Using gamification tools to enhance self-organized echo-learning in a hospital setting

Objectives: This study aimed to identify the areas of strength and areas needing improvement in the internal medicine residency curriculum in a developing country - Sudan. Materials and Methods: This qualitative study was conducted at six major teaching hospitals in Sudan. Purposive sampling was used to select 48 residents who participated in six focus group discussions (FGDs). All FGDs were audio taped and lasted between 60 and 90 min. Data collection continued until theoretical saturation took place. The transcribed data were analyzed using the content analysis technique, and codes were generated and categorized into subthemes. Three emerging themes were identified: training curriculum, training in research, and assessment of residents. Results: The residents were generally satisfied with the curriculum at the planning level. They reported that the structure of the program is suitable and the duration of the curriculum appropriate; the number of patients and theoretical training in the research were considered optimum. They suggested that training in research should begin earlier in the curriculum, with time reserved for conducting research, and that assessment needs improvement. Conclusion: This study highlighted the utility of the qualitative approach in identifying residents' perspectives of their educational programs. However, the residents provided suggestions for improvement in the following areas: training curriculum, research training, and assessment. The practical recommendations from this study could be used to improve the quality of postgraduate medical training in Sudan and elsewhere.

RATIONALE: Point of care ultrasound (POCUS) is increasingly recognized as a useful tool for internal medicine clinicians. For internal medicine residents, there is no established recommendation or curriculum for POCUS training. Many authors report efficacy of short duration POCUS training, but rigor of assessment is variable. We aimed to evaluate efficacy of self-study and a single training session on residents’ ability to use cardiac POCUS to assist in clinical diagnosis and management. METHODS: Internal medicine residents were invited to participate and gave consent to have their data used in research. All residents had completed post graduate year 1 and were in either categorial medicine or combined internal medicine/pediatrics programs. Residents were provided with self-study videos describing technique and pathology. They received hands on instruction with both live models and high-fidelity ultrasound simulators. After this first session, residents were encouraged to practice and seek feedback from attendings on ICU rotations. Residents later returned for testing where a combined high fidelity ultrasound simulator (CAE Vimedix Ultrasound Simulator) and patient simulator (CAE Metiman) challenged them with 3 patient scenarios: 1. cardiac tamponade with a large pericardial effusion, 2. septic shock with hyperdynamic ejection fraction (EF), and 3. cardiogenic shock with severely reduced EF. The scenario-based sessions were recorded. Checklist assessments were modified from examples available in literature in an iterative fashion. A survey gathering demographic information and POCUS experience was conducted. RESULTS: A total of 10 residents completed training, testing with simulated scenarios, and the survey. Residents reported performing between 0 and 15 POCUS echos clinically. Overall, scores were variable. The mean score for residents who had performed ≥ 10 echos clinically was 79.6% compared to a mean of 56.4% for those who had performed < 10. Medical school exposure to POCUS was variable, but generally limited. Of residents performing poorly on scenarios, most points were lost on image interpretation and clinical application rather than image acquisition. CONCLUSION: Internal medicine residents’ clinical experiences and performance on scenario-based simulation testing was highly variable. Brief training may be helpful in acquiring image acquisition skills, but clinical mentoring is needed for accurate interpretation and clinical application. Given the growing availability of ultrasound as a tool for internal medicine clinicians, it will be important to develop practical ways to ensure trainees are prepared to perform POCUS and integrate its use into patient care and medical decision making. Self-study resources and simulation have potential to contribute to this.

Effective communication skills are widely recognized as an important aspect of medical practice. Several tools and curricula for communications training in medicine have been proposed, with increasing attention to the need for an evidence-based curriculum for communication with families of patients in the intensive care unit (ICU). We developed a curriculum for internal medicine residents rotating through the medical ICU that consisted of a didactic session introducing basic and advanced communication skills, computer-based scenarios exposing participants to commonly encountered dilemmas in simulated family meetings, and experiential learning through the opportunity to identify potential communication challenges prior to facilitating actual family meetings, followed by structured peer debriefing. Seventeen residents participated in the study. We administered the Communication Skills Attitude Scale to participants before and after participation in the curriculum, as well as a global self-efficacy survey, with some items based on the Common Ground rating instrument, at the end of the academic year. There were no significant changes in either positive or negative attitudes toward learning communication skills. Resident self-perceived efficacy in several content domains improved but did not reach statistical significance. Our curriculum provided interactive preparatory training and an authentic experience for learners to develop skills in family meeting facilitation. Learners responded favorably to the curriculum. Use of the Family Meeting Behavioral Skills (FMBS) tool helped residents and educators identify and focus on specific skills related to the family meeting. Next steps include gathering and analyzing data from the FMBS tool.

The Process of Re-developing a National Training Curriculum for Radiation Oncology: The Irish Experience

During the last few decades, the use of intraoperative echocardiography has become increasingly evident as anesthesiologists, cardiologists, and surgeons continue to appreciate its potential application as an invaluable tool for monitoring cardiac performance and diagnosing pathology in patients undergoing cardiac surgery (1,2). The essential information provided by intraoperative echocardiography regarding hemodynamic management, cardiac valve function, congenital heart lesions, and great vessel pathology has contributed to its widespread popularity. In fact, perioperative echocardiography has been shown to influence cardiac anesthetic and surgical management in as many as 50% of cases (3). The publication of guidelines describing the indications for performing intraoperative echocardiography based on reviews of the literature and expert opinion of task force members from the Society of Cardiovascular Anesthesiologists (SCA), American Society of Anesthesiologists, and American Society of Echocardiography (ASE) has also facilitated the growth of this important diagnostic tool (4,5). Despite its overwhelming popularity and favorable influence on perioperative clinical decision-making and outcomes (1,2,6), the transesophageal echocardiographic (TEE) approach to a comprehensive echocardiographic examination has some limitations. For example, TEE imaging of the distal ascending aorta and aortic arch may be impaired by the interposition of the trachea and main bronchi (7–9). In addition, a TEE probe may occasionally be difficult or impossible to advance into the esophagus or, in patients with significant gastroesophageal pathology, TEE probe placement may even be contraindicated (10). Furthermore, TEE may be rarely associated with perioperative morbidity from oropharyngeal and gastroesophageal injury (e.g., dysphagia, gastrointestinal hemorrhage, gastroesophageal rupture) (10,11). Thus, an experienced echocardiographer must be familiar with other imaging approaches to conduct a comprehensive perioperative echocardiographic examination. More than a decade before the introduction of TEE, epicardial echocardiography was already in use as a diagnostic imaging modality to assist cardiac surgeons, anesthesiologists, and cardiologists with clinical decision-making (12). A comprehensive epicardial echocardiographic examination can be performed efficiently and safely (13), and may be the most practical intraoperative imaging technique when a TEE probe cannot be inserted or when probe placement is contraindicated. Epicardial echocardiography may be superior to TEE because it can provide more optimal image resolution when using higher frequency probes (14). In addition, epicardial echocardiography may offer better windows for imaging anterior cardiac structures including the aorta, aortic valve (AV), pulmonic valve, and pulmonary arteries, and, therefore, may have a favorable influence on perioperative surgical decision-making (15,16). However, epicardial imaging requires direct access to the anterior surface of the heart, and consequently cannot be performed without a sternotomy. Furthermore, the epicardial approach does not permit continuous monitoring, and requires interruption of the surgical procedure for imaging. The most recent recommendations by the ASE and SCA Task Force Guidelines for Training in Perioperative Echocardiography include epicardial and epiaortic imaging as core components of advanced training (5). Thus, the following guidelines for performing a comprehensive epicardial echocardiographic examination have been developed by the ASE Council for Intraoperative Echocardiography to establish requirements for training, and to standardize a comprehensive epicardial examination using a set of 7 reliably obtained views. TRAINING GUIDELINES The epicardial approach is unique among the readily used echocardiographic imaging windows in that it requires a collaborative effort with the cardiac surgeon to either allow the echocardiographer to guide them in obtaining images, or alternatively permit the echocardiographer to have direct access to the epicardial surface within the operative field. Experience in epicardial echocardiography is an important component of advanced, rather than basic perioperative echocardiographic training as defined by the ASE and SCA Task Force Guidelines for Training in Perioperative Echocardiography (5). Epicardial echocardiographic training should include the study of 25 epicardial examinations of which five are personally directed under the supervision of an advanced echocardiographer, before a trainee should pursue independent interpretation and application of the information to perioperative clinical decision-making. EPICARDIAL PROBE PREPARATION Epicardial echocardiography is performed by placing the ultrasound transducer on the epicardial surface of the heart to acquire 2-dimensional, color flow, and spectral Doppler images in multiple planes. Because of the proximity of the probe to the heart, epicardial echocardiography typically uses higher frequency probes (5–12 MHz). The probe is placed in a sterile sheath along with sterile acoustic gel or saline to optimize acoustic transmission. Two sheaths may also be used in an attempt to increase sterility. Warm sterile saline can be poured into the mediastinal cavity to further enhance acoustic transmission from the probe to the epicardial surface. The depth setting and the depth of transmit focus is then adjusted to visualize the near field. If a multifrequency probe is used, the frequency is increased to obtain the highest resolution image possible. Epicardial images may only be obtained by an operator who is wearing a sterile gown and gloves, and uses sterile technique within the operative field as described in these guidelines. This task may be performed either by a diagnosing physician with advanced perioperative echocardiography training or, alternatively and perhaps more practically, by a cardiac surgeon under the direct guidance of an advanced echocardiographer. Interpretation of epicardial echocardiographic images for the purpose of directing intraoperative surgical and anesthesia decision-making should only be performed by a physician with advanced perioperative echocardiography training. IMAGING PLANES The following proposed guidelines describe 7 epicardial echocardiographic imaging planes consistent with the ASE recommendations for transthoracic echocardiograph (TTE) nomenclature (17). We recognize that placement of the transducer directly on the heart provides views that can be slightly different than those obtained by TTE. These views will be identified as "modified" views. Individual patient characteristics, anatomic variations, or time constraints may limit the ability to obtain every component of the recommended comprehensive epicardial echocardiographic examination. Furthermore, there may be certain clinical situations where additional views may be necessary to address specific anatomic or pathologic questions. However, the 7 recommended views should permit the completion of a comprehensive 2-dimensional and Doppler echocardiographic evaluation in the vast majority of cardiac surgical cases, and should be obtainable in 5–10 min (13). Epicardial AV Short-Axis View (TTE Parasternal AV Short-Axis Equivalent) The ultrasound transducer is placed on the aortic root above the AV annulus, with the ultrasound beam directed toward the AV in a short-axis (SAX) orientation to obtain the epicardial AV SAX view (Fig. 1A). Appropriate transducer alignment and orientation is critical and requires the orientation marker (indentation) on the transducer to face toward the patient's left. The transducer typically has to be rotated approximately 30 degrees clockwise to develop this view. The right coronary cusp will be at the top of the monitor screen, the left coronary cusp will be on the right, and the noncoronary cusp will be on the left side of the screen adjacent to the interatrial septum (Fig. 1B). By slowly moving the transducer, the coronary ostia can be visualized. The area of the AV can also be measured in this view using planimetry.Figure 1.: Epicardial aortic valve (AV) short-axis (SAX) view (transthoracic echocardiographic parasternal AV SAX equivalent). A, Porcine anatomic specimen demonstrating ultrasound transducer oriented above AV annulus so that ultrasound beam can be aligned in SAX plane to AV. B, When orientation marker (indentation) on transducer is pointed toward patient's left, right coronary cusp (R) will be at top of monitor screen, left coronary cusp (L) will be on right, and noncoronary cusp (N) will be on left side of screen adjacent to interatrial septum. PA, Pulmonary artery.Epicardial AV Long-Axis View (TTE Suprasternal AV Long-Axis Equivalent) The epicardial AV long-axis (LAX) view is obtained from the epicardial AV SAX view by positioning the probe upward along the right-sided surface of the aortic root with the orientation marker slightly rotated clockwise and directed to the patient's left. The ultrasound beam is directed posteriorly to visualize the left ventricular (LV) outflow tract (LVOT) and AV (Fig. 2). This view can be used to determine LVOT, aortic annulus, and sinotubular junction diameters. Furthermore, the LAX orientation provided by this view permits optimal alignment of a continuous wave and pulse wave Doppler ultrasound beam, to measure pressure gradients across the AV and LVOT. Similarly, color flow Doppler interrogation of the AV can be used to grade the degree of aortic insufficiency.Figure 2.: Epicardial aortic (AO) valve (AV) long-axis (LAX) view (transthoracic echocardiographic suprasternal AV LAX equivalent). A, Porcine anatomic specimen demonstrating ultrasound transducer oriented along AO root, and directing ultrasound beam posteriorly to visualize left ventricular outflow tract (LVOT) and AV. B, AV and LVOT are well visualized. PA, Pulmonary artery.Epicardial LV Basal SAX View (TTE Modified Parasternal Mitral Valve Basal SAX Equivalent) The epicardial LV basal SAX view is obtained from the epicardial AV SAX position by moving the probe toward the apex along the right ventricle (RV) with the transducer orientation marker again directed toward the patient's left (Fig. 3A). This view will approximate what will be achieved with a right parasternal TTE imaging plane, and shows more of the RV and tricuspid valve than the standard left parasternal TTE orientation (Fig. 3B). The RV will be on top in the near field and the LV below it in the far field of the ultrasound beam sector. The mitral valve (MV) annulus is well visualized in this view with its typical "fish mouth" appearance. The MV anterolateral commissure will be on the right and the posteromedial commissure will be on the left of the screen. The anterior leaflet will appear on the top of the screen and the posterior leaflet will be underneath. The epicardial LV basal SAX view can be used to evaluate the anterior and posterior leaflets of the MV in 2-dimensional imaging. Color flow Doppler can also be used to determine the origin of mitral regurgitation jets and obtain an estimate of the regurgitant orifice area. Finally, basal LV regional wall motion can be assessed using the same LV wall orientation as seen in the epicardial LV mid-SAX view discussed below.Figure 3.: Epicardial left ventricle (LV) basal short-axis (SAX) view (transthoracic echocardiographic modified parasternal mitral valve [MV] basal SAX equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning for developing epicardial LV basal SAX view. B, MV annulus is well visualized with its typical "fish mouth" appearance. MV anterior leaflet (AL) appears on top of screen and posterior leaflet (PL) is underneath. When transducer orientation marker is directed toward patient's left, MV anterolateral commissure will be on right and posteromedial commissure will be on left of screen. RV, Right ventricle.Epicardial LV Mid-SAX View (TTE Parasternal LV Mid-SAX Equivalent) Repositioning or angulating the probe inferiorly and to the left from the epicardial LV basal SAX view in an apical direction along the RV myocardial surface allows visualization of the RV and LV in SAX at the level of the papillary muscles and the LV apex (Fig. 4A). When the transducer orientation marker faces the patient's left, the anterolateral papillary muscle will be on the right side of the display and the posteromedial papillary muscle will be on the left side. The septal wall of the LV will be displayed on the left followed by the anterior, lateral, and inferior walls, respectively, in a clockwise rotation (Fig. 4B). The RV can be evaluated similarly by moving the transducer further toward the patient's right. LV and RV areas, global LV function, and LV regional wall motion can all be evaluated with this view.Figure 4.: Epicardial left ventricle (LV) mid short-axis (SAX) view (transthoracic echocardiographic parasternal LV mid-SAX equivalent). A, Porcine anatomic specimen demonstrating proper epicardial probe positioning toward right ventricle apex for developing epicardial LV mid-SAX view. B, With transducer orientation marker directed toward patient's left, LV anterolateral papillary muscle will be on right and posteriomedial papillary muscle will be on left of ultrasound sector displayed on monitor. Septal (S) wall of LV is displayed on left followed by anterior (A), lateral (L), and inferior (I) walls, respectively, in clockwise rotation.Epicardial LV LAX View (TTE Parasternal LAX Equivalent) From the epicardial LV mid-SAX view, the ultrasound beam can be angled superiorly and rotated toward the patient's right shoulder to generate the epicardial LV LAX view as depicted in Figure 5A. This view allows visualization of the inferolateral and anteroseptal walls of the LV and the RV, left atrium (LA), LVOT, AV, and MV (Figs. 5B and C). Color Doppler interrogation of the AV and MV is possible in this view. A rightward orientation of the beam allows evaluation of the right atrium and tricuspid valve (not shown). Further probe manipulation also permits spectral Doppler of the tricuspid valve. Hence, this view is useful for diagnosing and quantifying aortic, mitral, and tricuspid regurgitation. The interventricular septum can also be evaluated for ventricular septal defects, LVOT obstruction, or systolic anterior motion of the MV.Figure 5.: Epicardial left ventricle (LV) long-axis (LAX) view (transthoracic echocardiographic parasternal LAX equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning with ultrasound beam angled superiorly and toward patients left shoulder to obtain epicardial LV LAX view. B, Porcine anatomic specimen with resected anterior ventricular wall demonstrating visualization of LV and right ventricle (RV), left atrium (LA), LV outflow tract (LVOT), interventricular septum (IVS), aortic valve (AV), and mitral valve (MV). C, Corresponding epicardial LV LAX echocardiographic view.Epicardial 2-Chamber View (TTE Modified Parasternal LAX Equivalent) From the epicardial LV LAX view, movement of the probe toward the anterior surface of the LV and further rotation of the transducer clockwise from the parasternal LAX view as described above will develop the epicardial 2-chamber view, permitting evaluation of the LA, LA appendage, MV, and LV (Fig. 6). Pathology that can be assessed in this view includes LA masses, and abnormalities in LA size, MV anatomy, and MV leaflet motion. Finally, regional wall motion of the basal and mid segments of the anterior and inferior LV walls can also be obtained. This view is the most difficult to consistently obtain unless the LV is dilated.Figure 6.: Epicardial 2-chamber view (transthoracic echocardiographic modified parasternal long-axis [LAX] equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning with ultrasound transducer rotated 90 degrees from epicardial left ventricle (LV) LAX view to obtain epicardial 2-chamber view. B, Porcine anatomic specimen with resected anterior ventricular wall demonstrating left atrium (LA), mitral valve (MV), and LV. To completely eliminate right ventricle, transducer must be place directly on LV, which is possible only in patients with severe LV dilation (not shown). C, Corresponding epicardial 2-chamber echocardiographic image in patient with LV dilation.Epicardial RV Outflow Tract View (TTE Parasternal SAX Equivalent) The epicardial RV outflow tract view is developed by moving the transducer over the RV outflow tract and directing the ultrasound beam toward the patients left shoulder (Fig. 7). The RV outflow tract, pulmonic valve, and proximal main pulmonary artery can be visualized. Orienting a spectral Doppler beam parallel to blood flow permits the evaluation of chamber pressures and quantification of pulmonic stenosis. Color flow Doppler can also be used to evaluate pulmonic regurgitation or stenosis. Finally, this view is also useful for diagnosing a proximal pulmonary embolism or assisting with positioning a pulmonary artery catheter.Figure 7.: Epicardial right ventricular (RV) outflow tract (RVOT) view (transthoracic echocardiographic parasternal short-axis equivalent). A, Porcine anatomic specimen with resected anterior ventricular wall demonstrating proper probe positioning for developing epicardial RV inflow tract/RVOT view. B, RVOT, pulmonic valve (PV), proximal main pulmonary artery, and aortic valve (AV) can be visualized.CONCLUSION As the population of patients with complex cardiac surgical conditions and increasing comorbidity becomes more prevalent, there will be a greater and perhaps more important role for experienced perioperative echocardiographers, who should assume the responsibility of acquiring advanced echocardiographic cognitive and technical skills. The most recent recommendations by the ASE and SCA Task Force Guidelines for Training in Perioperative Echocardiography state that advanced training includes the "ability to acquire or direct the acquisition of all necessary echocardiographic data including epicardial and epiaortic imaging" (5). Although intraoperative epicardial echocardiography was introduced into clinical practice in the early 1970s for the evaluation of open MV commissurotomy, its use has declined during the last decade because of the increasing availability and improved technologic design of TEE probes. The epicardial approach to a comprehensive echocardiographic examination does present certain potential limitations and disadvantages compared with TEE. Nonetheless, a fundamental understanding of the skills required to obtain and interpret images as suggested in these guidelines for performing a comprehensive epicardial examination may be an advantageous adjunct or even a substitute when TEE probe insertion is contraindicated or cannot be performed. Epicardial echocardiography may also provide the best balance between safety and the efficient acquisition of vital information necessary to optimize the perioperative treatment of patients who are critically ill.

BackgroundHealthcare cost management strategies are limited in number and resource intensive. Budget constraints in the National Health Service Scotland (NHS Scotland) apply pressure on regional health boards to improve efficiency...

Tissue Doppler Echocardiography (TDE) method has been developed which permits quantification of the myocardial. In the clinic conventionally displacement is measured by use of color tissue Doppler imaging and there is no report of myocardial displacement based on integration of maximum myocardial velocity. The purpose of this study was a time integral assessment of spectral tissue Doppler by use of maximum traced data during systolic phase of cardiac cycle as a new method for evaluation of myocardium displacement. It performed by a developed computer program based on Simpson's numerical integral method. Spectral tissue Doppler echocardiograms were saved as a full color images and transferred to a personal computer for off-line analysis with use of the proposed method. There were significant differences at 95% confidence level between the spectral and color tissue Doppler displacements respectively. By means of Bland-Altman analysis; arithmetic means was 7.49 and 6.96 mm with SD mean differences of plusmn2.74 mm and plusmn2.26 mm in all base and mid evaluated segments. The correlation of coefficient was R=0.79, (p<0.01) for all segments between the methods.

Changes to Training Practices during a Pandemic - The Experience of the Irish National Trauma & Orthopaedic Training Scheme

Automated staging of knee osteoarthritis severity using deep neural networks

Fatigue and exercise intolerance are symptoms in children with metabolic myopathy. Frequently this is combined with muscle pain in children with mitochondrial myopathy. Offering therapeutic advice remains challenging in this patient group. Here we describe five children above the age of four years, with normal intelligence, myopathy, exercise intolerance, motor developmental delay, and fatigue, who were diagnosed with a mitochondrial dysfunction. Based on the positive experience of condition training in adults with mitochondrial disease and inactivity, aerobic exercise training was advised for all the children. Because of the lack of clear protocols for individualized mitochondrial myopathies, regular training was initiated. The Movement Assessment Battery of Children, the Jamar dynamometer for grip force, and the Bruce protocol treadmill test were applied for evaluation. No patient showed significant disease progression on a weekly scheme of strength training or on aerobic training during periods varying between 6 and 18 months. Only one out of the five patients has shown an improvement after a period of structured, aerobic training, demonstrating good compliance and motivation over the course of 18 months. Some patients developed severe muscle pain after explosive exercise. Even in a relatively homogenous, intelligent group of patients and motivated parents, we could not reach full compliance. With our case studies, we would like to draw attention to the importance and pitfalls of movement therapy in children with mitochondrial disease.

It is known that patients with diastolic dysfunction have usually impaired left ventricular (LV) longitudinal systolic function, and the latter parameter shows strong correlation with the (tissue) Doppler parameters of the LV diastolic function. The role of non-velocity-type parameters of the global LV diastolic function have not been investigated yet. LV mass and left atrial volume, however, seem to be important factors as the former influences passive ventricular distension and the latter is established as a marker of the diastolic dysfunction's severity. The aim of our study was to investigate the relationship between LV longitudinaJ systolic function and these parameters. The same correlations were also investigated in patients with impaired systolic function. Patients: 16 healthy subjects, 29 patients suffering from hypertrophic cardiomyopathy (HCM) (ejection fraction >50%) and 24 patients with dilated cardiomyopathy (DCM) (EF< 35%) were studied. The three groups matched in age and gender. Inclusion criteria were: normal sinus rhythm, absence of moderate to severe mitraJ valve disease. Methods: In addition to the conventional transmitral flow patterns pulmonary vein Doppler parameters were measured by ATL HDI 5000 ultrasound system. Myocardial systolic velocity (S) was measured at the lateral border of the mitraJ annulus using tissue Doppler imaging. Ma~ximaJ left atrial volume (Vma~x) was measured from the apical 4and 2-chamber views using Simpson's method. The use of Devereux's mass index is probably limited in patients with HCM and DCM, so cardiac magnetic resonance imaging (1.5 T Siemens Vision plus) was used to determine the LV mass. LV mass and Vmax were normalized to body surface area (LVMI; Vma~x index). Results: In HCM patients isolated diastolic dysfunction while in DCM patients combined systolic and diastolic dysfunction were found. In HCM patients lateral S correlated negatively with LVMI (r= -0.492, p<0.01) and Vma~x index (r= -0.492, p<0.01). In DCM patients similar correlations were found with LVMI (r= -0.418, p<0.05) and Vma~x index (r=0.515, p<0.05), too. No significant correlation was found in the group of healthy volunteers. Conclusion: LV longitudinal systolic function showed a significant negative correlation with non-velocity-type parameters of the LV diastolic function such as LVMI and Vma~x index in patients with diastolic dysfunction and in patients with combined systolic and diastolic dysfunction as well.

The global shift toward Competency-Based Curriculum (CBC) underscores the need for educational systems to realign teaching practices with learner-centered and outcome-based methodologies. This theoretical review examines the impact of regular in service teacher training on the effective delivery of CBC in Nigerian schools. Drawing on recent literature and empirical evidence, the study highlights inservice training as a critical tool for equipping teachers with contemporary pedagogical, assessment, and content-related skills. Findings indicate a strong correlation between continuous in service training and successful curriculum delivery of CBC However, systemic barriers such as unstable funding, insufficient follow-up support, and resistance to change undermine training effectiveness. The paper offers practical recommendations for policymakers, educational administrators, and teacher educators, emphasizing policy reform, context responsive program design, mentorship and institutional collaboration to reinforce in-service training and support sustainable CompetencyBased Curriculum (CBC).

Vocational education has become the instrument in Australia to create a more effective workforce in an age of technological change and intense international competition. Policies have been introduced which have focused narrowly upon competency-based training (CBT), the end product, with empirical research revealing that CBT has not been effective or effectively introduced. The importance of processes, particularly effective learning and curriculum, and teacher pedagogical and pedagogical content knowledge (Shulman, 1986), as well as implementation issues, have been ignored. There has also been failure to recognise that many vocational education and training (VET) teachers/trainers have received minimal or no teacher training and even those formally trained have not been exposed to sufficient educational psychology, especially more recent research on skill learning and the development of expertise, transfer of learning and lifelong learning, key areas for effective learning in VET. Good curriculum documents can help maintain content knowledge currency and increase teaching capability through incorporation of knowledge from these key areas of psychology. Some implications for curriculum of these key areas are explored. Increased efficiency in the workplace can only be achieved through recognition of the importance of learning and serious efforts to develop curricula which provide adequate guidance and in-service education for teachers/trainers

Long-term regular exercise is associated with physiologic and morphologic cardiac alterations. Tissue Doppler Imaging(TDI) and Strain Myocardial Imaging(SI) are new tools in the evaluation systolic and diastolic myocardial function. We sought to compare TDI and SI findings in professional football players and age adjusted sedentary controls to assess the effect of regular athletic training on myocardial function. Transthoracic echocardiography, M-mode, 2-D measurements, Doppler derived mitral-tricuspid annular velocities, reconstructed spectral pulsed wave tissue Doppler velocities, strain and strain rate imaging of seven different myocardial regions were obtained from 24 professional football players and age, sex and weight adjusted 20 controls. Age, body surface area, blood pressure and heart rate were comparable between 2 groups. Football players had significantly increased LV mass, mass index (due to both higher wall thickness and end-diastolic diameter), end-systolic and end-diastolic volume, left atrial diameter and decreased transmitral diastolic late velocity. In athletes TDI analysis showed significantly increased mitral annulus septal TDI peak early diastolic(e) velocity(0.22 +/- 0.04 vs. 0.19 +/- 0.04 m/s, P < 0.05), lateral TDI peak e velocity (0.19 +/- 0.03 vs. 0.16 +/- 0.02 m/s, P < 0.05) and lateral TDI e/a ratio (1.96 +/- 0.41 and 1.66 +/- 0.23, P < 0.05). In SI analysis mid septal walls (1.71 +/- 0.23 in athletes and 1.49 +/- 0.25 in controls, P < 0.05) and mid lateral walls (1.55 +/- 0.28 and 1.34 +/- 0.25 respectively, P < 0.05) peak systolic strain rate values differences were found to be increased in athletes. Professional football playing is associated with morphologic alteration in left ventricle and left atrium and improvement in left ventricle diastolic function which can be detected by TDI. Strain rate imaging may be a new tool to define subtle change in systolic left ventricular function in "athletes heart" which cannot be determined in standard echocardiographic parameters.

Background Abstract The Centers for Disease Control and Prevention (CDC) in the United States has found that more children than ever before are being classified as having autism spectrum disorders (ASDs) (Chiri and Warfield 2011: 1081). According to Matenge (2014: 1), ASD is a pervasive developmental disorder characterised by two essential features: a combination of impairments in social interaction and social communication, and restricted, repetitive, and stereotyped patterns of behaviour, interests and activities. Malcolm-Smith et al. (2013: 4) report that data on the incidence, prevalence, and impact of ASD in South Africa are almost entirely lacking. No epidemiological studies of ASD have been conducted in the country (Malcolm- Smith et al. 2013: 4). Diagnostic and intervention services, particularly at state level, are scarce (Malcolm-Smith et al. 2013: 4). Hence, those that are in place are heavily overburdened. Of particular concern for South Africa are research findings indicating that ASD is under-identified in low socioeconomic status communities, so in these contexts ASD often goes undiagnosed, or is diagnosed late (Malcolm-Smith et al. 2013: 4). Matenge (2014: 19) argues that there is, therefore, a need to assess the level of knowledge, understanding and the experiences of South African nurses regarding autism, as they are usually the first professionals that families of children with autism contact. Research purpose The purpose of this research was to determine the knowledge, understanding and perceptions of professional nurses who work in primary health clinics in eThekwini Health District, KwaZulu-Natal, regarding ASD. Research design A quantitative, non-experimental, descriptive research survey design was utilised. A self-reporting questionnaire was used to collect data. Sampling and sample size Simple random sampling was used to determine which clinics in the eThekwini health district would be part of the study. The sample size for the clinics was thirty four, of those thirty were eThekwini municipality clinics and four KwaZulu-Natal Department of Health clinics. These clinics were utilised and provided the 275 professional nurses needed. The sample was calculated with a margin of error and an alpha value of 0.05; the researcher needed a minimum of 275 respondents. The researcher selected the respondents utilising non-probability, convenience sampling. Data analysis Data was analysed with the assistance of the statistician, using SPSS version 22. Descriptive statistics were used to explore differences between or among groups (Grove, Burns and Gray 2013: 217). Inferential statistics are used to draw conclusions regarding the differences between groups in the population from which the samples are drawn and the relationship between the variables in the population (Morgan et al. 2015: 84). Both descriptive and inferential statistics were used to analyse data in this study. Conclusion and findings It was found that the average professional nurse working in a primary healthcare clinic has 65.8% knowledge and understanding of ASD. Of particular concern is that the majority of respondents 51% (n=141) did not know or understand that the child with autism loves routine which is a key symptom in making a diagnosis of ASD, which may lead to late, or missed diagnosis. Eighty eight percent (n = 242) of respondents felt that they would benefit from further training on the identification and diagnosis of ASD. It was also found that respondents that have completed the Psychiatric Nursing Science course were more knowledgeable about ASD and confident in diagnosing ASD and counselling parents on ASD and available ASD services in the community. Recommendations The researcher recommended that: Autism spectrum disorder to be included in the curriculum for nurses training and that regular in-service training be done to keep the professional nurses up to date with on new information related to ASD. It was also recommended that all children should be screened for ASD at 18 and 24 months at all PHCs in eThekwini district and that posters on the signs and symptoms of ASD should be displayed at primary healthcare clinics in full view of patients, parents and staff