-resource settings remains unknown. METHODS: This study was based on a statewide, high fidelity in-situ simulation training program developed by PRONTO International and implemented in collaboration with CARE India on PE/E management in Bihar, India. Using a mixed methods approach, we evaluated changes over time in nurse mentees' use of evidence-based practices during simulated births at primary health clinics. We compared the proportion and efficiency of evidence-based practices completed during nurse mentees' first and last participation in simulated PE/E cases. Twelve semi-structured interviews with nurse mentors explored barriers and enablers to high quality PE/E care in Bihar. RESULTS: A total of 39 matched first and last simulation videos, paired by facility, were analyzed. Videos occurred a median of 62 days apart and included 94 nurses from 33 primary health centers. Results showed significant increases in the median number of 'key history questions asked,' (1.0 to 2.0, p = 0.03) and 'key management steps completed,' (2.0 to 3.0, p = 0.03). The time from BP measured to magnesium sulfate given trended downwards by 3.2 min, though not significantly (p = 0.06). Key barriers to high quality PE/E care included knowledge gaps, resource shortages, staff hierarchy between physicians and nurses, and poor relationships with patients. Enablers included case-based and simulation learning, promotion of teamwork and communication, and effective leadership. CONCLUSION: Simulation training improved the use of evidence-based practices in PE/E simulated cases and has the potential to increase nurse competency in diagnosing and managing complex maternal complications such as PE/E. However, knowledge gaps, resource limitations, and interpersonal barriers must be addressed in order to improve care. Teamwork, communication, and leadership are key mechanisms to facilitate high quality PE/E care in Bihar

Does teamwork and communication improve with simulation training? An evaluation of simulation training videos in Bihar, India

BACKGROUND High rates of medical error – attributed to ineffective communication among health care providers – poses a threat to patient safety. We embedded Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™) concepts within a simulation-based curriculum and trained clinical teams providing intrapartum care in low-income settings. We evaluated whether simulation can be used to improve teamwork and communication among clinical teams. METHODS Nurse mentors facilitated and video-recorded simulated clinical scenarios to give health care providers (mentees) the opportunity to practice both technical and non-technical skills. Independent evaluators reviewed video-recorded simulation scenarios at midpoint and endpoint to evaluate changes in use of evidence-based practices. Semi-structured interviews were also conducted with nurse mentors to explore their experiences teaching non-technical skills to clinical teams. RESULTS Five hundred and sixty-six simulated clinical scenarios were included in the final analysis. Adoption of techniques to improve communication and teamwork, such as the ‘SBAR’ technique and ‘think out loud’, increased from midpoint to endpoint in all simulated scenarios. CONCLUSION Incorporation of TeamSTEPPS™ concepts into a simulation training program for health care providers improved teamwork and communication in simulated scenarios and can potentially be extended to actual emergency cases

Assessment of CryoSat-2 interferometric and non-interferometric SAR altimetry over ice sheets

The launch of CryoSat-2 heralded a new era of interferometric Synthetic Aperture Radar altimetry over the Polar Ice Sheets. The mission’s novel SAR interferometric (SARIn) mode of operation has enabled monitoring of rapidly changing coastal regions, which had been challenging for previous low resolution altimeters. Given the growing requirement to continue the 25-year altimeter record, there is now a need to assess the differences between existing SAR and SARIn altimeter datasets, with a view to understanding the impact on ice sheet retrievals of the different radar hardware and processing methodologies. Uniquely, CryoSat-2 data can be processed both with and without interferometric information, offering the opportunity to directly compare the SAR and SARIn products generated by the current ground segment. Here, we provide a first comparison of these Level-2 datasets, and evaluate their capacity to measure ice sheet elevation and elevation change. We find that the current interferometric product has substantially improved precision, accuracy and coverage compared to its non-interferometric counterpart, yielding a ∼35% improvement in the root-mean-square-difference (RMSD) of elevations recorded at orbital cross-overs, and a ∼30% lower RMSD of elevation rates relative to Operation IceBridge airborne altimeter measurements. This analysis demonstrates the value that the interferometer adds to the current CryoSat-2 configuration, and highlights the importance for non-interferometric SAR Level-2 processing of the auxiliary data used to identify the location of the echoing point. These results provide a benchmark of the relative performance of the Level-2 interferometric and non-interferometric products currently produced by the ground segment, which will help to inform the design and implementation of a future polar radar altimeter mission

Ensembl Genomes 2016: more genomes, more complexity

Ensembl Genomes (http://www.ensemblgenomes.org) is an integrating resource for genome-scale data from non-vertebrate species, complementing the resources for vertebrate genomics developed in the context of the Ensembl project (http://www.ensembl.org). Together, the two resources provide a consistent set of programmatic and interactive interfaces to a rich range of data including reference sequence, gene models, transcriptional data, genetic variation and comparative analysis. This paper provides an update to the previous publications about the resource, with a focus on recent developments. These include the development of new analyses and views to represent polyploid genomes (of which bread wheat is the primary exemplar); and the continued up-scaling of the resource, which now includes over 23 000 bacterial genomes, 400 fungal genomes and 100 protist genomes, in addition to 55 genomes from invertebrate metazoa and 39 genomes from plants. This dramatic increase in the number of included genomes is one part of a broader effort to automate the integration of archival data (genome sequence, but also associated RNA sequence data and variant calls) within the context of reference genomes and make it available through the Ensembl user interfaces