The S.T.A.B. Trial - Standardised Testing of Artificial Blood. A comparative study of various products that may be used as artificial blood for high fidelity simulation training in the critical care setting

Aim: In the current climate of medical education, there is an ever-increasing demand for and emphasis on simulation as both a teaching and training tool. The objective of our study was to compare the realism and practicality of a number of artificial blood products that could be used for high-fidelity simulation. Method: A literature and internet search was performed and 15 artificial blood products were identified from a variety of sources. One product was excluded due to its potential toxicity risks. Five observers, blinded to the products, performed two assessments on each product using an evaluation tool with 14 predefined criteria including color, consistency, clotting, and staining potential to manikin skin and clothing. Each criterion was rated using a five-point Likert scale. The products were left for 24 hours, both refrigerated and at room temperature, and then reassessed. Statistical analysis was performed to identify the most suitable products, and both inter- and intra-rater variability were examined. Results: Three products scored consistently well with all five assessors, with one product in particular scoring well in almost every criterion. This highest-rated product had a mean rating of 3.6 of 5.0 (95% posterior Interval 3.4-3.7). Inter-rater variability was minor with average ratings varying from 3.0 to 3.4 between the highest and lowest scorer. Intrarater variability was negligible with good agreement between first and second rating as per weighted kappa scores (K = 0.67). Conclusion: The most realistic and practical form of artificial blood identified was a commercial product called KD151 Flowing Blood Syrup. It was found to be not only realistic in appearance but practical in terms of storage and stain removal.

Spatial population genetic structure reveals strong natal site fidelity in Echinocladius martini (Diptera: Chironomidae) in northeast Queensland, Australia

1. A diverse array of patterns has been reported regarding the spatial extent of population genetic structure and effective dispersal in freshwater macroinvertebrates. In river systems, the movements of many taxa can be restricted to varying degrees by the natural stream channel hierarchy. 2. In this study, we sampled populations of the non-biting freshwater midge Echinocladius martini in the Paluma bioregion of tropical northeast Queensland to investigate fine scale patterns of within- and among-stream dispersal and gene flow within a purported historical refuge. We amplified a 639 bp fragment of mitochondrial COI and analysed genetic structure using pairwise ΦST, hierarchical AMOVA, Mantel tests and a parsimony network. Genetic variation was partitioned among stream sections using Streamtree to investigate the effect of potential instream dispersal barriers. 3. The data revealed strong natal site fidelity and significant differentiation among neighbouring, geographically proximate streams. We found evidence for only episodic adult flight among sites on separate stream reaches. Overall, however, our data suggested that both larval and adult dispersal was largely limited to within a stream channel. 4. This may arise from a combination of the high density of riparian vegetation physically restricting dispersal and from the joint effects of habitat stability and large population sizes. Together these may mitigate the requirement for movement among streams to avoid inbreeding and local extinction due to habitat change and may thus enable persistence of upstream populations in the absence of regular compensatory upstream flight. Taken together, these data suggest that dispersal of E. martini is highly restricted, to the scale of only a few kilometres, and hence occurs predominantly within the natal stream.

High fidelity simulation; challenges encountered in developing and implementing student learning experiences, staff education and researching approaches to learning

High fidelity simulation as a teaching and learning approach is being embraced by many schools of nursing. Our school embarked on integrating high fidelity (HF) simulation into the undergraduate clinical education program in 2011. Low and medium fidelity simulation has been used for many years, but this did not simplify the integration of HF simulation. Alongside considerations of how and where HF simulation would be integrated, issues arose with: student consent and participation for observed activities; data management of video files; staff development, and conceptualising how methods for student learning could be researched. Simulation for undergraduate student nurses commenced as a formative learning activity, undertaken in groups of eight, where four students undertake the ‘doing’ role and four are structured observers, who then take a formal role in the simulation debrief. Challenges for integrating simulation into student learning included conceptualising and developing scenarios to trigger students’ decision making and application of skills, knowledge and attitudes explicit to solving clinical ‘problems’. Developing and planning scenarios for students to ‘try out’ skills and make decisions for problem solving lay beyond choosing pre-existing scenarios inbuilt with the software. The supplied scenarios were not concept based but rather knowledge, skills and technology (of the manikin) focussed. Challenges lay in using the technology for the purpose of building conceptual mastery rather than using technology simply because it was available. As we integrated use of HF simulation into the final year of the program, focus was on building skills, knowledge and attitudes that went beyond technical skill, and provided an opportunity to bridge the gap with theory-based knowledge that students often found difficult to link to clinical reality. We wished to provide opportunities to develop experiential knowledge based on application and clinical reasoning processes in team environments where problems are encountered, and to solve them, the nurse must show leadership and direction. Other challenges included students consenting for simulations to be videotaped and ethical considerations of this. For example if one student in a group of eight did not consent, did this mean they missed the opportunity to undertake simulation, or that others in the group may be disadvantaged by being unable to review their performance. This has implications for freely given consent but also for equity of access to learning opportunities for students who wished to be taped and those who did not. Alongside this issue were the details behind data management, storage and access. Developing staff with varying levels of computer skills to use software and undertake a different approach to being the ‘teacher’ required innovation where we took an experiential approach. Considering explicit learning approaches to be trialled for learning was not a difficult proposition, but considering how to enact this as research with issues of blinding, timetabling of blinded groups, and reducing bias for testing results of different learning approaches along with gaining ethical approval was problematic. This presentation presents examples of these challenges and how we overcame them.

Using ‘think aloud’ as a strategy for learning clinical reasoning in high fidelity case-based simulation for undergraduate nursing students

AIMS This paper reports on the implementation of a research project that trials an educational strategy implemented over six months of an undergraduate third year nursing curriculum. This project aims to explore the effectiveness of ‘think aloud’ as a strategy for learning clinical reasoning for students in simulated clinical settings. BACKGROUND Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting [1]. Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. For students learning to manage complex clinical situations, teaching approaches are required that make these instinctive cognitive processes explicit and clear [2-5]. In line with professional expectations, nursing students in third year at Queensland University of Technology (QUT) are expected to display clinical reasoning skills in practice. This can be a complex proposition for students in practice situations, particularly as the degree of uncertainty or decision complexity increases [6-7]. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students [4, 8]. This project aims to use the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students are assisted to uncover cognitive approaches that best assist them to make effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection on their practice. MEHODS In semester 2 2011 at QUT, third year nursing students will undertake high fidelity simulation, some for the first time commencing in September of 2011. There will be two cohorts for strategy implementation (group 1= use think aloud as a strategy within the simulation, group 2= not given a specific strategy outside of nursing assessment frameworks) in relation to problem solving patient needs. Students will be briefed about the scenario, given a nursing handover, placed into a simulation group and an observer group, and the facilitator/teacher will run the simulation from a control room, and not have contact (as a ‘teacher’) with students during the simulation. Then debriefing will occur as a whole group outside of the simulation room where the session can be reviewed on screen. The think aloud strategy will be described to students in their pre-simulation briefing and allow for clarification of this strategy at this time. All other aspects of the simulations remain the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). RESULTS Methodology of the project and the challenges of implementation will be the focus of this presentation. This will include ethical considerations in designing the project, recruitment of students and implementation of a voluntary research project within a busy educational curriculum which in third year targets 669 students over two campuses. CONCLUSIONS In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs. References 1. Lasater, K., High-fidelity simulation and the development of clinical judgement: students' experiences. Journal of Nursing Education, 2007. 46(6): p. 269-276. 2. Lapkin, S., et al., Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: a systematic review. Clinical Simulation in Nursing, 2010. 6(6): p. e207-22. 3. Kaddoura, M.P.C.M.S.N.R.N., New Graduate Nurses' Perceptions of the Effects of Clinical Simulation on Their Critical Thinking, Learning, and Confidence. The Journal of Continuing Education in Nursing, 2010. 41(11): p. 506. 4. Banning, M., The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. Nurse Education Today, 2008. 28: p. 8-14. 5. Porter-O'Grady, T., Profound change:21st century nursing. Nursing Outlook, 2001. 49(4): p. 182-186. 6. Andersson, A.K., M. Omberg, and M. Svedlund, Triage in the emergency department-a qualitative study of the factors which nurses consider when making decisions. Nursing in Critical Care, 2006. 11(3): p. 136-145. 7. O'Neill, E.S., N.M. Dluhy, and C. Chin, Modelling novice clinical reasoning for a computerized decision support system. Journal of Advanced Nursing, 2005. 49(1): p. 68-77. 8. Lee, J.E. and N. Ryan-Wenger, The "Think Aloud" seminar for teaching clinical reasoning: a case study of a child with pharyngitis. J Pediatr Health Care, 1997. 11(3): p. 101-10.

Using ‘think aloud’ as a strategy for improving clinical reasoning in high fidelity case-based simulation for undergraduate nursing students.

Theme Paper for Curriculum innovation and enhancement theme AIM: This paper reports on a research project that trialled an educational strategy implemented in an undergraduate nursing curriculum. The project aimed to explore the effectiveness of ‘think aloud’ as a strategy for improving clinical reasoning for students in simulated clinical settings. BACKGROUND: Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting (Lasater, 2007). Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students (Banning, 2008, Lee and Ryan-Wenger, 1997). This project used the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students were assisted to uncover cognitive approaches to assist in making effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection about their practice. MEHODS: In semester 2 2011 at QUT, third year nursing students undertook high fidelity simulation (some for the first time), commencing in September of 2011. There were two cohorts for strategy implementation (group 1= used think aloud as a strategy within the simulation, group 2= no specific strategy outside of nursing assessment frameworks used by all students) in relation to problem solving patient needs. The think aloud strategy was described to students in their pre-simulation briefing and allowed time for clarification of this strategy. All other aspects of the simulations remained the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). Ethics approval has been obtained for this project. RESULTS: Results of a qualitative analysis (in progress- will be completed by March 2012) of student and facilitator reports on students’ ability to meet the learning objectives of solving patient problems using clinical reasoning and experience with the ‘think aloud’ method will be presented. A comparison of clinical reasoning learning outcomes between the two groups will determine the effect on clinical reasoning for students responding to patient problems. CONCLUSIONS: In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs.

Translating training in the NYU Caregiver Intervention in Australia: Maintaining fidelity and meeting graduate standards in an online continuing professional education setting

The aim of this study was to develop an Internet-based self-directed training program for Australian healthcare workers to facilitate learning and competence in delivery of a proven intervention for caregivers of people with dementia: The New York University Caregiver Intervention (NYUCI). The NYUCI is a nonpharmacological, multicomponent intervention for spousal caregivers. It is aimed at maintaining well-being by increasing social support and decreasing family discord, thereby delaying or avoiding nursing home placement of the person with dementia. Training in the NYUCI in the United States has, until now, been conducted in person to trainee practitioners. The Internet-based intervention was developed simultaneously for trainees in the U.S. and Australia. In Australia, due to population geography, community healthcare workers, who provide support to older adult caregivers of people with dementia, live and work in many regional and rural areas. Therefore, it was especially important to have online training available to make it possible to realize the health and economic benefits of using an existing evidence-based intervention. This study aimed to transfer knowledge of training in, and delivery of, the NYUCI for an Australian context and consumers. This article details the considerations given to contextual differences and to learners’ skillset differences in translating the NYUCI for Australia.

Development of a switch mode assisted linear amplifier for use as a high fidelity voltage source

Frequency Domain Spectroscopy (FDS) is one of the major techniques used for determining the condition of the cellulose based paper and pressboard components in large oil/paper insulated power transformers. This technique typically makes use of a sinusoidal voltage source swept from 0.1 mHz to 1 kHz. The excitation test voltage source used must meet certain characteristics, such as high output voltage, high fidelity, low noise and low harmonic content. The amplifier used; in the test voltage source; must be able to drive highly capacitive loads. This paper proposes that a switch-mode assisted linear amplifier (SMALA) can be used in the test voltage source to meet these criteria. A three level SMALA prototype amplifier was built to experimentally demonstrate the effectiveness of this proposal. The developed SMALA prototype shows no discernable harmonic distortion in the output voltage waveform, or the need for output filters, and is therefore seen as a preferable option to pulse width modulated digital amplifiers. The lack of harmonic distortion and high frequency switching noise in the output voltage of this SMALA prototype demonstrates its feasibility for applications in FDS, particularly on highly capacitive test objects such as transformer insulation systems.

Impact of rRNA methylations on ribosome recycling and fidelity of initiation in Escherichia coli

Ribosomal RNA (rRNA) contains a number of modified nucleosides in functionally important regions including the intersubunit bridge regions. As the activity of ribosome recycling factor (RRF) in separating the large and the small subunits of the ribosome involves disruption of intersubunit bridges, we investigated the impact of rRNA methylations on ribosome recycling. We show that deficiency of rRNA methylations, especially at positions 1518 and 1519 of 16S rRNA near the interface with the 50S subunit and in the vicinity of the IF3 binding site, adversely affects the efficiency of RRF-mediated ribosome recycling. In addition, we show that a compromise in the RRF activity affords increased initiation with a mutant tRNA(fMet) wherein the three consecutive G-C base pairs ((29)GGG(31):39CCC41), a highly conserved feature of the initiator tRNAs, were mutated to those found in the elongator tRNA(Met) ((29)UCA(31):(39)psi GA(41)). This observation has allowed us to uncover a new role of RRF as a factor that contributes to fidelity of initiator tRNA selection on the ribosome. We discuss these and earlier findings to propose that RRF plays a crucial role during all the steps of protein synthesis.

Crucial contribution of the multiple copies of the initiator tRNA genes in the fidelity of tRNA(fMet) selection on the ribosomal P-site in Escherichia coli

The accuracy of the initiator tRNA (tRNA(fMet)) selection in the ribosomal P-site is central to the fidelity of protein synthesis. A highly conserved occurrence of three consecutive G-C base pairs in the anticodon stem of tRNA(fMet) contributes to its preferential selection in the P-site. In a genetic screen, using a plasmid borne copy of an inactive tRNA(fMet) mutant wherein the three G-C base pairs were changed, we isolated Escherichia coli strains that allow efficient initiation with the tRNA(fMet) mutant. Here, extensive characterization of two such strains revealed novel mutations in the metZWV promoter severely compromising tRNA(fMet) levels. Low cellular abundance of the chromosomally encoded tRNA(fMet) allows efficient initiation with the tRNA(fMet) mutant and an elongator tRNA(Gln), revealing that a high abundance of the cellular tRNA(fMet) is crucial for the fidelity of initiator tRNA selection on the ribosomal P-site in E. coli. We discuss possible implications of the changes in the cellular tRNA(fMet) abundance in proteome remodeling.

Quantum fidelity for one-dimensional Dirac fermions and two-dimensional Kitaev model in the thermodynamic limit

We study the scaling behavior of the fidelity (F) in the thermodynamic limit using the examples of a system of Dirac fermions in one dimension and the Kitaev model on a honeycomb lattice. We show that the thermodynamic fidelity inside the gapless as well as gapped phases follow power-law scalings, with the power given by some of the critical exponents of the system. The generic scaling forms of F for an anisotropic quantum critical point for both the thermodynamic and nonthermodynamic limits have been derived and verified for the Kitaev model. The interesting scaling behavior of F inside the gapless phase of the Kitaev model is also discussed. Finally, we consider a rotation of each spin in the Kitaev model around the z axis and calculate F through the overlap between the ground states for the angle of rotation eta and eta + d eta, respectively. We thereby show that the associated geometric phase vanishes. We have supplemented our analytical calculations with numerical simulations wherever necessary.

Quantum fidelity for one-dimensional Dirac fermions and two-dimensional Kitaev model in the thermodynamic limit

We study the scaling behavior of the fidelity (F) in the thermodynamic limit using the examples of a system of Dirac fermions in one dimension and the Kitaev model on a honeycomb lattice.We show that the thermodynamic fidelity inside the gapless as well as gapped phases follow power-law scalings, with the power given by some of the critical exponents of the system. The generic scaling forms of F for an anisotropic quantum critical point for both the thermodynamic and nonthermodynamic limits have been derived and verified for the Kitaev model. The interesting scaling behavior of F inside the gapless phase of the Kitaev model is also discussed. Finally, we consider a rotation of each spin in the Kitaev model around the z axis and calculate F through the overlap between the ground states for the angle of rotation η and η + dη, respectively. We thereby show that the associated geometric phase vanishes. We have supplemented our analytical calculations with numerical simulations wherever necessary

Fidelity susceptibility of one-dimensional models with twisted boundary conditions

Recently it has been shown that the fidelity of the ground state of a quantum many-body system can be used todetect its quantum critical points (QCPs). If g denotes the parameter in the Hamiltonian with respect to which the fidelity is computed, we find that for one-dimensional models with large but finite size, the fidelity susceptibility chi(F) can detect a QCP provided that the correlation length exponent satisfies nu < 2. We then show that chi(F) can be used to locate a QCP even if nu >= 2 if we introduce boundary conditions labeled by a twist angle N theta, where N is the system size. If the QCP lies at g = 0, we find that if N is kept constant, chi(F) has a scaling form given by chi(F) similar to theta(-2/nu) f (g/theta(1/nu)) if theta << 2 pi/N. We illustrate this both in a tight-binding model of fermions with a spatially varying chemical potential with amplitude h and period 2q in which nu = q, and in a XY spin-1/2 chain in which nu = 2. Finally we show that when q is very large, the model has two additional QCPs at h = +/- 2 which cannot be detected by studying the energy spectrum but are clearly detected by chi(F). The peak value and width of chi(F) seem to scale as nontrivial powers of q at these QCPs. We argue that these QCPs mark a transition between extended and localized states at the Fermi energy. DOI: 10.1103/PhysRevB.86.245424

Quantum phases of dimerized and frustrated Heisenberg spin chains with s=1/2, 1 and 3/2: an entanglement entropy and fidelity study

We study here different regions in phase diagrams of the spin-1/2, spin-1 and spin-3/2 one-dimensional antiferromagnetic Heisenberg systems with frustration (next-nearest-neighbor interaction J(2)) and dimerization (delta). In particular, we analyze the behaviors of the bipartite entanglement entropy and fidelity at the gapless to gapped phase transitions and across the lines separating different phases in the J(2)-delta plane. All the calculations in this work are based on numerical exact diagonalizations of finite systems.

Distinctive contributions of the ribosomal P-site elements m(2)G966, m(5)C967 and the C-terminal tail of the S9 protein in the fidelity of initiation of translation in Escherichia coli

The accuracy of pairing of the anticodon of the initiator tRNA (tRNA(fMet)) and the initiation codon of an mRNA, in the ribosomal P-site, is crucial for determining the translational reading frame. However, a direct role of any ribosomal element(s) in scrutinizing this pairing is unknown. The P-site elements, m(2)G966 (methylated by RsmD), m(5)C967 (methylated by RsmB) and the C-terminal tail of the protein S9 lie in the vicinity of tRNA(fMet). We investigated the role of these elements in initiation from various codons, namely, AUG, GUG, UUG, CUG, AUA, AUU, AUC and ACG with tRNA(CAU)(fmet) (tRNA(fMet) with CAU anticodon); CAC and CAU with tRNA(GUG)(fme); UAG with tRNA(GAU)(fMet) using in vivo and computational methods. Although RsmB deficiency did not impact initiation from most codons, RsmD deficiency increased initiation from AUA, CAC and CAU (2- to 3.6-fold). Deletion of the S9 C-terminal tail resulted in poorer initiation from UUG, GUG and CUG, but in increased initiation from CAC, CAU and UAC codons (up to 4-fold). Also, the S9 tail suppressed initiation with tRNA(CAU)(fMet)lacking the 3GC base pairs in the anticodon stem. These observations suggest distinctive roles of 966/967 methylations and the S9 tail in initiation.