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Residents randomized to an SBML intervention performed thoracenteses with low rates of clinically meaningful complications. Rigorous education represents a successful quality improvement strategy.

This study demonstrates highly variable simulated central venous catheter insertion performance among a national cohort of experienced attending physicians. Hospitals, healthcare systems, and governing bodies should recognize that even experienced physicians require periodic clinical skill assessment and retraining.

Internal medicine (IM) residents and hospitalist physicians commonly perform thoracenteses. National data show that thoracenteses are also frequently referred to other services such as interventional radiology (IR), increasing healthcare costs. Simulation-based mastery learning (SBML) is an effective method to boost physicians' procedural skills and self-confidence. This study aimed to (1) assess the effect of SBML on IM residents' simulated thoracentesis skills and (2) compare thoracentesis referral patterns, selfconfidence, and reasons for referral between traditionally trained residents (non-SBML-trained), SBML-trained residents, and hospitalist physicians. A random sample of 112 IM residents at an academic medical center completed thoracentesis SBML from December 2012 to May 2015. We surveyed physicians caring for hospitalized patients with thoracenteses during the same time period and compared referral patterns, self-confidence, and reasons for referral. SBML-trained resident thoracentesis skills improved from a median of 57.6% (interquartile range [IQR] 43.3-76.9) at pretest to 96.2% (IQR 96.2-100.0) at post-test (P < 0.001). Surveys demonstrated that traditionally trained residents were more likely to refer to IR and cited lower confidence as reasons. SBML-trained residents were more likely to perform bedside thoracenteses. Hospitalist physicians were most likely to refer to pulmonary medicine and cited lack of time to perform the procedure as the main reason. SBMLtrained residents were most confident about their thoracentesis skills, despite hospitalist physicians having more experience. This study identifies confidence and time as reasons physicians refer thoracenteses rather than perform them at the bedside. Thoracentesis SBML boosts skills and promotes bedside procedures that are safe and less expensive than referrals. Internal medicine (IM) residents and hospitalist physicians commonly conduct bedside thoracenteses for both diagnostic and therapeutic purposes. 1 The American Board of Internal Medicine only requires that certification candidates understand the indications, complications, and management of thoracenteses. 2 A disconnect between clinical practice patterns and board requirements may increase patient risk because poorly trained physicians are more likely to cause complications. 3 National practice patterns show that many thoracenteses are referred to interventional radiology (IR). 4 However, research links performance of bedside procedures to reduced hospital length of stay and lower costs, without increasing risk of complications. 1,5,6 Simulation-based education offers a controlled environment where trainees improve procedural knowledge and skills without patient harm. 7 Simulationbased mastery learning (SBML) is a rigorous form of competency-based education that improves clinical skills and reduces iatrogenic complications and healthcare costs. 5,6,8 SBML also is an effective method to boost thoracentesis skills among IM residents. 9 However, there are no data to show that thoracentesi...

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This study aims to investigate if engaging in physical activity (PA) and gender influences people's entrepreneurial intention (EI). A survey for measuring EI and PA was developed and administered to the general population. The data were collected with a questionnaire distributed across all continental Portuguese regions. A two-way analysis of variance was used to test the influence of PA level and gender in EI. The results highlight that PA and gender have an impact on EI. This study's main practical implication is that evidence was found that people need to be involved in more PA, especially in high PA level, because the results show that there is an association with increased levels of EI. This paper contributes to filling a gap in the literature by identifying the importance of PA for the increase of EI. This relationship may be a consequence of skills promoted by the practice of PA and also the development of some personal psychological and cognitive characteristics such as autonomy, risk tolerance, and leadership. The main implication resulting from this study is that it is essential to develop and booster PA into society, namely through PA programmes in organisations, not only for improving persons' health condition but also as a social benefit, that can promote social innovation and entrepreneurship.

Summary Skin cancer is increasing worldwide. However, it is not always practical to send all patients with skin symptoms to dermatology clinics. Artificial intelligence holds great promise in helping the screening for and diagnosis of skin cancer. Although several computer‐aided classification systems have been introduced that achieve high sensitivity of melanoma detection, low specificity was a trade‐off for high sensitivity. Sensitivity measures the proportion of ‘actual positives’ that are correctly identified (e.g. the percentage of sick people who are correctly identified as having the condition). Specificity measures the proportion of ‘actual negatives’ that are correctly identified as such (e.g. the percentage of healthy people who are correctly identified as not having the condition). The application of a new machine learning method, called deep convolutional neural network (DCNN), to a skin cancer classifier can potentially improve skin cancer screening sensitivity and specificity. However, the number of training images required for such a system is thought to be extremely large and compiling a large data set for rare skin conditions is difficult. In this study, we trained DCNN using fewer than 5000 images, and developed a DCNN classifier that can classify 14 different skin tumors and related conditions. Its performance was tested against 13 board‐certified dermatologists. As a result, our system requires only a single image and comes with 96.3% sensitivity and 89.5% specificity in the detection of skin cancer. The accuracy of malignant or benign classification by the DCNN achieved statistically greater accuracy compared with board‐certified dermatologists, 85.3% and 92.4%, respectively. In conclusion, we used DCNN trained with a relatively small number of images to develop an efficient skin tumor classifier. The current system could be used in screening purposes in general medical practice but it needs to be thoroughly tested in clinical trials first.

Background. Physical activity (PA) is a keystone of diabetes management, but although self-exercise is beneficial, supervised exercise (SE), adapted to individual characteristics, and is more effective. Objectives. The main research goal is to compare SE patterns among diabetic and non-diabetic Portuguese adults. Methods. A total of 484 participants (85 diabetics, 399 non-diabetics), aged 41-90 years old (mean=58.9; SD=11.9) were interviewed. PA level was assessed using short form of the International Physical Activity Questionnaire. Attendance in different SE programs was evaluated across three kinds of PA programs providers: gym/health-clubs; swimming pools and other club/ sports facilities. Itens like Barriers to Exercise; Intention to participate; Importance of the structure and PA information sources were also evaluated. Independent t-tests were used to examine the difference between the group means, and Levene's test was used to check the homokedasticity of the groups' variances. Results. PA level of diabetics (32% low; 25% moderate; 44% high) and non-diabetics (29% low; 33% moderate; 39% high) display no differences. 90% of diabetics do not attend SE. The main barrier for diabetics' non-participation is the perception that the exercise is not adequate to their health. Doctors are the preferred information source for diabetics and they rely less on information provided by the Internet, with may impair on-line campaigns. Conclusion. Promoting exercise in diabetics should shift the focus from "promoting physical activity" to "promoting SE".