Simulation aus Fleisch und Blut: Schauspielpatienten

Der Begriff der Simulation wird manchmal vorschnell auf technische Simulatoren reduziert, welche mehr oder weniger aufwändig Anatomien oder bestimmte Szenarien des klinischen Alltages wiedergeben. In dem folgenden Kapitel soll nun der Begriff Simulation auch auf die sogenannten Simulationspatienten ausgeweitet und entsprechende Konzepte vorgestellt werde

FAIR_OSCE – Feedback structure for assessment of interactive roleplay in Objective Structured Clinical Exams

Introduction Since the quality of patient portrayal of standardized patients (SPs) during an Objective Structured Clinical Exam (OSCE) has a major impact on the reliability and validity of the exam, quality control should be initiated. Literature about quality control of SPs’ performance focuses on feedback [1, 2] or completion of checklists [3, 4]. Since we did not find a published instrument meeting our needs for the assessment of patient portrayal, we developed such an instrument after being inspired by others [5] and used it in our high-stakes exam. Project description SP trainers from five medical faculties collected and prioritized quality criteria for patient portrayal. Items were revised twice, based on experiences during OSCEs. The final instrument contains 14 criteria for acting (i.e. adequate verbal and non-verbal expression) and standardization (i.e. verbatim delivery of the first sentence). All partners used the instrument during a high-stakes OSCE. SPs and trainers were introduced to the instrument. The tool was used in training (more than 100 observations) and during the exam (more than 250 observations). Outcome High quality of SPs’ patient portrayal during the exam was documented. More than 90% of SP performances were rated to be completely correct or sufficient. An increase in quality of performance between training and exam was noted. For example, the rate of completely correct reaction in medical tests increased from 88% to 95%. Together with 4% of sufficient performances these 95% add up to 99% of the reactions in medical tests meeting the standards of the exam. SP educators using the instrument reported an augmentation of SPs’ performance induced by the use of the instrument. Disadvantages mentioned were the high concentration needed to observe all criteria and the cumbersome handling of the paper-based forms. Discussion We were able to document a very high quality of SP performance in our exam. The data also indicates that our training is effective. We believe that the high concentration needed using the instrument is well invested, considering the observed enhancement of performance. The development of an iPad-based application for the form is planned to address the cumbersome handling of the paper.

Quality assurance of simulated patient feedback in communication training for fourth-year medical students

Introduction In our program, simulated patients (SPs) give feedback to medical students in the course of communication skills training. To ensure effective training, quality control of the SPs’ feedback should be implemented. At other institutions, medical students evaluate the SPs’ feedback for quality control (Bouter et al., 2012). Thinking about implementing quality control for SPs’ feedback in our program, we wondered whether the evaluation by students would result in the same scores as evaluation by experts. Methods Consultations simulated by 4th-year medical students with SPs were video taped including the SP’s feedback to the students (n=85). At the end of the training sessions students rated the SPs’ performance using a rating instrument called Bernese Assessment for Role-play and Feedback (BARF) containing 11 items concerning feedback quality. Additionally the videos were evaluated by 3 trained experts using the BARF. Results The experts showed a high interrater agreement when rating identical feedbacks (ICCunjust=0.953). Comparing the rating of students and experts, high agreement was found with regard to the following items: 1. The SP invited the student to reflect on the consultation first, Amin (= minimal agreement) 97% 2. The SP asked the student what he/she liked about the consultation, Amin = 88%. 3. The SP started with positive feedback, Amin = 91%. 4. The SP was comparing the student with other students, Amin = 92%. In contrast the following items showed differences between the rating of experts and students: 1. The SP used precise situations for feedback, Amax (=maximal agreement) 55%, Students rated 67 of SPs’ feedbacks to be perfect with regard to this item (highest rating on a 5 point Likert scale), while only 29 feedbacks were rated this way by the experts. 2. The SP gave precise suggestions for improvement, Amax 75%, 62 of SPs’ feedbacks obtained the highest rating from students, while only 44 of SPs’ feedbacks achieved the highest rating in the view of the experts. 3. The SP speaks about his/her role in the third person, Amax 60%. Students rated 77 feedbacks with the highest score, while experts judged only 43 feedbacks this way. Conclusion Although evaluation by the students was in agreement with that of experts concerning some items, students rated the SPs’ feedback more often with the optimal score than experts did. Moreover it seems difficult for students to notice when SPs talk about the role in the first instead of the third person. Since precision and talking about the role in the third person are important quality criteria of feedback, this result should be taken into account when thinking about students’ evaluation of SPs’ feedback for quality control. Bouter, S., E. van Weel-Baumgarten, and S. Bolhuis. 2012. Construction and Validation of the Nijmegen Evaluation of the Simulated Patient (NESP): Assessing Simulated Patients’ Ability to Role-Play and Provide Feedback to Students. Academic Medicine: Journal of the Association of American Medical Colleges

Preliminary Study on Finite Element Simulation for Optimizing Acetabulum Reorientation after Periacetabular Osteotomy

Periacetabular osteotomy (PAO) is an effective approach for surgical treatment of hip dysplasia. The aim of PAO is to increase acetabular coverage of the femoral head and to reduce contact pressures by reorienting the acetabulum fragment after PAO. The success of PAO significantly depends on the surgeon’s experience. Previously, we have developed a computer-assisted planning and navigation system for PAO, which allows for not only quantifying the 3D hip morphology for a computer-assisted diagnosis of hip dysplasia but also a virtual PAO surgical planning and simulation. In this paper, based on this previously developed PAO planning and navigation system, we developed a 3D finite element (FE) model to investigate the optimal acetabulum reorientation after PAO. Our experimental results showed that an optimal position of the acetabulum can be achieved that maximizes contact area and at the same time minimizes peak contact pressure in pelvic and femoral cartilages. In conclusion, our computer-assisted planning and navigation system with FE modeling can be a promising tool to determine the optimal PAO planning strategy.

Extratropical fronts in the lower troposphere-global perspectives obtained from two automated methods

In this study two commonly used automated methods to detect atmospheric fronts in the lower troposphere are compared in various synoptic situations. The first method is a thermal approach, relying on the gradient of equivalent potential temperature (TH), while the second method is based on temporal changes in the 10 m wind (WND). For a comprehensive objective comparison of the outputs of these methods of frontal identification, both schemes are firstly applied to an idealised strong baroclinic wave simulation in the absence of topography. Then, two case-studies (one in the Northern Hemisphere (NH) and one in the Southern Hemisphere (SH)) were conducted to contrast fronts detected by the methods. Finally, we obtain global winter and summer frontal occurrence climatologies (derived from ERA-Interim for 1979–2012) and compare the structure of these. TH is able to identify cold and warm fronts in strong baroclinic cases that are in good agreement with manual analyses. WND is particularly suited for the detection of strongly elongated, meridionally oriented moving fronts, but has very limited ability to identify zonally oriented warm fronts. We note that the areas of the main TH frontal activity are shifted equatorwards compared to the WND patterns and are located upstream of regions of main WND front activity. The number of WND fronts in the NH shows more interseasonal variations than TH fronts, decreasing by more than 50% from winter to summer. In the SH there is a weaker seasonal variation of the number of observed WND fronts, however TH front activity reduces from summer (DJF) to winter (JJA). The main motivation is to give an overview of the performance of these methods, such that researchers can choose the appropriate one for their particular interest.

Faunal analysis and Mg/Ca records of planktic foraminifera in sediment core SO189/2_039KL

Climate phenomena like the monsoon system, El Niño Southern Oscillation (ENSO) and the Indian Ocean Dipole (IOD) are interconnected via various feedback mechanisms and control the climate of the Indian Ocean and its surrounding continents on various timescales. The eastern tropical Indian Ocean is a key area for the interplay of these phenomena and for reconstructing their past changes and forcing mechanisms. Here we present records of upper ocean thermal gradient, thermocline temperatures (TT) and relative abundances of planktic foraminifera in core SO 189-39KL taken off western Sumatra (0°47.400' S, 99°54.510' E) for the last 8 ka that we use as proxies for changes in upper ocean structure. The records suggest a deeper thermocline between 8 ka and ca 3 ka compared to the late Holocene. We find a shoaling of the thermocline after 3 ka, most likely indicating an increased occurrence of upwelling during the late Holocene compared to the mid-Holocene which might represent changes in the IOD-like mean state of the Indian Ocean with a more negative IOD-like mean state during the mid-Holocene and a more positive IOD-like mean state during the past 3 ka. This interpretation is supported by a transient Holocene climate model simulation in which an IOD-like mode is identified that involves an insolation-forced long-term trend of increasing anomalous surface easterlies over the equatorial eastern Indian Ocean.

Analysis of jitter influence in fast frequency measurements

This paper presents a theoretical analysis of possible jitter impact in application of numeric criterion for fastmeasurement of frequency by coincidence principle. The primary goal is the generation of a signal containing a known amount of each jitter components. This signal was used for testing signals with regular pulse trains. Initially, jitter components are analyzed and modeled individually. Next, sequences for combining different kinds of jitter are modeled, simulated and evaluated. Jitter model simulation in Matlab is utilized to show the independence of frequencymeasurement results on the total jitter present in the reference and desired pulse trains independently. A good agreement between previously introduced theory of fastmeasurement of frequency and simulation in jitter presence is verified; these results allows to engineers use the numeric criterion for fastmeasurement of frequency in spite to interactions among jitter components in various applications for frequency domain sensors.

Maximum Likelihood Estimation of Modal Parameters in Structures Using the Expectation Maximization Algorithm

This paper presents a time-domain stochastic system identification method based on maximum likelihood estimation (MLE) with the expectation maximization (EM) algorithm. The effectiveness of this structural identification method is evaluated through numerical simulation in the context of the ASCE benchmark problem on structural health monitoring. The benchmark structure is a four-story, two-bay by two-bay steel-frame scale model structure built in the Earthquake Engineering Research Laboratory at the University of British Columbia, Canada. This paper focuses on Phase I of the analytical benchmark studies. A MATLAB-based finite element analysis code obtained from the IASC-ASCE SHM Task Group web site is used to calculate the dynamic response of the prototype structure. A number of 100 simulations have been made using this MATLAB-based finite element analysis code in order to evaluate the proposed identification method. There are several techniques to realize system identification. In this work, stochastic subspace identification (SSI)method has been used for comparison. SSI identification method is a well known method and computes accurate estimates of the modal parameters. The principles of the SSI identification method has been introduced in the paper and next the proposed MLE with EM algorithm has been explained in detail. The advantages of the proposed structural identification method can be summarized as follows: (i) the method is based on maximum likelihood, that implies minimum variance estimates; (ii) EM is a computational simpler estimation procedure than other optimization algorithms; (iii) estimate more parameters than SSI, and these estimates are accurate. On the contrary, the main disadvantages of the method are: (i) EM algorithm is an iterative procedure and it consumes time until convergence is reached; and (ii) this method needs starting values for the parameters. Modal parameters (eigenfrequencies, damping ratios and mode shapes) of the benchmark structure have been estimated using both the SSI method and the proposed MLE + EM method. The numerical results show that the proposed method identifies eigenfrequencies, damping ratios and mode shapes reasonably well even in the presence of 10% measurement noises. These modal parameters are more accurate than the SSI estimated modal parameters.

Calculus of the uncertainty in acoustic field measurements: comparative study between the uncertainty propagation method and the distribution propagation method

The new Spanish Regulation in Building Acoustic establishes values and limits for the different acoustic magnitudes whose fulfillment can be verify by means field measurements. In this sense, an essential aspect of a field measurement is to give the measured magnitude and the uncertainty associated to such a magnitude. In the calculus of the uncertainty it is very usual to follow the uncertainty propagation method as described in the Guide to the expression of Uncertainty in Measurements (GUM). Other option is the numerical calculus based on the distribution propagation method by means of Monte Carlo simulation. In fact, at this stage, it is possible to find several publications developing this last method by using different software programs. In the present work, we used Excel for the Monte Carlo simulation for the calculus of the uncertainty associated to the different magnitudes derived from the field measurements following ISO 140-4, 140-5 and 140-7. We compare the results with the ones obtained by the uncertainty propagation method. Although both methods give similar values, some small differences have been observed. Some arguments to explain such differences are the asymmetry of the probability distributions associated to the entry magnitudes,the overestimation of the uncertainty following the GUM

Latent hardening size effect in small-scale plasticity

We aim at understanding the multislip behaviour of metals subject to irreversible deformations at small-scales. By focusing on the simple shear of a constrained single-crystal strip, we show that discrete Dislocation Dynamics (DD) simulations predict a strong latent hardening size effect, with smaller being stronger in the range [1.5 µm, 6 µm] for the strip height. We attempt to represent the DD pseudo-experimental results by developing a flow theory of Strain Gradient Crystal Plasticity (SGCP), involving both energetic and dissipative higher-order terms and, as a main novelty, a strain gradient extension of the conventional latent hardening. In order to discuss the capability of the SGCP theory proposed, we implement it into a Finite Element (FE) code and set its material parameters on the basis of the DD results. The SGCP FE code is specifically developed for the boundary value problem under study so that we can implement a fully implicit (Backward Euler) consistent algorithm. Special emphasis is placed on the discussion of the role of the material length scales involved in the SGCP model, from both the mechanical and numerical points of view.

High fidelity simulations of failure in fiber-reinforced composites

Los ensayos virtuales de materiales compuestos han aparecido como un nuevo concepto dentro de la industria aeroespacial, y disponen de un vasto potencial para reducir los enormes costes de certificación y desarrollo asociados con las tediosas campañas experimentales, que incluyen un gran número de paneles, subcomponentes y componentes. El objetivo de los ensayos virtuales es sustituir algunos ensayos por simulaciones computacionales con alta fidelidad. Esta tesis es una contribución a la aproximación multiescala desarrollada en el Instituto IMDEA Materiales para predecir el comportamiento mecánico de un laminado de material compuesto dadas las propiedades de la lámina y la intercara. La mecánica de daño continuo (CDM) formula el daño intralaminar a nivel constitutivo de material. El modelo de daño intralaminar se combina con elementos cohesivos para representar daño interlaminar. Se desarrolló e implementó un modelo de daño continuo, y se aplicó a configuraciones simples de ensayos en laminados: impactos de baja y alta velocidad, ensayos de tracción, tests a cortadura. El análisis del método y la correlación con experimentos sugiere que los métodos son razonablemente adecuados para los test de impacto, pero insuficientes para el resto de ensayos. Para superar estas limitaciones de CDM, se ha mejorado la aproximación discreta de elementos finitos enriqueciendo la cinemática para incluir discontinuidades embebidas: el método extendido de los elementos finitos (X-FEM). Se adaptó X-FEM para un esquema explícito de integración temporal. El método es capaz de representar cualitativamente los mecanismos de fallo detallados en laminados. Sin embargo, los resultados muestran inconsistencias en la formulación que producen resultados cuantitativos erróneos. Por último, se ha revisado el método tradicional de X-FEM, y se ha desarrollado un nuevo método para superar sus limitaciones: el método cohesivo X-FEM estable. Las propiedades del nuevo método se estudiaron en detalle, y se concluyó que el método es robusto para implementación en códigos explícitos dinámicos escalables, resultando una nueva herramienta útil para la simulación de daño en composites. Virtual testing of composite materials has emerged as a new concept within the aerospace industry. It presents a very large potential to reduce the large certification costs and the long development times associated with the experimental campaigns, involving the testing of a large number of panels, sub-components and components. The aim of virtual testing is to replace some experimental tests by high-fidelity numerical simulations. This work is a contribution to the multiscale approach developed in Institute IMDEA Materials to predict the mechanical behavior of a composite laminate from the properties of the ply and the interply. Continuum Damage Mechanics (CDM) formulates intraply damage at the the material constitutive level. Intraply CDM is combined with cohesive elements to model interply damage. A CDM model was developed, implemented, and applied to simple mechanical tests of laminates: low and high velocity impact, tension of coupons, and shear deformation. The analysis of the results and the comparison with experiments indicated that the performance was reasonably good for the impact tests, but insuficient in the other cases. To overcome the limitations of CDM, the kinematics of the discrete finite element approximation was enhanced to include mesh embedded discontinuities, the eXtended Finite Element Method (X-FEM). The X-FEM was adapted to an explicit time integration scheme and was able to reproduce qualitatively the physical failure mechanisms in a composite laminate. However, the results revealed an inconsistency in the formulation that leads to erroneous quantitative results. Finally, the traditional X-FEM was reviewed, and a new method was developed to overcome its limitations, the stable cohesive X-FEM. The properties of the new method were studied in detail, and it was demonstrated that the new method was robust and can be implemented in a explicit finite element formulation, providing a new tool for damage simulation in composite materials.

Modelling a biomass supply chain through discrete-event simulation

The organizational structure of the companies in the biomass energy sector, regarding the supply chain management services, can be greatly improved through the use of software decision support tools. These tools should be able to provide real-time alternative scenarios when deviations from the initial production plans are observed. To make this possible it is necessary to have representative production chain process models where several scenarios and solutions can be evaluated accurately. Due to its nature, this type of process is more adequately represented by means of event-based models. In particular, this work presents the modelling of a typical biomass production chain using the computing platform SIMEVENTS. Throughout the article details about the conceptual model, as well as simulation results, are provided