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.

Long-term outcomes following Medtronic Open Pivot valved conduit

Aortic root replacement is a complex procedure, though subsequent modifications of the original Bentall procedure have made surgery more reproducible. The study aim was to examine the outcomes of a modified Bentall procedure, using the Medtronic Open PivotTM valved conduit. Whilst short-term data on the conduit and long-term data on the valve itself are available, little is known of the long-term results with the valved conduit. Patients undergoing aortic root replacement between February 1999 and February 2010, using the Medtronic Open Pivot valved conduit were identified from the prospectively collected Cardiothoracic Register at The Prince Charles Hospital, Brisbane, Australia. All patients were followed up echocardiographically and clinically. The primary end-point was death, and a Cox proportional model was used to identify factors associated.with survival. Secondary end-points were valve-related morbidity (as defined by STS guidelines) and postoperative morbidity. Predictors of morbidity were identified using logistic regression. A total of 246 patients (mean age 50 years) was included in the study. The overall mortality was 12%, with actuarial 10-year survival 79% and a 10-year estimate of valve-related death of 0.04 (95% CI: 0.004, 0.07). Preoperative myocardial infarction (p = 0.004, HR 4.74), urgency of operation (p = 0.038, HR 2.8) and 10% incremental decreases in ejection fraction (p = 0.046, HR 0.69) were predictive of mortality. Survival was also affected by the valve gradients, with a unit increase in peak gradient reducing mortality (p = 0.021, HR 0.93). Valve-related morbidity occurred in 11 patients. Urgent surgery (p <0.001, OR 4.12), aortic dissection (p = 0.015, OR 3.35), calcific aortic stenosis (p = 0.016, OR 2.35) and Marfan syndrome (p 0.009, OR 3.75) were predictive of postoperative morbidity. The reoperation rate was 1.2%. The Medtronic Open Pivot valved conduit is a safe and durable option for aortic root replacement, and is associated with low morbidity and 10-year survival of 79%. However, further studies are required to determine the effect of valve gradient on survival.

Two stage Gifford-McMahon cycle cryorefrigerator operating at 20 K

A two stage Gifford-McMahon cycle cryorefrigerator operating at 20 K is described. This refrigerator uses a very simple ‘spool valve’ and a modified indigenous compressor to compress helium gas. This cryorefrigerator reaches a lowest temperature of 15.5 K; it takes ≈ 50 min to reach 20 K and the cooling capacity is ≈ 2.5 W at 25 K. The cool-down characteristics and load characteristics are presented in graphical form. The effect of changing the operating pressure ratio and the second stage regenerator matrix size are also reported. Pressure-volume (P-V) diagrams obtained at various temperatures indicate that P-V losses form the major fraction of the total losses and this becomes more pronounced as the temperature is decreased. A heat balance analysis shows the relative magnitudes of various losses.

Lead-acid batteries for partial-state-of-charge applications

2 V/40 Ah valve-regulated lead-acid (VRLA) cells have been constructed with negative plates employing carbon black as well as an admixture of carbon black fumed silica as additives in negative active material for partial-state-of-charge (PSoC) applications. Electrical performance of such cells is compared with conventional 2 V/40 Ah VRLA cells for PSoC operation. Active material utilization has been found to be higher for carbon-black fumed-silica mixed negative plates while formation is faster for cells with carbon-black mixed negative plates. Both faradaic efficiency and percentage capacity delivered have been found to be higher for cells with carbon-black + fumed-silica mixed negative plates. However, a high self-discharge rate is observed for cells with carbon-black + fumed-silica mixed negative plates.

Cellular Mechanisms of Sleep Homeostasis : Studies on Brain Energy Metabolism and Aging

Sleep is governed by a homeostatic process in which the duration and quality of previous wake regulate the subsequent sleep. Active wakefulness is characterized with high frequency cortical oscillations and depends on stimulating influence of the arousal systems, such as the cholinergic basal forebrain (BF), while cessation of the activity in the arousal systems is required for slow wave sleep (SWS) to occur. The site-specific accumulation of adenosine (a by-product of ATP breakdown) in the BF during prolonged waking /sleep deprivation (SD) is known to induce sleep, thus coupling energy demand to sleep promotion. The adenosine release in the BF is accompanied with increases in extracellular lactate and nitric oxide (NO) levels. This thesis was aimed at further understanding the cellular processes by which the BF is involved in sleep-wake regulation and how these processes are affected by aging. The BF function was studied simultaneously at three levels of organization: 1) locally at a cellular level by measuring energy metabolites 2) globally at a cortical level (the out-put area of the BF) by measuring EEG oscillations and 3) at a behavioral level by studying changes in vigilance states. Study I showed that wake-promoting BF activation, particularly with glutamate receptor agonist N-methyl-D-aspatate (NMDA), increased extracellular adenosine and lactate levels and led to a homeostatic increase in the subsequent sleep. Blocking NMDA activation during SD reduced the high frequency (HF) EEG theta (7-9 Hz) power and attenuated the subsequent sleep. In aging, activation of the BF during SD or experimentally with NMDA (studies III, IV), did not induce lactate or adenosine release and the increases in the HF EEG theta power during SD and SWS during the subsequent sleep were attenuated as compared to the young. These findings implicate that increased or continuous BF activity is important for active wake maintenance during SD as well as for the generation of homeostatic sleep pressure, and that in aging these mechanisms are impaired. Study II found that induction of the inducible NO synthase (iNOS) during SD is accompanied with activation of the AMP-activated protein kinase (AMPK) in the BF. Because decreased cellular energy charge is the most common cause for AMPK activation, this finding implicates that the BF is selectively sensitive to the metabolic demands of SD as increases were not found in the cortex. In aging (study III), iNOS expression and extracellular levels of NO and adenosine were not significantly increased during SD in the BF. Furthermore, infusion of NO donor into the BF did not lead to sleep promotion as it did in the young. These findings indicated that the NO (and adenosine) mediated sleep induction is impaired in aging and that it could at least partly be due to the reduced sensitivity of the BF to sleep-inducing factors. Taken together, these findings show that reduced sleep promotion by the BF contributes to the attenuated homeostatic sleep response in aging.

Breathing, swallowing and voice in laryngeal disorsers

The aim of this work was to examine how breathing, swallowing and voicing are affected in different laryngeal disorders. For this purpose, we examined four different patient groups: patients who had undergone total laryngectomy, anterior cervical decompression (ACD), or injection laryngoplasty with autologous fascia (ILAF), and patients with dyspnea during exercise. We studied the problems and benefits related to the automatic speech valve used for the rehabilitation of speech in laryngectomized patients. The device was given to 14 total laryngectomized patients who used the traditional valve especially well. The usefulness of voice and intelligibility of speech were assessed by speech pathologists. The results demonstrated better performance with the traditional valve in both dimensions. Most of the patients considered the automatic valve a helpful additional device but because of heavier breathing and the greater work needed for speech production, it was not suitable as a sole device in speech rehabilitation. Dysphonia and dysphagia are known complications of ACD. These symptoms are caused due to the stretching of tissue needed during the surgery, but the extent and the recovery from them was not well known before our study. We studied two patient groups, an early group with 50 patients who were examined immediately before and after the surgery and a late group with 64 patients who were examined 3 9 months postoperatively. Altogether, 60% reported dysphonia and 69% dysphagia immediately after the operation. Even though dysphagia and dysphonia often appeared after surgery, permanent problems seldom occurred. Six (12 %) cases of transient and two (3 %) permanent vocal cord paresis were detected. In our third study, the long-term results of ILAF in 43 patients with unilateral vocal cord paralysis were examined. The mean follow-up was 5.8 years (range 3 10). Perceptual evaluation demonstrated improved results for voice quality, and videostroboscopy revealed complete or partial glottal closure in 83% of the patients. Fascia showed to be a stable injection material with good vocal results. In our final study we developed a new diagnostic method for exertional laryngeal dyspnea by combining a cardiovascular exercise test with simultaneous fiberoptic observation of the larynx. With this method, it is possible to visualize paradoxal closure of the vocal cords during inspiration, which is a diagnostic criterion for vocal cord dysfunction (VCD). We examined 30 patients referred to our hospital because of suspicion of exercise-induced vocal cord dysfunction (EIVCD). Twenty seven out of thirty patients were able to perform the test. Dyspnea was induced in 15 patients, and of them five had EIVCD and four high suspicion of EIVCD. With our test it is possible to set an accurate diagnosis for exertional laryngeal dyspnea. Moreover, the often seen unnecessary use of asthma drugs among these patients can be avoided.

Micropillar Array Based Microchips for Electrospray Ionization Mass Spectrometry, Microreactors, and Liquid Chromatographic Separation

This dissertation deals with the design, fabrication, and applications of microscale electrospray ionization chips for mass spectrometry. The microchip consists of microchannel, which leads to a sharp electrospray tip. Microchannel contain micropillars that facilitate a powerful capillary action in the channels. The capillary action delivers the liquid sample to the electrospray tip, which sprays the liquid sample to gas phase ions that can be analyzed with mass spectrometry. The microchip uses a high voltage, which can be utilized as a valve between the microchip and mass spectrometry. The microchips can be used in various applications, such as for analyses of drugs, proteins, peptides, or metabolites. The microchip works without pumps for liquid transfer, is usable for rapid analyses, and is sensitive. The characteristics of performance of the single microchips are studied and a rotating multitip version of the microchips are designed and fabricated. It is possible to use the microchip also as a microreactor and reaction products can be detected online with mass spectrometry. This property can be utilized for protein identification for example. Proteins can be digested enzymatically on-chip and reaction products, which are in this case peptides, can be detected with mass spectrometry. Because reactions occur faster in a microscale due to shorter diffusion lengths, the amount of protein can be very low, which is a benefit of the method. The microchip is well suited to surface activated reactions because of a high surface-to-volume ratio due to a dense micropillar array. For example, titanium dioxide nanolayer on the micropillar array combined with UV radiation produces photocatalytic reactions which can be used for mimicking drug metabolism biotransformation reactions. Rapid mimicking with the microchip eases the detection of possibly toxic compounds in preclinical research and therefore could speed up the research of new drugs. A micropillar array chip can also be utilized in the fabrication of liquid chromatographic columns. Precisely ordered micropillar arrays offer a very homogenous column, where separation of compounds has been demonstrated by using both laser induced fluorescence and mass spectrometry. Because of small dimensions on the microchip, the integrated microchip based liquid chromatography electrospray microchip is especially well suited to low sample concentrations. Overall, this work demonstrates that the designed and fabricated silicon/glass three dimensionally sharp electrospray tip is unique and facilitates stable ion spray for mass spectrometry.

Compensator for constant relative stability in process control systems

Process control systems are designed for a closed-loop peak magnitude of 2dB, which corresponds to a damping coefficient () of 0.5 approximately. With this specified constraint, the designer should choose and/or design the loop components to maintain a constant relative stability. However, the manipulative variable in almost all chemical processes will be the flow rate of a process stream. Since the gains and the time constants of the process will be functions of the manipulative variable, a constant relative stability cannot be maintained. Up to now, this problem has been overcome either by selecting proper control valve flow characteristics or by gain scheduling of controller parameters. Nevertheless, if a wrong control valve selection is made then one has to account for huge loss in controllability or eventually it may lead to an unstable control system. To overcome these problems, a compensator device that can bring back the relative stability of the control system was proposed. This compensator is similar to a dynamic nonlinear controller that has both online and offline information on several factors related to the control system. The design and analysis of the proposed compensator is discussed in this article. Finally, the performance of the compensator is validated by applying it to a two-tank blending process. It has been observed that by using a compensator in the process control system, the relative stability could be brought back to a great extent despite the effects of changes in manipulative flow rate.

Artificial commutation for inversion into a weak AC system in a multiterminal HVDC system

This paper deals with the application of artificial commutation for a normally rated inverter connecting a weak AC system in a multiterminal HVDC (MTDC) system. Artificial commutation is achieved using series capacitors. A modular digital simulation technique is developed to study the dynamic performance of the system. It is shown that by a proper selection of the value of the capacitor it is possible to limit the valve stresses and the DC harmonics to acceptable levels and achieve an improved performance during severe transient conditions. The determination of the value of the series capacitor is based on a parametric study.

A quasi-steady performance prediction model for dynamic characteristics of a volute pump

A performance prediction model generally applicable for volute-type centrifugal pumps has been extended to predict the dynamic characteristics of a pump during its normal starting and stopping periods. Experiments have been conducted on a volute pump with different valve openings to study the dynamic behaviour of the pump during normal start-up and stopping, when a small length of discharge pipeline is connected to the discharge flange of the pump. Such experiments have also been conducted when the test pump was part of a hydraulic system, an experimental rig, where it is pumping against three similar pumps, known as supply pumps, connected in series, with the supply pumps kept idle or running. Instantaneous rotational speed, flowrate, and delivery and suction pressures of the pump were recorded and it was observed in all the tested cases that the change of pump behaviour during the transient period was quasi-steady, which validates the quasi-steady approach presented in this paper. The nature of variation of parameters during the transients has been discussed. The model-predicted dynamic head-capacity curves agree well with the experimental data for almost all the tested cases.

Parameter estimation in water-distribution systems by least squares

The weighted-least-squares method using sensitivity-analysis technique is proposed for the estimation of parameters in water-distribution systems. The parameters considered are the Hazen-Williams coefficients for the pipes. The objective function used is the sum of the weighted squares of the differences between the computed and the observed values of the variables. The weighted-least-squares method can elegantly handle multiple loading conditions with mixed types of measurements such as heads and consumptions, different sets and number of measurements for each loading condition, and modifications in the network configuration due to inclusion or exclusion of some pipes affected by valve operations in each loading condition. Uncertainty in parameter estimates can also be obtained. The method is applied for the estimation of parameters in a metropolitan urban water-distribution system in India.

Design and development of a self-supported polymer electrolyte fuel cell system with anodic dead-end operation

Design and operational details for a self-supported polymer electrolyte fuel cell (PEFC) system with anodic dead-end fuel supply and internally humidified cathodic oxidant flow are described. During the PEFC operation, nitrogen and water back diffuse across the Nafion membrane from the cathode to the anode and accumulate in the anode flow channels affecting stack performance. The accumulated inert species are flushed from the stack by purging the fuel cell stack with a timer-activated purge valve to address the aforesaid problem. To minimize the system complexity, stack is designed in such a way that all the inert species accumulate in only one cell called the purge cell. A pulsed purge sequence comprises opening the valve for purge duration followed by purge-valve closing for the hold period and repeating the sequence in cycles. Since self-humidification is inadequate to keep the membrane wet, the anodic dead-end-operated PEFC stack with composite membrane comprising perflourosulphonic acid (Nafion) and silica is employed for keeping the membrane humidified even while operating the stack with dry hydrogen and internally humidified air.

Centrifugal pump transient characteristics and analysis using the method of characteristics

A theoretical and experimental study has been carried out on the transient characteristics of a centrifugal pump during starting and stopping periods. Experiments have been conducted on a volute pump with different valve openings to study the dynamic behaviour of the pump during normal start up and stopping, when a small length of discharge pipe line is connected to discharge flange of the pump. Similar experiments have also been conducted when the test pump was part of a hydraulic system to study the system effect on the transient characteristics. Instantaneous rotational speed, flowrate, and delivery and suction pressures of the pump are recorded and it is observed in ail the tested cases that the change of pump behaviour during the transient period is quasi-steady. The dynamic characteristics of the pump have been analysed by a numerical model using the method of characteristics. The model is presented and the results are compared with the experimental data. As the model contains speed acceleration and unsteady discharge terms, the model can be applied for analyses of purely unsteady cases where the pump dynamic characteristics show considerable departure from their steady-state characteristics.

Origin of the unconventional magnetoresistance in Sr(2)FeMoO6(6)

The unusual magnetoresistance (MR) behavior in Sr2FeMoO6, recently termed as spin-valve-type MR (SVMR), presents several anomalies that are little understood so far. The difficulty in probing the origin of this phenomenon, arising from the magnetic property of only a small volume fraction of the ferromagnetic bulk, is circumvented in the present study by the use of ac susceptibility measurements that are sensitive to the slope rather than the magnitude of the magnetization. The present study unravels a spin-glass (SG) like surface layer around each soft ferromagnetic (FM) grain of Sr2FeMoO6. It is also observed that there is a very strong exchange coupling between the two, generating ``exchange bias'' effect, which consequently creates the ``valve'', responsible for the unusual MR effects. Copyright (C) EPLA, 2011