A longitudinal interpretative phenomenological analysis study of athletes' lived experiences in elite disc golf competitions

Gaining the inside perspective of an elite athlete throughout the competitive season provides a unique approach to understand the lived experience during multiple competitive events. The purpose of the present study was to investigate how elite disc golf athletes perceive and interpret their experiences of performing during various training and competitive events over the course of an elite disc golf season. Two elite disc golf athletes, one man and one woman, were recruited using homogeneous purposive sampling. The participants were interviewed three times and observed during three competitive events, as well as before and after a training session. A longitudinal interpretative phenomenological analysis (LIPA) was adopted to capture temporal and dynamic changes of the participants' lived experiences. The findings illustrated the athletes' personal experiences of performing during competitive disc golf events, with both athletes' experiences of competition changing during the season. Their competitive experiences appear to relate to the meaning disc golf has for the athletes, which in this study had both an experiential and existential level of meaning over time. Such a finding illustrates the importance of honoring athletes' unique experiences in making sense of their performances during an elite disc golf season. Taking the time to understand athletes' perceptions of their personal experiences appear important in attempting to understand their sense-making of their hot cognition before, during, and after competitions.

The Social, Mental, and Physical Health Impacts of the COVID-19 Pandemic on People With HIV: Protocol of an Observational International Multisite Study

ABSTRACT

As the COVID-19 pandemic spread across the world, immunocompromised individuals such as people with HIV (PWH) may have faced a disproportionate impact on their health and HIV outcomes, both from COVID-19 and from the strategies enacted to contain it. Based on the SPIRIT guidelines, we describe the protocol for an international multisite observational study being conducted by The International Nursing Network for HIV Research, with the Coordinating Center based at the University of California, San Francisco (UCSF) School of Nursing. Site Principal Investigators implement a standardized protocol to recruit PWH to complete the study online or in-person. Questions address demographics; HIV continuum of care indicators; mental and social health; COVID-19 and vaccination knowledge, attitudes, behaviors, and fears; and overall outcomes. Results of this study will contribute to knowledge that can inform responses to future public health crises to minimize their impacts on vulnerable populations such as PWH.

Moving Together, Apart: Impacts of Travel Restrictions on a UK-Egypt Collaboration in Health Profession Education

Objective

University College London (UCL) and Newgiza University (NGU) have been in an academic collaboration since 2016 to establish undergraduate healthcare programmes in Egypt with an underlying ethos of capacity building and co-development. We explored impacts of pandemic-related travel restrictions on staff across both organisations.

Methods

We conducted 30 semi-structured interviews with academic and professional services staff from UCL and NGU schools of medicine, dentistry, and pharmacy. Data were jointly coded using reflexive thematic analysis and categorised according to the American Council on Education's Comprehensive Internationalisation Framework.

Results

Nine themes were identified, which related to each of the six components of the framework. In addition to mobility, participants' experiences also spread across the other five components (institutional commitment, leadership, curriculum, faculty support, and partnerships). Successful adaptations were made and staff felt able to 'keep the show on the road'. However, staff remained keen to keep in-person engagement a priority when possible, especially for quality management site visits.

Conclusions

Travel restrictions can have widespread impacts on all aspects of international collaborations. In this well-established relationship, there was sufficient resilience to withstand these impacts and, many positive unintended consequences emerged. A hybrid engagement model should be prioritised in future partnerships.

Cultural contributions to adults' self-rated mental health problems and strengths: 7 culture clusters, 28 societies, 16 906 adults

BACKGROUND

It is unknown how much variation in adult mental health problems is associated with differences between societal/cultural groups, over and above differences between individuals.

METHODS

To test these relative contributions, a consortium of indigenous researchers collected Adult Self-Report (ASR) ratings from 16 906 18- to 59-year-olds in 28 societies that represented seven culture clusters identified in the Global Leadership and Organizational Behavioral Effectiveness study (e.g. Confucian, Anglo). The ASR is scored on 17 problem scales, plus a personal strengths scale. Hierarchical linear modeling estimated variance accounted for by individual differences (including measurement error), society, and culture cluster. Multi-level analyses of covariance tested age and gender effects.

RESULTS

Across the 17 problem scales, the variance accounted for by individual differences ranged from 80.3% for DSM-oriented anxiety problems to 95.2% for DSM-oriented avoidant personality (mean = 90.7%); by society: 3.2% for DSM-oriented somatic problems to 8.0% for DSM-oriented anxiety problems (mean = 6.3%); and by culture cluster: 0.0% for DSM-oriented avoidant personality to 11.6% for DSM-oriented anxiety problems (mean = 3.0%). For strengths, individual differences accounted for 80.8% of variance, societal differences 10.5%, and cultural differences 8.7%. Age and gender had very small effects.

CONCLUSIONS

Overall, adults' self-ratings of mental health problems and strengths were associated much more with individual differences than societal/cultural differences, although this varied across scales. These findings support cross-cultural use of standardized measures to assess mental health problems, but urge caution in assessment of personal strengths.

Polyhandicap, profound intellectual multiple disabilities : Concept and definition of a highly specific public health issue

OBJECTIVES

The concept of polyhandicap first emerged in the late '60s in France, with actually a consensus on its definition. This consensus has yet to be reached internationally. The absence of an international consensus on a definition and name for persons with polyhandicap limits progress in research and health planning for these people.

METHODS

This article describes the history of the emergence of the concept of polyhandicap in France and internationally.

RESULTS

The emergence of the concept and definition of polyhandicap is part of the history of the development of special education and care for children with disabilities started at the end of the 19th century and during the first half of the 20th century. In France, between 1970 and 2002, working groups composed of professionals and family associations gradually developed and refined the definition of polyhandicap, differentiating it from other clinical entities such as cerebral palsy. Internationally, the term polyhandicap is used in 4 European countries: in France where it first appeared, in Italy, in French-speaking Belgium, and in French-speaking Switzerland but also outside the EU. Various terms may be used around the world to describe clinical entities similar to polyhandicap; the most frequently used in the literature is the term Profound Intellectual and Multiple Disabilities (PIMD) or PIMD Spectrum which does not systematically refer to an early brain injury.

DISCUSSION

We are currently in the process of internationalizing the concept and definition of polyhandicap, and hopefully, as was the case for cerebral palsy in the 2000s, the various research teams working on this subject around the world will create collaborations and research networks targeting this specific population.

CONCLUSION

A consensus around a precise definition of polyhandicap is important to ensure that these people are recognized for their uniqueness and specific qualities and to provide them adapted care.

Nurturing the Positive Mental Health of Autistic Children, Adolescents and Adults alongside That of Their Family Care-Givers: A Review of Reviews

The rising prevalence of autism internationally has been accompanied by an increased appreciation of the poorer mental health experienced by people with this condition and also of their family care-givers. In particular, higher incidences of anxiety and depression are reported in high-income nations and these conditions are likely to be under-recognised and under-reported in lower-resourced regions or countries. Mainstream mental health services seem to be ill-equipped to respond adequately to the needs of autistic persons and their care-givers. This literature review of 29 recently published reviews covering nearly 1000 journal articles summarises the insights and strategies that have been shown to promote the mental health and emotional wellbeing of autistic persons. In particular, a focus on family-centred, community-based supports is recommended that aim to enhance social communication, extend social connections and promote an individual's self-esteem, self-determination and social motivation. These low-cost interventions are especially pertinent in low-resourced settings, but they can be used internationally to prevent mental illness and assist in the treatment of anxiety and depression in autistic persons and their family carers. The priority is to focus on primary-care responses with cross-sectoral working rather than investing in high-cost psychiatric provision.

Barriers and Challenges for Visually Impaired Students in PE-An Interview Study with Students in Austria, Germany, and the USA

Physical education (PE) is an important part of school education worldwide, and at the same time, almost the only subject that explicitly deals with body and movement. PE is therefore of elementary importance in the upbringing of young people. This also applies to children with visual impairments. However, existing findings on participation and belonging in PE as well as on physical and motor development reveal that this group of children and adolescents is noticeably disadvantaged in this respect. Against this background, this paper aims to explore fundamental barriers and challenges across different types of schools, types of schooling, and countries from the perspective of visually impaired children. The qualitative interview study with 22 children with visual impairments at different types of schools in three countries (Austria, Germany, USA) reveals that none of the respondents could escape the power of social distinctions and related problematic and existing hierarchies. Hence, ideas of normality and associated values remain the main challenge for all of them. However, the type-forming analysis provides important insight across settings on how visually impaired children differ on this, allowing for greater sensitivity to the concerns of children with visual impairments.

Ethical issues in clinical neuropsychology: International diversity perspectives

OBJECTIVE

Much of the information about the ethical practice of clinical neuropsychology has focused on North America. Additionally, of the scholarly publications on the intersection of ethical issues and cultural diversity practices in neuropsychology, most have focused on North America. The extent to which practitioners in other parts of the world are aware of, and find useful, such information is largely unknown. Similarly, the extent to which North American neuropsychologists are familiar with ethical issues and challenges encountered around the world is unknown. The purpose of this article is to advance the discussion of ethical issues in clinical neuropsychology from an international diversity perspective.

METHOD

The article presents, via a panel interview format, the thoughts and experiences of a small sample of neuropsychologists who represent all continents except North America (and Antarctica).

RESULTS

Neuropsychologists across continents share an ethical commitment to providing services that are beneficial, and not harmful, to the recipients of the services. Professional competence is at the heart of such services.

CONCLUSIONS

Through continued and expanded dialogue about ethical issues with neuropsychology colleagues around the world, the potential exists for improvement in the provision of effective and compassionate care in our own towns.

Recognizing and Adapting to Cultural Differences: Influence of International Educational Programs on Future Nursing and Midwifery Practice

INTRODUCTION

International educational programs build cultural humility and safety skills in nursing and midwifery students; however, long-term outcomes of these programs are unclear. The purpose of this study was to explore the impact of international educational programs on nurses' and midwives' future professional practice.

METHOD

Using grounded theory informed by Charmaz, 13 general nurses, two mental health nurses, three midwives, and four dual-qualified nurse/midwives across eight different countries were interviewed. Three categories evolved from the analysis. This article reports on the category Recognizing and adapting to cultural differences.

FINDINGS

Participants developed cultural safety and awareness from participation in programs extending into future practice. Experiencing and adapting to cultural similarities and differences, they developed culturally congruent practices many years after program completion.

DISCUSSION

International programs contributed to participants' professional practice. Positive and ongoing influences are important for employers to promote patient safety and culturally congruent quality care. Findings are also relevant for education providers to inform quality cultural learning.

Results of an international survey on the status of prehospital care

BACKGROUND

Prehospital care including recognition of stroke symptoms by the public and professionals combined with an efficient and effective emergency medical service (EMS) is essential to increase access to effective acute stroke care. We undertook a survey to document the status of stroke prehospital care globally.

METHODS

A survey was distributed via email to the World Stroke Organization (WSO) members. Information was sought on the current status of stroke prehospital delay globally, including (1) ambulance availability and whether payment for use is required, (2) ambulance response times and the proportion of patients arriving at hospital by ambulance, (3) the proportion of patients arriving within 3 h and more than 24 h after symptom, (4) whether stroke care training of paramedics, call handlers, and primary care staff, (5) availability of specialist centers, and (6) the proportion of patients taken to specialist centers. Respondents were also asked to identify the top three changes in prehospital care that would benefit their population. Data were analyzed descriptively at both country and continent level.

RESULTS

Responses were received from 116 individuals in 43 countries, with a response rate of 4.7%. Most respondents (90%) reported access to ambulances, but 40% of respondents reported payment was required by the patient. Where an ambulance service was available (105 respondents) 37% of respondents reported that less than 50% of patients used an ambulance and 12% less than 20% of patients used an ambulance. Large variations in ambulance response times were reported both within and between countries. Most of the participating high-income countries (HIC) offered a service used by patients, but this was rarely the case for the low- and middle-income countries (LMIC). Time to admission was often much longer in LMIC, and there was less access to stroke training for EMS and primary care staff.

CONCLUSIONS

Significant deficiencies in stroke prehospital care exist globally especially in LMIC. In all countries, there are opportunities to improve the quality of the service in ways that would likely result in improved outcomes after acute stroke.

Health Experiences of Women University Students of Color and Women International Students in the United States During the First Year of the COVID-19 Pandemic: Findings From a Transnational, Virtual Photovoice Study

Women university students in the United States who are students of color and international students consistently experience health disparities. These were exacerbated due to the COVID-19 pandemic and racial upheaval following the murder of George Floyd. Within that context, this study aimed to explore the health and well-being experiences of women students of color and international women students at a university in the Midwestern United States in 2020-2021. This participatory, transnational study utilized a virtual adaptation of Photovoice with 14 participants who joined the study from five different countries. Participatory elements included participant co-researchers co-leading development of the photo "mission," icebreakers, naming of the project, design of the project logo, choosing photos for discussion and exhibits, initial analysis of emergent themes, and approval and editing of photos for exhibit. Inductive thematic analysis revealed three themes: (1) grief and loss, (2) barriers and facilitators to social health, and (3) fear and stress from simultaneous social stressors. Data was not mutually exclusive with some photos and narratives illustrating more than one theme. The women experienced grief and loss while negotiating effects of social isolation and adapting to maintain social health. Negative mental and emotional health experiences were amplified as the social context of police brutality and anti-immigrant sentiments overlaid the stress of the pandemic. Study results demonstrate need for increased and tailored health and social service support for women students of color and international women university students.

Reconsidering a Global Agency for Medical Education: Back to the Drawing Board?

Issue: The World Federation for Medical Education (WFME) was established in 1972 and in the five decades that followed, has been the de facto global agency for medical education. Despite this apparently formidable remit, it has received little analysis in the academic literature. Evidence: In this article, we examine the historical context at the time WFME was established and summarize the key decisions it has taken in its history to date, highlighting particularly how it has adopted positions and programmes that have seemingly given precedence to the values and priorities of countries in the Global North. In doing so, we challenge the inevitability of the path that it has taken and consider other possible avenues that such a global agency in medical education could have taken, including to advocate for, and to develop policies that would support countries in the Global South. Implications: This article proposes a more democratic and equitable means by which a global organization for medical education might choose its priority areas, and a more inclusive method by which it could engage the medical education community worldwide. It concludes by hypothesizing about the future of global representation and priority-setting, and outlines a series of principles that could form the basis for a reimagined agency that would have the potential to become a force for empowerment and global justice in medical education.

The Influence of Regional Differences on the Reliability of the AO Spine Sacral Injury Classification System

STUDY DESIGN

Global cross-sectional survey.

OBJECTIVE

To explore the influence of geographic region on the AO Spine Sacral Classification System.

METHODS

A total of 158 AO Spine and AO Trauma members from 6 AO world regions (Africa, Asia, Europe, Latin and South America, Middle East, and North America) participated in a live webinar to assess the reliability, reproducibility, and accuracy of classifying sacral fractures using the AO Spine Sacral Classification System. This evaluation was performed with 26 cases presented in randomized order on 2 occasions 3 weeks apart.

RESULTS

A total of 8320 case assessments were performed. All regions demonstrated excellent intraobserver reproducibility for fracture morphology. Respondents from Europe (k = .80) and North America (k = .86) achieved excellent reproducibility for fracture subtype while respondents from all other regions displayed substantial reproducibility. All regions demonstrated at minimum substantial interobserver reliability for fracture morphology and subtype. Each region demonstrated >90% accuracy in classifying fracture morphology and >80% accuracy in fracture subtype compared to the gold standard. Type C morphology (p2 = .0000) and A3 (p1 = .0280), B2 (p1 = .0015), C0 (p1 = .0085), and C2 (p1 =.0016, p2 =.0000) subtypes showed significant regional disparity in classification accuracy (p1 = Assessment 1, p2 = Assessment 2). Respondents from Asia (except in A3) and the combined group of North, Latin, and South America had accuracy percentages below the combined mean, whereas respondents from Europe consistently scored above the mean.

CONCLUSIONS

In a global validation study of the AO Spine Sacral Classification System, substantial reliability of both fracture morphology and subtype classification was found across all geographic regions.

Pandemic paranoia in the general population: international prevalence and sociodemographic profile

BACKGROUND

The term 'pandemic paranoia' has been coined to refer to heightened levels of mistrust and suspicion towards other people specifically due to the COVID-19 pandemic. In this study, we examine the international prevalence of pandemic paranoia in the general population and its associated sociodemographic profile.

METHODS

A representative international sample of general population adults (N = 2510) from five sites (USA N = 535, Germany N = 516, UK N = 512, Australia N = 502 and Hong Kong N = 445) were recruited using stratified quota sampling (for age, sex, educational attainment) and completed the Pandemic Paranoia Scale (PPS).

RESULTS

The overall prevalence rate of pandemic paranoia was 19%, and was highest in Australia and lowest in Germany. On the subscales of the PPS, prevalence was 11% for persecutory threat, 29% for paranoid conspiracy and 37% for interpersonal mistrust. Site and general paranoia significantly predicted pandemic paranoia. Sociodemographic variables (lower age, higher population size and income, being male, employed and no migrant status) explained additional variance and significantly improved prediction of pandemic paranoia.

CONCLUSIONS

Pandemic paranoia was relatively common in a representative sample of the general population across five international sites. Sociodemographic variables explained a small but significant amount of the variance in pandemic paranoia.

Children's Oncology Group's 2023 blueprint for research: Liver tumors

Liver tumors account for approximately 1%-2% of all pediatric malignancies, with the two most common tumors being hepatoblastoma (HB) and hepatocellular carcinoma (HCC). Previous Children's Oncology Group studies have meaningfully contributed to the current understanding of disease pathophysiology and treatment, laying groundwork for the ongoing prospective international study of both HB and HCC. Future work is focused on elucidating the biologic underpinnings of disease to support an evolution in risk categorization, advancements in the multidimensional care required to treat these patients, and the discovery of novel therapies.

Critical care nursing policy, practice, and research priorities: An international cross-sectional study

PURPOSE

To examine the status of critical care nursing internationally, assess the impact of the COVID-19 pandemic, and identify research priorities by surveying professional critical care nursing organizations (CCNOs) worldwide.

DESIGN

A descriptive survey methodology was used. This study is the sixth worldwide quadrennial review to assess international critical care nursing needs and provide evidence to inform critical care nursing policy, practice and research priorities globally.

METHODS

The sixth World Federation of Critical Care Nurses survey of CCNOs was emailed to potential participants from countries with CCNOs or known critical care nurse leaders. Data were collected online using Survey Monkey™. Responses were entered into SPSS version 28 software (IBM Corp.) and analyzed by geographical region and national wealth group.

FINDINGS

Ninety-nine national representative respondents participated in the survey (70.7% response rate). The most important issues identified were working conditions, teamwork, staffing levels, formal practice guidelines, wages, and access to quality education programs. The top five CCNO services that were of most importance were providing national conferences, local conferences, workshops and education forums, practice standards and guidelines, and professional representation. Important pandemic-related services and activities provided by CCNOs included addressing emotional and mental well-being of nurses, providing guidance related to nurse staffing/workforce needs, assisting to coordinate efforts to obtain personal protective equipment supplies, serving as a country liaison with the World Health Organization's COVID-19 response activities, and assisting in the development and implementation of policies regarding standards of care. The most important contributions expected from the World Federation of Critical Care Nurses were standards for professional practice, standards for clinical practice, website resources, professional representation, and providing online education and training materials. The top five research priority areas were: stress levels (inclusive of burnout, emotional exhaustion and compassion fatigue); critical care nursing shortage, skill mix and workforce planning; recruitment, retention, turnover, working conditions; critical care nursing education and patient outcomes; and adverse events, staffing levels, patient outcomes.

CONCLUSIONS

The results highlight priority areas for critical care nursing internationally. The COVID-19 pandemic impacted critical care nurses as direct care providers. As a result, addressing the ongoing needs of critical care nurses remains a priority area of focus. The results also highlight important policy and research priorities for critical care nursing globally. Results of this survey should be incorporated into strategic action plans at the national and international levels.

CLINICAL RELEVANCE

Issues of importance to critical care nurses including research and policy priorities during and following COVID-19 are now clarified through this survey. The impact and importance that COVID-19 has had on critical care nurses and their preferences and priorities are provided. Clear guidance to leaders and policy makers on where critical care nurses would like to see greater focus and attention to help strengthen the contribution of critical care nursing practice to the global healthcare agenda.

Internal and external workload in national and international netball competition

Differences in workload exist between netball playing positions and competition levels, but no research has compared workloads experienced by the same elite players during national and international competitions. This study collected internal (heart rate) and external (PlayerLoad·min-1) workload data per match quarter from 44 players during a national competition and 12 players during an international competition. Nine players played in both competitions. Linear mixed models compared percentage of match quarter in each heart rate zone and PlayerLoad·min-1 between competitions for each playing position. Workloads against low- and high-ranked international opponents were also compared. Internal workloads were greater in national compared to international competition for GD and WD positions. PlayerLoad·min-1 was significantly higher by 8-13% in the national competition for positions WD and C, and by 5-8% in the international competition for GD and GA. Positional differences may indicate a role of the team's tactical style of play. Workloads were generally greater against higher- rather than lower-ranked international opponents. These results indicate that tactical factors in combination with playing position and opposition characteristics should be considered when preparing physically for matches.

Diversity and Inclusion in Mental Health: A Collaborative Online International Learning Experience

Graduate students in a psychiatric mental health nurse practitioner program in the United States and undergraduate students in a first-year English course, Writing and Rhetoric, at a university in Ecuador participated in a Collaborative Online International Learning (COIL) experience in Fall Semester 2021. The purpose of the COIL experience was to develop global perspectives and cultural competencies regarding diversity and inclusion in mental health. The objectives of the COIL experience were to identify and discuss changes in thinking in four areas: eugenics and cultural bias, cultural bias in research, culture and mental illness, and institutional and care policies. Groups of students created educational posters about diversity and inclusion in mental health that were presented at a virtual mini conference to which other students and faculty at the participating universities were invited.

Pre-pandemic psychological and behavioral predictors of responses to the COVID-19 pandemic in nine countries

Prior to the COVID-19 pandemic, adolescents (N = 1,330; Mages = 15 and 16; 50% female), mothers, and fathers from nine countries (China, Colombia, Italy, Jordan, Kenya, Philippines, Sweden, Thailand, United States) reported on adolescents' internalizing and externalizing problems, adolescents completed a lab-based task to assess tendency for risk-taking, and adolescents reported on their well-being. During the pandemic, participants (Mage = 20) reported on changes in their internalizing, externalizing, and substance use compared to before the pandemic. Across countries, adolescents' internalizing problems pre-pandemic predicted increased internalizing during the pandemic, and poorer well-being pre-pandemic predicted increased externalizing and substance use during the pandemic. Other relations varied across countries, and some were moderated by confidence in the government's handling of the pandemic, gender, and parents' education.

Professional Adaptation Experiences of Chinese Migrant Nurses in Australia: A Qualitative Study

Chinese-educated nurses are increasingly important to the international labor market. This study aimed to examine how Chinese migrant nurses adapt and evolve professionally while pursuing nursing careers in Australia, using a qualitative descriptive approach. A total of 17 Chinese-educated nurses were recruited by purposive and snowball sampling in Australia during 2017. Data were collected by individual semi-structured interviews and analyzed using thematic analysis. Three central themes and eight subthemes were generated. Perceived differences in nursing involved: work options and flexibility, professional autonomy and independence, and freedom of expressing professional opinions. Elements comprising challenges to adaptation included communication barriers, nursing workload and responsibilities, and collegial relationships. Participants' professional transition journeys were accompanied by two key areas of self-evolution: Embracing the authentic self and embracing individual differences. Our findings have important implications for migrant-host nursing workforce integration in Australia and internationally.

Development and Validation of a Predictive Risk Algorithm for Bleeding in Individuals on Long-term Hemodialysis: An International Prospective Cohort Study (BLEED-HD)

Background

Individuals with kidney disease are at a high risk of bleeding and as such tools that identify those at highest risk may aid mitigation strategies.

Objective

We set out to develop and validate a prediction equation (BLEED-HD) to identify patients on maintenance hemodialysis at high risk of bleeding.

Design

International prospective cohort study (development); retrospective cohort study (validation).

Settings

Development: 15 countries (Dialysis Outcomes and Practice Patterns Study [DOPPS] phase 2-6 from 2002 to 2018); Validation: Ontario, Canada.

Patients

Development: 53 147 patients; Validation: 19 318 patients.

Measurements

Hospitalization for a bleeding event.

Methods

Cox proportional hazards models.

Results

Among the DOPPS cohort (mean age, 63.7 years; female, 39.7%), a bleeding event occurred in 2773 patients (5.2%, event rate 32 per 1000 person-years), with a median follow-up of 1.6 (interquartile range [IQR], 0.9-2.1) years. BLEED-HD included 6 variables: age, sex, country, previous gastrointestinal bleeding, prosthetic heart valve, and vitamin K antagonist use. The observed 3-year probability of bleeding by deciles of risk ranged from 2.2% to 10.8%. Model discrimination was low to moderate (c-statistic = 0.65) with excellent calibration (Brier score range = 0.036-0.095). Discrimination and calibration of BLEED-HD were similar in an external validation of 19 318 patients from Ontario, Canada. Compared to existing bleeding scores, BLEED-HD demonstrated better discrimination and calibration (c-statistic: HEMORRHAGE = 0.59, HAS-BLED = 0.59, and ATRIA = 0.57, c-stat difference, net reclassification index [NRI], and integrated discrimination index [IDI] all P value <.0001).

Limitations

Dialysis procedure anticoagulation was not available; validation cohort was considerably older than the development cohort.

Conclusion

In patients on maintenance hemodialysis, BLEED-HD is a simple risk equation that may be more applicable than existing risk tools in predicting the risk of bleeding in this high-risk population.

Adverse Gastrointestinal Events With Sodium Polystyrene Sulfonate Use in Patients on Maintenance Hemodialysis: An International Cohort Study

Background

There are concerns regarding the gastrointestinal (GI) safety of sodium polystyrene sulfonate (SPS), a medication commonly used in the management of hyperkalemia.

Objective

To compare the risk of GI adverse events among users versus non-users of SPS in patients on maintenance hemodialysis.

Design

International prospective cohort study.

Setting

Seventeen countries (Dialysis Outcomes and Practice Patterns Study [DOPPS] phase 2-6 from 2002 to 2018).

Patients

50 147 adults on maintenance hemodialysis.

Measurements

An adverse GI event defined by a GI hospitalization or GI fatality with SPS prescription compared with no SPS prescription.

Methods

Overlap propensity score-weighted Cox models.

Results

Sodium polystyrene sulfonate prescription was present in 13.4% of patients and ranged from 0.42% (Turkey) to 20.6% (Sweden) with 12.5% use in Canada. A total of 935 (1.9%) adverse GI events (140 [2.1%] with SPS, 795 [1.9%] with no SPS; absolute risk difference 0.2%) occurred. The weighted hazard ratio (HR) of a GI event was not elevated with SPS use compared with non-use (HR = 0.93, 95% confidence interval = 0.83-1.6). The results were consistent when examining fatal GI events and/or GI hospitalization separately.

Limitations

Sodium polystyrene sulfonate dose and duration were unknown.

Conclusions

Sodium polystyrene sulfonate use in patients on hemodialysis was not associated with a higher risk of an adverse GI event. Our findings suggest that SPS use is safe in an international cohort of maintenance hemodialysis patients.

Simulation Training in a Lower Middle-Income Country: Supporting a New Center and Developing Low-Cost Models for Critical Skill Acquisition

INTRODUCTION

 There is a demand for surgical simulation training to be made accessible in low-resource countries. We conducted a pilot workshop at a new state-of-the-art simulation center and evaluated two novel low-cost surgical simulation models in a lower middle-income country (LMIC).

METHODS

A hands-on workshop to train local educators about simulation training was held at a new simulation center. Participant surveys were analyzed following the "training-the-trainer" workshop. Low-cost, hybrid-fidelity pericardiocentesis and thoracic cavity simulation training models were created using locally available materials. These models recreated the pertinent anatomy at a cost under 20 US dollars each. The models were used to train 109 postgraduate anesthesiology trainees during two hands-on medical education workshops. Participant surveys were collected and analyzed.

RESULTS

Of the local educators who participated in the "training-the-trainer" workshop, 65% "agreed" and 35% "strongly agreed" with the claim that the simulations better prepared the trainees to teach the clinical scenarios. Additionally, 65% of local educators "agreed" and 35% "strongly agreed" that the simulations prepared them to navigate interprofessional care in those scenarios. The low-cost pericardiocentesis simulation was ranked as "good" or "outstanding" by 100% of survey respondents. The low-cost thoracostomy simulation was ranked as "good" or "outstanding" by 64% of survey respondents. Both the pericardiocentesis and thoracostomy simulators were valued for their low-cost design, the recreation of essential anatomy, and immersive design elements.

CONCLUSION

Our team successfully implemented novel simulators for skill training in an LMIC by working in close collaboration with local experts, with the advancement of local simulation instruction practices. Collaboration is key to increasing access to surgical simulations, particularly in low- to middle-income countries.