Training in and assessment of the procedural skills required to perform peripheral nerve blockade

The training and ongoing education of medical practitioners has undergone major changes in an incremental fashion over the past 15 years. These changes have been driven by patient safety, educational, economic and legislative/regulatory factors. In the near future, training in procedural skills will undergo a paradigm shift to proficiency based progression with associated requirements for competence-based programmes, valid, reliable assessment tools and simulation technology. Before training begins, the learning outcomes require clear definition; any form of assessment applied should include measurement of these outcomes. Currently training in a procedural skill often takes place on an ad hoc basis. The number of attempts necessary to attain a defined degree of proficiency varies from procedure to procedure. Convincing evidence exists that simulation training helps trainees to acquire skills more efficiently rather than relying on opportunities in their clinical practice. Simulation provides a safe, stress free environment for trainees for skill acquisition, generalization and transfer via deliberate practice. The work described in this thesis contributes to a greater understanding of how medical procedures can be performed more safely and effectively through education. The effect of feedback, provided to novices in a standardized setting on a bench model, based on knowledge of performance was associated with an increase in the speed of skill acquisition and a decrease in error rate during initial learning. The timing of feedback was also associated with effective learning of skill. A marked attrition of skills (independent of the type of feedback provided) was demonstrable 24 hrs after they have first been learned. Using the principles of feedback as described above, when studying the effect of an intense training program on novices of varied years of experience in anaesthesia (i.e. the present training programmes / courses of an intense training day for one or more procedures). There was a marked attrition of skill at 24 hours with a significant correlation with increasing years of experience; there also appeared to be an inverse relationship between years of experience in anaesthesia and performance. The greater the number of years of practice experience, the longer it required a learner to acquire a new skill. The findings of the studies described in this thesis may have important implications for the trainers, trainees and training bodies in the design and implementation of training courses and the formats of delivery of changing curricula. Both curricula and training modalities will need to take account of characteristics of individual learners and the dynamic nature of procedural healthcare.

Manifestations of heavenly light and fire and the construction of a saint: sanctity, mission and salvation in Adomnán's Vita Columbae

This thesis examines the late seventh-century Latin Life of Columba (Vita Columbae) in a context sympathetic to the spiritual aims and formative intellectual background of its author, Adomnán of Iona. It argues that the Vita Columbae is a sophisticated work, shaped by Adomnán’s spiritual and theological concerns. This sophistication is revealed by a forensic examination of Adomnán’s representation of Columba’s sanctity through a series of miracles, in particular, miracle stories depicting divine manifestations of fire and light. This thesis considers the form and function of these miracle stories in the context of biblical, patristic and medieval interpretations of their archetypes, towards revealing the underlying influence of scriptural, hagiographical and monastic models of sanctity. Chapter one evaluates the function of the Vita Columbae, and outlines the core themes of sanctity which pervade the work, by considering the technical terminology and literary devices found in the opening prefaces in the context of the wider monastic tradition. Chapter two examines Adomnán’s use of biblical models of sanctity to establish Columba’s sanctity, and their relationship between these models and certain miraculous episodes in the Vita Columbae. Chapter three investigates Adomnán’s description of the Holy Spirit as an illuminating fire, and its significance for his portrayal of the saint, by means of a forensic examination of biblical, exegetical and hagiographical treatments of the image. Chapter four examines the missiological, soteriological and providential elements contributing to Adomnán’s portrayal of Columba’s sanctity, as conveyed through the presence of biblical models, particularly the image of the column of fire. Chapter five establishes the influence of monastic examinations of the contemplative life on Adomnán’s portrayal of Columba’s sanctity, and shows how that sanctity is confirmed in terms of his ability to contemplate divine light.

Creating religious place in Ireland: Hindu public places of worship and the Indian sculpture park

This paper examines the creation of religious place. It argues that the designation of a place as “religious” is a subjective and creative act which is dependent upon the perception and past, or memory, of the viewer. The paper focuses specifically on the creation of public places of worship by Hindu groups in the Dublin city area of Ireland and on the varied perceptions of the Indian Sculpture Park in County Wicklow. The creation of public places of worship results in places classified as “religious” due to the intention of the creator, the terminology used and the types of activities that take place in the space. This is in contrast to places such as the Indian Sculpture Park in County Wicklow which was created as a secular space but which is viewed by some Hindus as an outdoor temple due to the presence of sculptures of the Hindu deity Ganesh. Other Hindus do not view the space as having any religious significance and so its religiosity is contested. This points to the fact that the creation of religious place is a creative act of interpretation which is dependent upon the perception and past of the viewer and which changes over time.

Child work and labour among orphaned and abandoned children in five low and middle income countries.

BACKGROUND: The care and protection of the estimated 143,000,000 orphaned and abandoned children (OAC) worldwide is of great importance to global policy makers and child service providers in low and middle income countries (LMICs), yet little is known about rates of child labour among OAC, what child and caregiver characteristics predict child engagement in work and labour, or when such work infers with schooling. This study examines rates and correlates of child labour among OAC and associations of child labour with schooling in a cohort of OAC in 5 LMICs. METHODS: The Positive Outcomes for Orphans (POFO) study employed a two-stage random sampling survey methodology to identify 1480 single and double orphans and children abandoned by both parents ages 6-12 living in family settings in five LMICs: Cambodia, Ethiopia, India, Kenya, and Tanzania. Regression models examined child and caregiver associations with: any work versus no work; and with working <21, 21-27, and 28+ hours during the past week, and child labour (UNICEF definition). RESULTS: The majority of OAC (60.7%) engaged in work during the past week, and of those who worked, 17.8% (10.5% of the total sample) worked 28 or more hours. More than one-fifth (21.9%; 13% of the total sample) met UNICEF's child labour definition. Female OAC and those in good health had increased odds of working. OAC living in rural areas, lower household wealth and caregivers not earning an income were associated with increased child labour. Child labour, but not working fewer than 28 hours per week, was associated with decreased school attendance. CONCLUSIONS: One in seven OAC in this study were reported to be engaged in child labour. Policy makers and social service providers need to pay close attention to the demands being placed on female OAC, particularly in rural areas and poor households with limited income sources. Programs to promote OAC school attendance may need to focus on the needs of families as well as the OAC.

Leptospirosis among hospitalized febrile patients in northern Tanzania.

We enrolled consecutive febrile admissions to two hospitals in Moshi, Tanzania. Confirmed leptospirosis was defined as a ≥ 4-fold increase in microscopic agglutination test (MAT) titer; probable leptospirosis as reciprocal MAT titer ≥ 800; and exposure to pathogenic leptospires as titer ≥ 100. Among 870 patients enrolled in the study, 453 (52.1%) had paired sera available, and 40 (8.8%) of these met the definition for confirmed leptospirosis. Of 832 patients with ≥ 1 serum sample available, 30 (3.6%) had probable leptospirosis and an additional 277 (33.3%) had evidence of exposure to pathogenic leptospires. Among those with leptospirosis the most common clinical diagnoses were malaria in 31 (44.3%) and pneumonia in 18 (25.7%). Leptospirosis was associated with living in a rural area (odds ratio [OR] 3.4, P < 0.001). Among those with confirmed leptospirosis, the predominant reactive serogroups were Mini and Australis. Leptospirosis is a major yet underdiagnosed cause of febrile illness in northern Tanzania, where it appears to be endemic.

"It is Quietly Chaotic. It Confuses Time"*: Final Report of Excavations at the Bordley-Randall Site in Annapolis, Maryland, 1993-1995 (18AP50)

*This extract is from Gay P. Crowther's description of the Randall Court pathway (Cowther 1985).

Metacognition in monkeys during an oculomotor task.

This study investigated whether rhesus monkeys show evidence of metacognition in a reduced, visual oculomotor task that is particularly suitable for use in fMRI and electrophysiology. The 2-stage task involved punctate visual stimulation and saccadic eye movement responses. In each trial, monkeys made a decision and then made a bet. To earn maximum reward, they had to monitor their decision and use that information to bet advantageously. Two monkeys learned to base their bets on their decisions within a few weeks. We implemented an operational definition of metacognitive behavior that relied on trial-by-trial analyses and signal detection theory. Both monkeys exhibited metacognition according to these quantitative criteria. Neither external visual cues nor potential reaction time cues explained the betting behavior; the animals seemed to rely exclusively on internal traces of their decisions. We documented the learning process of one monkey. During a 10-session transition phase, betting switched from random to a decision-based strategy. The results reinforce previous findings of metacognitive ability in monkeys and may facilitate the neurophysiological investigation of metacognitive functions.

In vivo guidance and assessment of liver radio-frequency ablation with acoustic radiation force elastography.

The initial results from clinical trials investigating the utility of acoustic radiation force impulse (ARFI) imaging for use with radio-frequency ablation (RFA) procedures in the liver are presented. To date, data have been collected from 6 RFA procedures in 5 unique patients. Large displacement contrast was observed in ARFI images of both pre-ablation malignancies (mean 7.5 dB, range 5.7-11.9 dB) and post-ablation thermal lesions (mean 6.2 dB, range 5.1-7.5 dB). In general, ARFI images provided superior boundary definition of structures relative to the use of conventional sonography alone. Although further investigations are required, initial results are encouraging and demonstrate the clinical promise of the ARFI method for use in many stages of RFA procedures.

Multi-program benchmark definition

© 2015 IEEE.Although definition of single-program benchmarks is relatively straight-forward-a benchmark is a program plus a specific input-definition of multi-program benchmarks is more complex. Each program may have a different runtime and they may have different interactions depending on how they align with each other. While prior work has focused on sampling multiprogram benchmarks, little attention has been paid to defining the benchmarks in their entirety. In this work, we propose a four-tuple that formally defines multi-program benchmarks in a well-defined way. We then examine how four different classes of benchmarks created by varying the elements of this tuple align with real-world use-cases. We evaluate the impact of these variations on real hardware, and see drastic variations in results between different benchmarks constructed from the same programs. Notable differences include significant speedups versus slowdowns (e.g., +57% vs -5% or +26% vs -18%), and large differences in magnitude even when the results are in the same direction (e.g., 67% versus 11%).

Guidelines on artificial nutrition versus hydration in terminal cancer patients

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step I: define the eight key elements necessary to reach a decision: Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e. improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

Effector functions of heparin-binding hemagglutinin-specific CD8+ T lymphocytes in latent human tuberculosis.

BACKGROUND: Most individuals infected with Mycobacterium tuberculosis do not develop tuberculosis (TB) and can be regarded as being protected by an appropriate immune response to the infection. The characterization of the immune responses of individuals with latent TB may thus be helpful in the definition of correlates of protection and the development of new vaccine strategies. The highly protective antigen heparin-binding hemagglutinin (HBHA) induces strong interferon (IFN)- gamma responses during latent, but not active, TB. Because of the recently recognized importance of CD8(+) T lymphocytes in anti-TB immunity, we characterized the CD8(+) T lymphocyte responses to HBHA in subjects with latent TB. RESULTS: HBHA-specific CD8(+) T lymphocytes expressed memory cell markers and synthesized HBHA-specific IFN- gamma .They also restricted mycobacterial growth and expressed cytotoxicity by a granule-dependent mechanism. This activity was associated with the intracellular expression of HBHA-induced perforin. Surprisingly, the perforin-producing CD8(+) T lymphocytes were distinct from the IFN- gamma -producing CD8(+) T lymphocytes. CONCLUSION: During latent TB, the HBHA-specific CD8(+) T lymphocyte population expresses all 3 effector functions associated with CD8(+) T lymphocyte-mediated protective immune mechanisms, which supports the notion that HBHA may be protective in humans and suggests that markers of HBHA-specific CD8(+) T lymphocyte responses may be useful in the monitoring of protection.

Immediate early gene expression in dog thyrocytes in response to growth, proliferation, and differentiation stimuli.

In dog thyroid cells, insulin or IGF-1 induces cell growth and is required for the mitogenic action of TSH through cyclic AMP, of EGF, and of phorbol esters. HGF per se stimulates cell proliferation and is thus the only full mitogenic agent. TSH and cAMP enhance, whereas EGF phorbol esters and HGF repress differentiation expression. In this study, we have investigated for each factor and regulatory cascade of the intermediate step of immediate early gene induction, that is, c-myc, c-jun, jun D, jun B, c-fos, fos B, fra-1, fra-2, and egr1; fra-1 and fra-2 expressions were very low. TSH or forskolin increased the levels of c-myc, jun B, jun D, c-fos, and fos B while decreasing those of c-jun and egr1. Phorbol myristate ester stimulated the expression of all the genes. EGF and HGF stimulated the expression of all the genes except jun D and for EGF fos B. All these effects were obtained in the presence and in the absence of insulin, which shows that insulin is not necessary for the effects of the mitogens on immediate early gene expression. The definition of the repertoire of early immediate genes inductible by the various growth cascades provides a framework for the analysis of gene expression in tumors. (1) Insulin was able to induce all the protooncogenes investigated except fos B. This suggests that fos B could be the factor missing for insulin to induce mitogenesis. (2) No characteristic pattern of immediate early gene expression has been observed for insulin, which induces cell hypertrophy and is permissive for the action of the other growth factors. These effects are therefore not accounted for by a specific immediate early gene expression. On the other hand, insulin clearly enhances the effects of TSH, phorbol ester, and EGF on c-myc, junB, and c-fos expression. This suggests that the effect of insulin on mitogenesis might result from quantitative differences in the transcription complexes formed. (3) c-myc, c-fos, and jun B mRNA induction by all stimulating agents, whether inducing cell hypertrophy, or growth and dedifferentiation, or growth and differentiation, suggests that, although these expressions are not sufficient, they may be necessary for the various growth responses of thyroid cells. (4) The inhibition of c-jun and egr1 mRNA expression, and the marked induction of jun D mRNA appear to be specific features of the TSH cAMP pathway. They might be related to its differentiating action. (5) fos B, which is induced by TSH, forskolin, phorbol ester, and HGF but not by insulin, could be involved in the mitogenic action of the former factors.

Exploitation of symbolic information in interprocedural dependence analysis

The requirement for a very accurate dependence analysis to underpin software tools to aid the generation of efficient parallel implementations of scalar code is argued. The current status of dependence analysis is shown to be inadequate for the generation of efficient parallel code, causing too many conservative assumptions to be made. This paper summarises the limitations of conventional dependence analysis techniques, and then describes a series of extensions which enable the production of a much more accurate dependence graph. The extensions include analysis of symbolic variables, the development of a symbolic inequality disproof algorithm and its exploitation in a symbolic Banerjee inequality test; the use of inference engine proofs; the exploitation of exact dependence and dependence pre-domination attributes; interprocedural array analysis; conditional variable definition tracing; integer array tracing and division calculations. Analysis case studies on typical numerical code is shown to reduce the total dependencies estimated from conventional analysis by up to 50%. The techniques described in this paper have been embedded within a suite of tools, CAPTools, which combines analysis with user knowledge to produce efficient parallel implementations of numerical mesh based codes.

Analysis of species hyper-diversity in the tropical rain forests of Indonesia: the problem of non-observance

The main interest in the assessment of forest species diversity for conservation purposes is in the rare species. The main problem in the tropical rain forests is that most of the species are rare. Assessment of species diversity in the tropical rain forests is therefore often concerned with estimating that which is not observed in recorded samples. Statistical methodology is therefore required to try to estimate the truncated tail of the species frequency distribution, or to estimate the asymptote of species/diversity-area curves. A Horvitz-Thompson estimator of the number of unobserved (“virtual”) species in each species intensity class is proposed. The approach allows a definition of an extended definition of diversity, ( or generalised Renyi entropy). The paper presents a case study from data collected in Jambi, Sumatra, and the “extended diversity measure” is used on the species data.