Lumbar puncture simulation in pediatric residency training: improving procedural competence and decreasing anxiety

Abstract Background Pediatric residents must become proficient with performing a lumbar puncture (LP) during training. Residents have traditionally acquired LP skills by observing the procedure performed by a more senior resident or staff physician and then attempting the procedure themselves. This process can result in variable procedural skill acquisition and trainee discomfort. This study assessed changes in resident procedural skill and self-reported anxiety when residents were provided with an opportunity to participate in an interactive training session and practice LPs using a simulator. Methods All pediatric residents at our institution were invited to participate. Residents were asked to report their post-graduate year (PGY), prior LP attempts and self-reported anxiety scores as measured by the standardized State-Trait Anxiety Inventory - State Anxiety Scale (STAI-S) prior to completing an observed pre-test using an infant-sized LP simulator. Staff physicians observed and scored each resident’s procedural skill using a previously published 21-point scoring system. Residents then participated in an interactive lecture on LP technique and were given an opportunity for staff-supervised, small group simulator-based practice within 1 month of the pre-test. Repeat post-test was performed within 4 months. Results Of the pediatric residents who completed the pre-test (N = 20), 16/20 (80 %) completed both the training session and post-test. Their PGY training level was: PGY1 (38 %), PGY2 (25 %), PGY3 (25 %) or PGY4 (12 %). Procedural skill improved in 15/16 residents (paired t-test; p < 0.001), driven by a significant improvement in skill for residents in PGY1 (P = 0.015) and PGY2 (p = 0.003) but not PGY3 or PGY4. Overall anxiety scores were higher at baseline than at post testing (mean ± SD; 44.8 ± 12.1 vs 39.7 ± 9.4; NS) however only PGY1 residents experienced a significant reduction in anxiety (paired t-test, p = 0.04). Conclusion LP simulation training combined with an interactive training session may be a useful tool for improving procedural competence and decreasing anxiety levels, particularly among those at an earlier stage of residency training

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Wechselkursrisiken und Möglichkeiten ihrere Eindämmung (untersucht am Beispiel der Firma Igefa Zentrallogistik GmbH & Co. KG)

Betriebswirtschaf

The Social Impact of Creative Participation in NSW Arts and Disability Partnership Projects (ADPP)

This is the final research report from a study that investigated the social impact of creative participation in various NSW Arts and Disability Partnership Projects (ADPP). The research was conducted by the Cosmopolitan Civil Societies (CCS) Research Centre at the University of Technology Sydney (UTS), and supported by the NSW Government through a partnership between Arts NSW (under the NSW Department of Trade and Investment) and Ageing, Disability and Home Care (ADHC; under the NSW Department of Family and Community Services)

Inclusive practice and comparative social impact of disability arts : a qualitative and abductive approach

This study comparatively examined two disability arts partnership projects’ stakeholder perspectives on inclusive practice and social impact. It did so through an innovative abductive research design to visualise the qualitative findings of a comparative social impact assessment of active citizenship. In this paper we examine the inclusive practices of the disability arts partnership projects and an inclusive methodological approach. The approach sought to visualise the social impact footprint, or scope, of disability arts projects on radar diagrams. In developing this approach, we were able to document the enabling outcomes for the lived experience of artists with disability. The research has implications for the inclusion of artists with disability as part of disability specific art projects, ensembles of artists with disability together with nondisabled artists, and the way that creative process outcomes have social impact on the stakeholders and communities where they are performed. For the organisations involved the project demonstrates the wider outcomes of the artistic practice through the social impact of their disability arts programs on their internal and external stakeholders. Further, for arts funders it provides a tool for comparative understanding of social impact across programs

Disability and the arts : inclusive practice for health and wellbeing

Hadley and McDonald’s statement illuminates the seriousness of enabling and facilitating participation by people with disability (PWD) in all facets of society. Since 1981, the International Year of Disabled People, most western countries have instituted human rights legislation that protects citizenship and ensures the inclusion of PWD in their communities and societies. More recently, 182 countries (out of 193) signed the United Nations’ (UN) Convention on the Rights of Persons with Disabilities (United Nations, 2015). These rights included Article 30, the right to a cultural life, which covered leisure and the arts. However, compared to the general population, PWD still participate less than those without a disability in all types of cultural activities. If access to cultural life is restricted then the advantages of participation in leisure activities are not achieved (Liu, 2009). Current social and cultural practices for PWD reflect a history of segregation and persisting issues of exclusion (Aitchison, 2003). Overall, it is widely acknowledged that PWD do not have the same liberties and prospects as non-disabled individuals (Darcy, 2019; Darcy et al., 2020). In this chapter we demonstrate how the inclusion of PWD in the arts produces individual, social and health benefits