Enhancing paramedics procedural skills using a cadaveric model

Background Paramedic education has evolved in recent times from vocational post-employment to tertiary pre-employment supplemented by clinical placement. Simulation is advocated as a means of transferring learned skills to clinical practice. Sole reliance of simulation learning using mannequin-based models may not be sufficient to prepare students for variance in human anatomy. In 2012, we trialled the use of fresh frozen human cadavers to supplement undergraduate paramedic procedural skill training. The purpose of this study is to evaluate whether cadaveric training is an effective adjunct to mannequin simulation and clinical placement. Methods A multi-method approach was adopted. The first step involved a Delphi methodology to formulate and validate the evaluation instrument. The instrument comprised of knowledge-based MCQs, Likert for self-evaluation of procedural skills and behaviours, and open answer. The second step involved a pre-post evaluation of the 2013 cadaveric training. Results One hundred and fourteen students attended the workshop and 96 evaluations were included in the analysis, representing a return rate of 84%. There was statistically significant improved anatomical knowledge after the workshop. Students' self-rated confidence in performing procedural skills on real patients improved significantly after the workshop: inserting laryngeal mask (MD 0.667), oropharyngeal (MD 0.198) and nasopharyngeal (MD 0.600) airways, performing Bag-Valve-Mask (MD 0.379), double (MD 0.344) and triple (MD 0.326,) airway manoeuvre, doing 12-lead electrocardiography (MD 0.729), using McGrath(R) laryngoscope (MD 0.726), using McGrath(R) forceps to remove foreign body (MD 0.632), attempting thoracocentesis (MD 1.240), and putting on a traction splint (MD 0.865). The students commented that the workshop provided context to their theoretical knowledge and that they gained an appreciation of the differences in normal tissue variation. Following engagement in/ completion of the workshop, students were more aware of their own clinical and non-clinical competencies. Conclusions The paramedic profession has evolved beyond patient transport with minimal intervention to providing comprehensive both emergency and non-emergency medical care. With limited availability of clinical placements for undergraduate paramedic training, there is an increasing demand on universities to provide suitable alternatives. Our findings suggested that cadaveric training using fresh frozen cadavers provides an effective adjunct to simulated learning and clinical placements.

Back to normal: A retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia

Background Currently, care providers and policy-makers internationally are working to promote normal birth. In Australia, such initiatives are being implemented without any evidence of the prevalence or determinants of normal birth as a multidimensional construct. This study aimed to better understand the determinants of normal birth (defined as without induction of labour, epidural/spinal/general anaesthesia, forceps/vacuum, caesarean birth, or episiotomy) using secondary analyses of data from a population survey of women in Queensland, Australia. Methods Women who birthed in Queensland during a two-week period in 2009 were mailed a survey approximately three months after birth. Women (n=772) provided retrospective data on their pregnancy, labour and birth preferences and experiences, socio-demographic characteristics, and reproductive history. A series of logistic regressions were conducted to determine factors associated with having labour, having a vaginal birth, and having a normal birth. Findings Overall, 81.9% of women had labour, 66.4% had a vaginal birth, and 29.6% had a normal birth. After adjusting for other significant factors, women had significantly higher odds of having labour if they birthed in a public hospital and had a pre-existing preference for a vaginal birth. Of women who had labour, 80.8% had a vaginal birth. Women who had labour had significantly higher odds of having a vaginal birth if they attended antenatal classes, did not have continuous fetal monitoring, felt able to ‘take their time’ in labour, and had a pre-existing preference for a vaginal birth. Of women who had a vaginal birth, 44.7% had a normal birth. Women who had a vaginal birth had significantly higher odds of having a normal birth if they birthed in a public hospital, birthed outside regular business hours, had mobility in labour, did not have continuous fetal monitoring, and were non-supine during birth. Conclusions These findings provide a strong foundation on which to base resources aimed at increasing informed decision-making for maternity care consumers, providers, and policy-makers alike. Research to evaluate the impact of modifying key clinical practices (e.g., supporting women׳s mobility during labour, facilitating non-supine positioning during birth) on the likelihood of a normal birth is an important next step.

Genetic influences on brain asymmetry: A DTI study of 374 twins and siblings

Brain asymmetry, or the structural and functional specialization of each brain hemisphere, has fascinated neuroscientists for over a century. Even so, genetic and environmental factors that influence brain asymmetry are largely unknown. Diffusion tensor imaging (DTI) now allows asymmetry to be studied at a microscopic scale by examining differences in fiber characteristics across hemispheres rather than differences in structure shapes and volumes. Here we analyzed 4. Tesla DTI scans from 374 healthy adults, including 60 monozygotic twin pairs, 45 same-sex dizygotic pairs, and 164 mixed-sex DZ twins and their siblings; mean age: 24.4 years ± 1.9 SD). All DTI scans were nonlinearly aligned to a geometrically-symmetric, population-based image template. We computed voxel-wise maps of significant asymmetries (left/right differences) for common diffusion measures that reflect fiber integrity (fractional and geodesic anisotropy; FA, GA and mean diffusivity, MD). In quantitative genetic models computed from all same-sex twin pairs (N=210 subjects), genetic factors accounted for 33% of the variance in asymmetry for the inferior fronto-occipital fasciculus, 37% for the anterior thalamic radiation, and 20% for the forceps major and uncinate fasciculus (all L > R). Shared environmental factors accounted for around 15% of the variance in asymmetry for the cortico-spinal tract (R > L) and about 10% for the forceps minor (L > R). Sex differences in asymmetry (men > women) were significant, and were greatest in regions with prominent FA asymmetries. These maps identify heritable DTI-derived features, and may empower genome-wide searches for genetic polymorphisms that influence brain asymmetry.

Private health care coverage and increased risk of obstetric intervention

Background: When clinically indicated, common obstetric interventions can greatly improve maternal and neonatal outcomes. However, variation in intervention rates suggests that obstetric practice may not be solely driven by case criteria. Methods: Differences in obstetric intervention rates by private and public status in Ireland were examined using nationally representative hospital discharge data. A retrospective cohort study was performed on childbirth hospitalisations occurring between 2005 and 2010. Multivariate logistic regression analysis with correction for the relative risk was conducted to determine the risk of obstetric intervention (caesarean delivery, operative vaginal delivery, induction of labour or episiotomy) by private or public status while adjusting for obstetric risk factors. Results: 403,642 childbirth hospitalisations were reviewed; approximately one-third of maternities (30.2%) were booked privately. After controlling for relevant obstetric risk factors, women with private coverage were more likely to have an elective caesarean delivery (RR: 1.48; 95% CI: 1.45-1.51), an emergency caesarean delivery (RR: 1.13; 95% CI: 1.12-1.16) and an operative vaginal delivery (RR: 1.25; 95% CI: 1.22-1.27). Compared to women with public coverage who had a vaginal delivery, women with private coverage were 40% more likely to have an episiotomy (RR: 1.40; 95% CI: 1.38-1.43). Conclusions: Irrespective of obstetric risk factors, women who opted for private maternity care were significantly more likely to have an obstetric intervention. To better understand both clinical and non-clinical dynamics, future studies of examining health care coverage status and obstetric intervention would ideally apply mixed-method techniques.

The impact of first pregnancy and delivery on pelvic floor dysfunction

Background: The first childbirth has the greatest impact on a woman’s pelvic floor when major changes occur. The aim of this study was to comprehensively describe pelvic floor dysfunction (PFD) in young nulliparous women, and its correlation with postnatal pathology. Methods: A prospective study was performed at Cork University Maternity Hospital, Ireland. Initially 1484 nulliparous women completed the validated Australian Pelvic Floor Questionnaire at 15 weeks’ gestation and repeatedly at one year postnatally (N=872). In the second phase, at least one year postnatally, 202 participants without subsequent pregnancies attended the clinical follow up which included: pelvic organ prolapse quantification, a 3D-Transperineal ultrasound scan and collagen level assessment. Results: A high pre-pregnancy prevalence of various types of PFD was detected, which in the majority of cases persisted postnatally and included multiple types of PFD. The first birth had a negative impact on severity of pre-pregnancy symptoms in <15% of cases. Apart from prolapse, vaginal delivery, including instrumental delivery did not increase the risk of PFD symptoms, where as Caesarean section was protective for all types of PFD. The first birth had a bigger impact on pre-existing symptoms of overactive bladder compared to stress urinary incontinence. Pelvic organ prolapse is extremely prevalent in young primiparous women, however usually it is low grade and asymptomatic. Congenital factors and high collagen type III levels play an important role in the aetiology of pelvic organs prolapse. Levator ani trauma is present in one in three women after the first pregnancy and delivery. Conclusion: The main damage to the pelvic floor most likely occurs due to an undiagnosed congenital intrinsic weakness of the pelvic floor structures. PFD is highly associated with first childbirth, however it seems that pregnancy and delivery are contributing factors only which unmask the congenital intrinsic weakness of the pelvic floor support.

Effects of chronic mild traumatic brain injury on white matter integrity in iraq and afghanistan war veterans

Mild traumatic brain injury (TBI) is a common source of morbidity from the wars in Iraq and Afghanistan. With no overt lesions on structural MRI, diagnosis of chronic mild TBI in military veterans relies on obtaining an accurate history and assessment of behavioral symptoms that are also associated with frequent comorbid disorders, particularly posttraumatic stress disorder (PTSD) and depression. Military veterans from Iraq and Afghanistan with mild TBI (n = 30) with comorbid PTSD and depression and non-TBI participants from primary (n = 42) and confirmatory (n = 28) control groups were assessed with high angular resolution diffusion imaging (HARDI). White matter-specific registration followed by whole-brain voxelwise analysis of crossing fibers provided separate partial volume fractions reflecting the integrity of primary fibers and secondary (crossing) fibers. Loss of white matter integrity in primary fibers (P < 0.05; corrected) was associated with chronic mild TBI in a widely distributed pattern of major fiber bundles and smaller peripheral tracts including the corpus callosum (genu, body, and splenium), forceps minor, forceps major, superior and posterior corona radiata, internal capsule, superior longitudinal fasciculus, and others. Distributed loss of white matter integrity correlated with duration of loss of consciousness and most notably with "feeling dazed or confused," but not diagnosis of PTSD or depressive symptoms. This widespread spatial extent of white matter damage has typically been reported in moderate to severe TBI. The diffuse loss of white matter integrity appears consistent with systemic mechanisms of damage shared by blast- and impact-related mild TBI that involves a cascade of inflammatory and neurochemical events. © 2012 Wiley Periodicals, Inc.

White matter fractional anisotrophy predicts balance performance in older adults

Aging is characterized by brain structural changes that may compromise motor functions. In the context of postural control, white matter integrity is crucial for the efficient transfer of visual, proprioceptive and vestibular feedback in the brain. To determine the role of age-related white matter decline as a function of the sensory feedback necessary to correct posture, we acquired diffusion weighted images in young and old subjects. A force platform was used to measure changes in body posture under conditions of compromised proprioceptive and/or visual feedback. In the young group, no significant brain structure-balance relations were found. In the elderly however, the integrity of a cluster in the frontal forceps explained 21% of the variance in postural control when proprioceptive information was compromised. Additionally, when only the vestibular system supplied reliable information, the occipital forceps was the best predictor of balance performance (42%). Age-related white matter decline may thus be predictive of balance performance in the elderly when sensory systems start to degrade.

In-the-Bag Intraocular Lens Placement via Secondary Capsulorhexis with Radiofrequency Diathermy in Pediatric Aphakic Eyes

Pediatric ophthalmologists increasingly recognize that the ideal site for intraocular lens (IOL) implantation is in the bag for aphakic eyes, but it is always very difficult via conventional technique. We conducted a prospective case series study to investigate the success rate and clinical outcomes of capsular bag reestablishment and in-the-bag IOL implantation via secondary capsulorhexis with radiofrequency diathermy (RFD) in pediatric aphakic eyes, in which twenty-two consecutive aphakic pediatric patients (43 aphakic eyes) enrolled in the Childhood Cataract Program of the Chinese Ministry of Health were included. The included children underwent either our novel technique for secondary IOL implantation (with RFD) or the conventional technique (with a bent needle or forceps), depending on the type of preoperative proliferative capsular bag present. In total, secondary capsulorhexis with RFD was successfully applied in 32 eyes (32/43, 74.4%, age 5.6±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved in 30 eyes (30/43, 70.0%), but in the remaining 2 eyes (2/32, 6.2%) the IOLs were implanted in the sulcus with a capsular bag that was too small. Secondary capsulorhexis with conventional technique was applied in the other 11 eyes (11/43, 25.6%, age 6.9±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved only in 3 eyes(3/43, 7.0%), and the IOLs were implanted in the sulcus in the remaining 8 eyes. A doughnut-like proliferative capsular bag with an extensive Soemmering ring (32/43, 74.4%) was the main success factor for secondary capsulorhexis with RFD, and a sufficient capsular bag size (33/43, 76.7%) was an additional factor in successful in-the-bag IOL implantation. In conclusion, RFD secondary capsulorhexis technique has 70% success rate in the capsular bag reestablishment and in-the-bag IOL implantation in pediatric aphakic eyes, particularly effective in cases with a doughnut-like, extensively proliferative Soemmering ring. © 2013 Luo et al.

L'effet de l'entrainement avec le ballon d'exercice pendant la grossesse sur l'accouchement.

Résumé Introduction : L’entrainement avec le ballon d’exercice pendant la grossesse a des effets positifs sur le déroulement de l’accouchement. Le but de l’étude était d’identifier si une association existe entre le volume d’entrainement avec le ballon d’exercice durant la grossesse en milieu naturel sur l’issue du déroulement de l’accouchement, soit la durée des phases 1 (dilatation/phase active) et 2 (expulsion), ainsi que l’usage de la péridurale et de la césarienne. Méthode: Cette étude quasi-expérimentale a été menée auprès d'un échantillon de convenance composée de 32 femmes enceintes qui ont pris part entre un et 28 cours d'exercice supervisé durant la grossesse (programme Ballon Forme), avec la possibilité d'effectuer des exercices supplémentaires à la maison avec le ballon d’exercice. Un questionnaire et un journal de bord ont été remplis par les participantes, avec l'aide d'une infirmière de l’hôpital pour les données médicales. Résultats: Un volume d’entrainement élevé, incluant l’entraînement sous forme de cours et à domicile, a été significativement associé à une durée plus courte d’accouchement, que ce soit pour le temps total de l’accouchement (r = -0,408, p = 0,031) ou pour les deux phases spécifiques de l’accouchement [la phase 1: r = -0,372 ; p = 0,043 et la phase 2: r = -0,415, p = 0,028]. Un volume d’entrainement élevé a aussi été lié à une réduction de la deuxième phase chez les femmes qui donnaient naissance pour la première fois. La durée totale des exercices exécutés lors des cours a été significativement associée à cette réduction comparativement aux exercices à la maison. Aucun effet indésirable n'a été observé avec le volume d’entrainement élevé sur les paramètres de l’accouchement et la santé du bébé (Apgar et poids du bébé à la naissance). En fait, un nombre très faible de césarienne (6%), de recours à la péridurale (47%) et d'extraction instrumentale (forceps ou ventouse: 13%) a été observé dans notre échantillon de femmes. Conclusion: La pratique du ballon d’exercice est une avenue prometteuse pour les femmes enceintes et un niveau élevé d’entraînement est associé à un accouchement plus rapide et sans complications pour le bébé. L’implantation de ce programme pourrait éventuellement contribuer à réduire considérablement les coûts de santé au Québec en favorisant l’accouchement naturel. Des interventions et des recherches ultérieures devront considérer et examiner cette modalité spécifique d’entrainement pour les femmes enceintes.

Caracterización de los pacientes con hemorragia de vías digestivas altas no varicosa atendidos en el Hospital Universitario de la Samaritana, Cundinamarca

La hemorragia de vías digestivas altas (HVDA) es una emergencia frecuente. La etiología más común es la úlcera péptica. La restauración del volumen intravascular y la presión arterial son la prioridad del manejo. La endoscopia (EGD) debe realizarse luego de la reanimación inicial y lograda la estabilización hemodinámica, tratar la lesión subyacente mediante hemostasia. Se realiza un estudio en un hospital de referencia de tercer nivel, Cundinamarca, Colombia Materiales y métodos: Estudio descriptivo retrospectivo, datos obtenidos de la historia clínica electrónica de pacientes adultos que consultaron por urgencias en el Hospital Universitario de la Samaritana (HUS) por HVDA, diagnosticada por hematemesis, melenas, hematoquezia y/o anemia; a quienes se les realizó EGD durante abril del 2010 - abril del 2011. Resultados: Se atendieron 385 pacientes en el período de estudio, 100 fueron excluidos debido a hemorragia secundaria a várices esofágicas, historia incompleta y hemorragia digestiva baja, para un total de 285 pacientes analizados. El 69.1% eran mayores de 60 años. El 73.3% presentaba hipertensión arterial, el 55.1% reportaba ingesta de Anti-inflamatorios no esteroideos (AINES) y Aspirina (ASA). El 19.6% reportaba episodios de sangrado previos y 17.9% presentó inestabilidad hemodinámica. Sesenta y tres pacientes (22,1%) requirieron hemostasia endoscópica, treinta y dos (11.2%) presentaron resangrado. La mortalidad reportada fue del 13.1%, del cual 55.3% correspondía a hombres. Discusión: La mayoría de la población atendida en el HUS por HVDA son adultos mayores de 60 años. La úlcera péptica, continúa siendo el diagnóstico más frecuente asociado al uso de AINES y ASA.

DNA transfer by examination tools--a risk for forensic casework?

The introduction of profiling systems with increased sensitivity has led to a concurrent increase in the risk of detecting contaminating DNA in forensic casework. To evaluate the contamination risk of tools used during exhibit examination we have assessed the occurrence and level of DNA transferred between mock casework exhibits, comprised of cotton or glass substrates, and high-risk vectors (scissors, forceps, and gloves). The subsequent impact of such transfer in the profiling of a target sample was also investigated. Dried blood or touch DNA, deposited on the primary substrate, was transferred via the vector to the secondary substrate, which was either DNA-free or contained a target sample (dried blood or touch DNA). Pairwise combinations of both heavy and light contact were applied by each vector in order to simulate various levels of contamination. The transfer of dried blood to DNA-free cotton was observed for all vectors and transfer scenarios, with transfer substantially lower when glass was the substrate. Overall touch DNA transferred less efficiently, with significantly lower transfer rates than blood when transferred to DNA-free cotton; the greatest transfer of touch DNA occurred between cotton and glass substrates. In the presence of a target sample, the detectability of transferred DNA decreased due to the presence of background DNA. Transfer had no impact on the detectability of the target profile, however, in casework scenarios where the suspect profiles are not known, profile interpretation becomes complicated by the addition of contaminating alleles and the probative value of the evidence may be affected. The results of this study reiterate the need for examiners to adhere to stringent laboratory cleaning protocols, particularly in the interest of contamination minimisation, and to reduce the handling of items to prevent intra-item transfer.

Residual DNA on examination tools following use

Recent studies observing the transfer of DNA via examination tools used within forensic laboratories (scissors, forceps and gloves) have highlighted the contamination risk of such implements if protocols following their use and replacement are not adhered to. Whilst these previous studies focus primarily on the transfer of biological substances to a substrate via high-risk vectors, this investigation considers the proportion of DNA that remains on the high-risk vectors following contact with the substrate. Dried blood or touch DNA was deposited on cotton or glass substrates to create mock exhibits. Following primary contact with the deposit, the vector similarly contacted a secondary DNA-free substrate. Combinations of singular and multiple contacts were applied. Immediately following contact with the secondary substrate, the vector was sampled in order to determine the proportion of DNA-containing material remaining on the vectors following contacts. Residual DNA was detected on the vectors in most instances, with the amount retained influenced by the vector, substrates and biological substance applied. The results demonstrate the potential for inter- and intra-exhibit contamination through further contacts.

Evaluation of the Integrity of Horse Hoof Dermal and Epidermal Tissues Collected by Dorsal Transmural Access

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Laparoscopy hepatic biopsy through cauterization

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Avaliação de método digital para análise do índice funcional do ciático em ratos

This work aimed to study the reproduction and description of technique for digital sampling images during rats gait and determination of the sciatic functional index (SFI), through a glass walkway to obtain shoots with a digital camera. After controlled injury by strangulation of sciatic nerve, with 3mm of length, during 30 seconds, using hemostatic forceps, a group of 32 rats was performed 24 hours before the lesion which served as control and 24 hours, 7, 14 and 21 days after injury. The tests consisted in the filming and shooting each animal in order to observe the view from below (by a mirror to 45 degrees) and subsequently analyzed using the IMAGE-J program. Measures were taken from the lengths of the legs (right and left), and the distance between the ankle. In the analysis of IFC, values close to zero (0) suggest that the function of the sciatic nerve is still preserved and values coming from "less one hundred" (-100) indicate total loss of function. It was verified in this study that 24 hours before surgery the average SFI was -7.07 +/- 7.88 and 24 hours after injury these values rose to an average of -77.95 +/- 13.81, being about 10 times larger, where 78% of the animals showed 60 to 100% of functional loss in motor activity, demonstrated by the gradual recovery over the days analyzed, confirming the accuracy and effectiveness of the proposed methodology. These results suggest that studies can be conducted to simplify and reduce costs using the technique for digital images of footprints during rats gait in the laboratory.