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The abrupt disruption of in-person instruction in health care during the COVID-19 pandemic resulted in the rapid adoption of distance simulation as an immediate alternative to providing in-person simulation-based education. This massive instructional shift, combined with the lack of educator training in this domain, led to challenges for both learners and educators. This study aimed to disseminate the first set of competencies required of and unique to effective distance simulation educators.This was a multiphasic and iterative modified Delphi study validating the content of carefully and rigorously synthesized literature. Experts were invited from around the globe to participate in this study with mandatory attendance at an annual health care simulation conference to openly discuss the guidelines presented as competencies in this document. We divided each competency into "Basic" and "Advanced" levels, and agreement was sought for these levels individually. The experts provided their opinion by choosing the options of "Keep, Modify, or Delete." A free-marginal kappa of 0.60 was chosen a priori.At the conclusion of the Delphi process, the number of competencies changed from 66 to 59, basic subcompetencies from 216 to 196, and advanced subcompetencies from 179 to 182.This article provides the first set of consensus guidelines to distance simulation educators in health care, and paved the way for further research in distance simulation as a modality.

Background COVID-19 pandemic is presenting serious challenges to the world’s healthcare systems. The high communicability of the COVID-19 necessitates robust medical preparedness and vigilance. Objective To report on the simulation-based training and test preparedness activities to prepare healthcare workers (HCWs) for effective and safe handling of patients with COVID-19. Methodology Two activities were conducted: simulation-based training to all HCWs and a full-scale unannounced simulation-based disaster exercise at King Fahad Medical City (KFMC). The online module was designed to enhance the knowledge on COVID-19. This module was available to all KFMC staff. The five hands-on practical part of the course was available to frontliner HCWs. The unannounced undercover simulated patients’ full-scale COVID-19 simulation-based disaster exercise took place in the emergency department over 3 hours. Six scenarios were executed to test the existing plan in providing care of suspected COVID-19 cases. Results 2620 HCWs took the online module, 17 courses were conducted and 337 frontliner HCWs were trained. 94% of learners were satisfied and recommended the activity to others. The overall compliance rate of the full-scale COVID-19 disaster drill with infection control guidelines was 90%. Post-drill debriefing sessions recommended reinforcing PPE training, ensuring availability of different sizes of PPEs and developing an algorithm to transfer patients to designated quarantine areas. Conclusion Simulation-based training and preparedness testing activities are vital in identifying gaps to apply corrective actions immediately. In the presence of a highly hazardous contagious disease like COVID-19, such exercises are a necessity to any healthcare institution.

In view of their superior soft tissue contrast compared to computed tomography, magnetic resonance images are commonly involved in stereotactic radiosurgery/radiotherapy applications for target delineation purposes. It is known, however, that magnetic resonance images are geometrically distorted, thus deteriorating dose delivery accuracy. The present work focuses on the assessment of geometric distortion inherent in magnetic resonance images used in stereotactic radiosurgery/radiotherapy treatment planning and attempts to quantitively evaluate the consequent impact on dose delivery. The geometric distortions for 3 clinical magnetic resonance protocols (at both 1.5 and 3.0 T) used for stereotactic radiosurgery/radiotherapy treatment planning were evaluated using a recently proposed phantom and methodology. Areas of increased distortion were identified at the edges of the imaged volume which was comparable to a brain scan. Although mean absolute distortion did not exceed 0.5 mm on any spatial axis, maximum detected control point disposition reached 2 mm. In an effort to establish what could be considered as acceptable geometric uncertainty, highly conformal plans were utilized to irradiate targets of different diameters (5-50 mm). The targets were mispositioned by 0.5 up to 3 mm, and dose–volume histograms and plan quality indices clinically used for plan evaluation and acceptance were derived and used to investigate the effect of geometrical uncertainty (distortion) on dose delivery accuracy and plan quality. The latter was found to be strongly dependent on target size. For targets less than 20 mm in diameter, a spatial disposition of the order of 1 mm could significantly affect (>5%) plan acceptance/quality indices. For targets with diameter greater than 2 cm, the corresponding disposition was found greater than 1.5 mm. Overall results of this work suggest that efficacy of stereotactic radiosurgery/radiotherapy applications could be compromised in case of very small targets lying distant from the scanner’s isocenter (eg, the periphery of the brain).

During the last decade, Social Networking (SN) tools have become increasingly popular and are now an important part of our daily lives. SN tools can be brought into the classroom to bear on some of the challenges the faculty face in enabling students to succeed in their education. This study explores various SN tools used by high school students in Lebanon. It gives insight into students’ suggestions and ideas for various formal learning tasks using SN tools that might be beneficial for teaching and learning. Lebanese students were found to use SN applications in their daily lives extensively, for communication, socialization and various formats of formal and informal learning. The most widely used app was the WhatsApp Instant Messenger. Keywords: social networking tools, formal learning, informal learning

Kaposi sarcoma (KS) is a low-grade angioproliferative tumor associated with infection with human herpes virus 8 (HHV-8). The disease was named after Moritz Kaposi, a Hungarian dermatologist who first described it in 1872 as ‘idiopathic multiple pigmented sarcoma of the skin.’ HHV-8 infection is required for the development of KS, but not all infected persons develop the disease. KS is also considered an acquired immune deficiency syndrome (AIDS)-defining illness by the Centers for Disease Control and Prevention guidelines. According to data from the United States AIDS and cancer registries, both KS and non-Hodgkin lymphoma are the most common malignancies associated with human immunodeficiency virus (HIV) infection. However, the incidence of both malignancies has decreased dramatically since 1996 following the widespread utilization of highly active antiretroviral therapies. HIV-associated KS can involve virtually any site in the body including lymph nodes, gastrointestinal tract, respiratory system, heart, pericardium, bone marrow, and other visceral organs. However, cutaneous disease is the most common and is the usual initial presentation for KS. KS-related pericardial effusion can be a life-threatening emergency and should be considered in HIV/AIDS patients who present with signs and symptoms of pericardial effusion. The importance of diagnosing and differentiating KS-related pericardial effusion from other causes of pericardial effusion lies in the differences in the treatment and management in comparison to other etiologies of pericardial effusion. We report a case of a 54-year old man who presented to our hospital with a large pericardial effusion and was subsequently diagnosed to have HIV-related KS pericardial effusion. A brief review of the literature on the diagnosis and management is also presented.Keywords: Kaposi sarcoma; malignancy; acquired immune deficiency syndrome; human immunodeficiency virus; pericardial effusion(Published: 11 December 2015)Citation: Journal of Community Hospital Internal Medicine Perspectives 2015, 5: 29054 -http://dx.doi.org/10.3402/jchimp.v5.29054

Objectives To utilize cumulative evaluation data of the pediatric airway management simulation-based learning course on knowledge and practical skills of residents in the Saudi Commission for Health Speciality (SCFHS) in order to measure its efficacy and areas for improvement. Methods The evaluation is a retrospective cohort study that compares pre- and post-test (knowledge and skills) of a pediatric airway management simulation course. The 2-day course has been conducted four times annually at CRESENT and is comprised of interactive lectures on airway management and crew resource management, a demonstration of fundamentals of intubation, three skill stations, and six case scenarios with debriefing. Our evaluation data includes all pediatric residents who attended the course between January and December 2015. Results Forty-six residents participated, of whom 30 (65.2%) are male and 16 (34.78%) are female. Overall, there is statistically significant improvement between the pre-test and post-test knowledge and practical skill scores. The pre-test scores are significantly different between the four different resident levels with p values of 0.003 and

IntroductionChest tube insertion can be associated with serious complications. A structured training programme is needed to minimise complications and enhance patient safety. Novices should pass a reliable test with solid evidence of validity before performing the procedure supervised on patients. The aim of this study was to establish a credible pass/fail standard.MethodsWe used an established assessment tool the Chest Tube Insertion Competency Test (TUBE-iCOMPT). Validity evidence was explored according to Messick’s five sources of validity. Two methods were used to establish a credible pass/fail standard. Contrasting groups’ method: 34 doctors (23 novices and 11 experienced surgeons) performed the procedure twice and all procedures were video recorded, edited, blinded and rated by two independent, international raters. Modified Angoff method: seven thoracic surgeons individually determined the scores that defined the pass/fail criteria. The data was gathered in Copenhagen, Denmark and Riyadh, Saudi Arabia.ResultsInternal consistency reliability was calculated as Cronbach’s alpha to 0.94. The generalisability coefficient with two raters and two procedures was 0.91. Mean scores were 50.7 (SD±13.2) and 74.7 (SD±4.8) for novices and experienced surgeons, respectively (pDiscussionWe have gathered valuable additional validity evidence for the assessment tool TUBE-iCOMPT including establishment of a credible pass/fail score. The TUBE-iCOMPT can now be integrated in mastery learning programmes to ensure competency before independent practice.

Objectives The aim of this study was to characterize the current practice of asthma among general practitioners (GPs) in Lebanon. Methods Out of 2450 Lebanese registered GPs, a representative sample of 330 were stratified by region to fill out the questionnaire constructed on the basis of surveys developed mainly by the Chicago Asthma Surveillance Initiative Report Team in newly moderate persistent asthma patients aged 5 years and above. The questionnaire included information about ascertaining diagnostic techniques, pharmacotherapeutic approaches, formal patient education program; asthma related continuing medical education and asthma practice guidelines. Results Totally, 302 completed the questionnaire achieving a response rate of 91.5%. Chest radiography was the most commonly used diagnostic test (98%), while stain for eosinophilia was the less commonly used (7.9%). For clinical monitoring, cough and wheezing (98.7%) were mostly assessed. Short acting inhaled β2-agonists were often the most prescribed (94.3%) followed by inhaled corticosteroids (87.4%) then by long acting β-agonist (LABA) and theophylline (27.5% and 20.9%, respectively). Moreover, 10% of GPs provided formal asthma education program, 72.2% attended professional education and 65% adopted guidelines. Conclusion Based on current international guidelines, the overall Lebanese GPs practice of asthma management is not at an acceptable standard. Therefore, it is recommended to improve monitoring parameters, implement the asthma guidelines nationally and improve patient education.

Background Venous thromboembolism (VTE) remains a common problem in critically ill patients. Pharmacologic prophylaxis is currently the standard of care based on high-level evidence from randomized controlled trials. However, limited evidence exists regarding the effectiveness of intermittent pneumatic compression (IPC) devices. The Pneumatic compREssion for preventing VENous Thromboembolism (PREVENT trial) aims to determine whether the adjunct use of IPC with pharmacologic prophylaxis compared to pharmacologic prophylaxis alone in critically ill patients reduces the risk of VTE. Methods/Design The PREVENT trial is a multicenter randomized controlled trial, which will recruit 2000 critically ill patients from over 20 hospitals in three countries. The primary outcome is the incidence of proximal lower extremity deep vein thrombosis (DVT) within 28 days after randomization. Radiologists interpreting the scans are blinded to intervention allocation, whereas the patients and caregivers are unblinded. The trial has 80 % power to detect a 3 % absolute risk reduction in proximal DVT from 7 to 4 %. Discussion The first patient was enrolled in July 2014. As of May 2015, a total of 650 patients have been enrolled from 13 centers in Saudi Arabia, Canada and Australia. The first interim analysis is anticipated in July 2016. We expect to complete recruitment by 2018. Trial registration Clinicaltrials.gov: NCT02040103 (registered on 3 November 2013). Current controlled trials: ISRCTN44653506 (registered on 30 October 2013).

The majority of the current surgical simulators employ specialized sensory equipment for instrument tracking. The Leap Motion controller is a new device able to track linear objects with sub-millimeter accuracy. The aim of this study was to investigate the potential of a virtual reality (VR) simulator for assessment of basic laparoscopic skills, based on the low-cost Leap Motion controller. A simple interface was constructed to simulate the insertion point of the instruments into the abdominal cavity. The controller provided information about the position and orientation of the instruments. Custom tools were constructed to simulate the laparoscopic setup. Three basic VR tasks were developed: camera navigation (CN), instrument navigation (IN), and bimanual operation (BO). The experiments were carried out in two simulation centers: MPLSC (Athens, Greece) and CRESENT (Riyadh, Kingdom of Saudi Arabia). Two groups of surgeons (28 experts and 21 novices) participated in the study by performing the VR tasks. Skills assessment metrics included time, pathlength, and two task-specific errors. The face validity of the training scenarios was also investigated via a questionnaire completed by the participants. Expert surgeons significantly outperformed novices in all assessment metrics for IN and BO (p

Simulation-based education is an effective tool for surgical skills training. Simulation centers vary in complexity depending on their usability, utilization, and functions. The simulation hospital is an innovative concept for immersive simulation-based education. The surgical training area in the simulation hospital consists of operating rooms, surgical skill training areas, virtual reality area, and replica of a hospital ward. The presence of other supportive services in the simulation hospital facilitates multidisciplinary and longitudinal simulation training. There are multiple challenges in establishing a simulation hospital including design, space, and cost.

Asthma is a common chronic disease and a major public health problem, especially among pediatric population (1-5). Bronchial asthma is defined as a chronic inflammatory disorder of the airways. The chronic inflammation causes an associated increase in airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment (6). In Lebanon and other Middle East countries, the terms chest allergy or recurrent dyspnea are often popularly used instead of asthma, probably to avoid the social stigma associated with chronic nature and functional impairment of the disease. Asthma has a hereditary basis but environment factors have also been implicated in its pathogenesis (7). Traditionally, it has been treated by allergen avoidance, beta-2 agonists, and inhaled corticosteroids. Despite improved understanding of the pathophysiology of asthma and the development of new therapeutic strategies, its incidence and related mortality and morbidity are still increasing annually in developed countries (1,8-13). It has been found that compliance with the National Heart, Lung, and Blood Institute guidelines is influenced by patient income and level of education (14) and that asthma incidence is higher among children from low socioeconomic class (8). Also, uncontrolled asthma was associated with low maternal education and parental concerns about adverse effects of medication (15). Optimal management can be achieved by educating patients and their families to make life-style changes and adhere to drug therapy for a long period even when symptoms are not present (15,16). This study was conducted to investigate beliefs, knowledge, and perceptions of parents in Lebanon toward asthma and its management.

Surveillance ultrasounds in critically ill patients detect many deep venous thrombi (DVTs) that would otherwise go unnoticed. However, the impact of surveillance for DVT on mortality among critically ill patients remains unclear.We are conducting a multicenter, multinational randomized controlled trial that examines the effectiveness of adjunct intermittent pneumatic compression use with pharmacologic thromboprophylaxis compared to pharmacologic thromboprophylaxis alone on the incidence of proximal lower extremity DVT in critically ill patients (the PREVENT trial). Enrolled patients undergo twice weekly surveillance ultrasounds of the lower extremities as part of the study procedures. We plan to compare enrolled patients who have surveillance ultrasounds to patients who meet the eligibility criteria but are not enrolled (eligible non-enrolled patients) and only who will have ultrasounds performed at the clinical team's discretion. We hypothesize that twice-weekly ultrasound surveillance for DVT in critically ill patients who are receiving thromboprophylaxis will have more DVTs detected, and consequently, fewer pulmonary emboli and lower all-cause 90-day mortality.We developed a detailed a priori plan to guide the analysis of the proposed study and enhance the validity of its results.

Diffuse alveolar hemorrhage complicating small vessel vasculitis is a life-threatening emergency and should be considered in the differential diagnosis of patients who develop rapidly progressive dyspnea with alveolar opacities on chest imaging. In these patients, the coexistence of pulmonary and renal involvement suggests a multisystem disease. We present a case of a man who presented to our hospital with diffuse alveolar hemorrhage, severe anemia, and rapidly progressive glomerulonephritis.

BackgroundWhile insertion of CVC (central venous catheter) is common, it is an intricate procedure and not risk-free. Traditionally, inexperienced residents learn to insert CVC on real patients and thus can put patients' life at risk. One way to reduce medical errors is to use high-fidelity simulation for training tomorrow's practitioners on ultrasound-guided CVC insertion.ObjectiveTo evaluate the efficacy of medical simulation based learning course on knowledge and skills improvement on ultrasound-guided CVC insertion.MethodsA pre-assessment was performed through a pre-test and hands-on skill assessment for central line insertion under U/S guidance (Internal Jugular, Subclavian or Femoral lines) utilizing a standardized checklist. All candidates then attended one day course that included theoretical and hands-on simulation training using phantoms. A post-test and hands-on assessment was performed at the end of the day.ResultsTwenty residents from Internal Medicine and Paediatrics were enrolled in the study at King Fahad Medical City Simulation Center. There was significant improvement in the knowledge based training: 90% showed significant increase in their MCQ scores (pConclusionA one day simulation course on CVC insertion under ultrasound guidance significantly improves the knowledge and skills for residents in training programs.RecommendationsSuch courses and other similar should be compulsory for all Residents training programs as it is called safe training.

Introduction In Stereotactic Radiosurgery (SRS), MR-images are widely used for target localization and delineation in order to take advantage of the superior soft tissue contrast they exhibit. However, spatial dose delivery accuracy may be deteriorated due to geometric distortions inherent in MRI. Purpose To develop and implement a quality control procedure for the assessment of total geometric distortion in MR-images clinically employed in SRS treatment planning. Materials and methods A specially designed acrylic-based phantom was utilized. In particular, the phantom encompasses five planes on which 947 3-mm diameter holes are drilled. The centers of mass of these holes serve as control points for geometric distortion detection. In terms of imaging the phantom is both CT and MR compatible. The phantom was MR-imaged at 1.5T (GE-Optima) and 3T (Siemens-Skyra). CT-detected control point locations served as the reference distribution. Distortion evaluation was performed for three typical pulse sequences used for SRS treatment planning using in-house developed software. The effect of specific imaging parameters on geometric distortion was also investigated. Results Overall geometric accuracy of the 1.5T scanner was found slightly superior than the 3.0T scanner for the specific sequences investigated (mean distortion values: 0.6 mm and 0.8 mm, respectively). However, the 1.5T unit exhibits increased distortion on z -axis in regions distant from the scanner’s isocenter (maximum detected distortion was 2.7 mm). Accuracy of the developed distortion detection algorithm was estimated to be 0.24 mm. Conclusion Phantom and methods developed in this multicenter study were found efficient for distortion characterization of MR pulse sequences used in SRS.

A broad spectrum of pathologies that involve the laryngotracheobronchial airway and imaging plays a crucial role in evaluating these abnormalities. Computed tomography with virtual bronchoscopy has been found to be very helpful in defining the location, extent, and nature of these lesions, and is increasingly being used even in patients with contraindications for fiberoptic bronchoscopy and laryngoscopy. Ionizing radiation, associated with virtual bronchoscopy, can be minimized by using low-dose multidetector computed tomography and hybrid iterative reconstruction techniques. Furthermore, retrospectively generated virtual bronchoscopy from a routinely acquired computed tomography data set eliminates additional cost and radiation. In the future, virtual bronchoscopy assisted with advanced navigational techniques will broaden the diagnostic and therapeutic landscape. This article presents the characteristic features of common and rare laryngotracheobronchial pathologies seen with virtual bronchoscopy.

Establishing a simulation centre remains a real challenge for many experts in the field of clinical simulation. A panel of experts presented some guidelines during the International Conference on Advanced Clinical Simulation that was held in Prince Sultan Military College of Health Sciences, Dhahran, Kingdom of Saudi Arabia, in October 2014. The round table discussion addressed eight themes: The planning stage, stakeholders' involvement, strategic planning, centre design, partnership development, faculty development, curriculum development and establishing a research strategy. The conclusions are presented in this paper.

This paper outlines the primary steps required in developing a simulation curriculum. We examine forms of simulation in postgraduate training, instructional design models, learner assessment, and modular pattern of postgraduate simulation curriculum. Further, we provide examples of how each of these components are practically described in the literature and applied at the Center for Research, Education, and Simulation-Enhanced Training.

Simulation has been widely used in the education of healthcare workers. In simulation training, there is an approximation to reality in which trainees are supposed to react to problems or conditions as they would under genuine circumstances. The educational value of simulations has been determined to be valuable. Simulation has a significant impact on health care education across the disciplines and in both undergraduate and postgraduate studies. Recent development in technologies permits the reproduction of real-life scenarios with acceptable fidelity, thus profoundly enhancing the learning environment. However, the educational outcomes of high- versus low-fidelity simulations remain controversial. This article aims to review the effectiveness of low- and high-fidelity simulations in teaching and assessing clinical skills.

Venous thromboembolism (VTE) remains a common problem in critically ill patients. Pharmacologic prophylaxis is currently the standard of care based on high-level evidence from randomized controlled trials. However, limited evidence exists regarding the effectiveness of intermittent pneumatic compression (IPC) devices. The Pneumatic compREssion for preventing VENous Thromboembolism (PREVENT trial) aims to determine whether the adjunct use of IPC with pharmacologic prophylaxis compared to pharmacologic prophylaxis alone in critically ill patients reduces the risk of VTE. The PREVENT trial is a multicenter randomized controlled trial, which will recruit 2000 critically ill patients from over 20 hospitals in three countries. The primary outcome is the incidence of proximal lower extremity deep vein thrombosis (DVT) within 28 days after randomization. Radiologists interpreting the scans are blinded to intervention allocation, whereas the patients and caregivers are unblinded. The trial has 80 % power to detect a 3 % absolute risk reduction in proximal DVT from 7 to 4 %. The first patient was enrolled in July 2014. As of May 2015, a total of 650 patients have been enrolled from 13 centers in Saudi Arabia, Canada and Australia. The first interim analysis is anticipated in July 2016. We expect to complete recruitment by 2018. Clinicaltrials.gov: NCT02040103 (registered on 3 November 2013). Current controlled trials: ISRCTN44653506 (registered on 30 October 2013).