Long-Term Impact of a Low-Cost Paediatric Intussusception Air Enema Reduction Simulation-Based Education Programme in a Low-Middle Income Country.

INTRODUCTION: Intussusception is one of the commonest causes of bowel obstruction in infants. Most infants in Low- and Middle-Income Countries (LMICs) undergo an invasive operative intervention. Supported by simulation-based education (SBE), the Air Enema (AE) non-operative technique was introduced in 2016 in Myanmar. This study assesses the long-term outcomes. METHODS: Mixed methods study design over 4 years including clinical outcomes and surgeon's attitudes towards the AE technique and SBE. Prospectively collected clinical outcomes and semi-structured interview with reflexive thematic analysis (RTA). Primary outcome measure was a long-term shift to non-operative intervention. SECONDARY OUTCOMES: Length of Stay (LoS), recurrence rates, intestinal resection rates, compared to the operative group. The data was analysed according to intention to treat. Quantitative data analysis with Mann-Whitney U test, Fisher's exact test, Student's T-Test or Wilcoxon Signed-Rank Test utilised. A p-value of <.05 was considered significant. RESULTS: A total of 311 infants with intussusception were included. A sustained shift to AE was revealed with high success rates (86.1-91.2%). AE had a reduced LoS (4 vs. 7 days p ≤ 0.0001), Duration of Symptoms (DoS) was lower with AE (1.9/7 vs. 2.5/7, p = 0.002). Low recurrence rates (0-5.8%) and intestinal resection rates stabilised at 30.5-31.8% vs.15.3% pre-intervention. Four RTA themes were identified: Expanding conceptions of healthcare professional education and training; realising far reaching advantages; promoting critical analysis and reflective practice of clinicians; and adapting clinical practice to local context. RTA revealed an overall positive paradigm shift in attitudes and application of SBE. CONCLUSIONS: A sustained change in clinical outcomes and appreciation of the value of SBE was demonstrated following the intervention.

Microbial composition affects the performance of an artificial Tephritid larval diet.

The present study investigated the patterns of microorganisms in an artificial larval diet during Dacus ciliatus (Diptera; Tephritidae) larval development. Microbial population contents in the diet of total heterotrophic bacteria, yeast and molds, coliform and lactobacilli, and their dynamics during development, were monitored. Initially, the microbial composition in diet trays failing to produce viable pupae and in trays successfully producing pupae and adult flies was characterized. The failing diet trays contained large populations of lactobacilli that increased during larval development, and low populations of coliforms. In contrast, the successful diet showed an increasing population of coliforms and a low, or undetected, population of lactobacilli. To study the hypothesis that lactobacilli affect D. ciliatus larval development, we conducted controlled inoculation experiments in which Lactobacillus plantarum was added into fresh diet at the time of egg seeding. L. plantarum inoculated trays showed no production of D. ciliatus. Control trays without lactobacilli inoculation showed variable results. One tray successfully produced viable pupae and adults, and showed a slight and slow increase in the indigenous populations of lactobacilli. The second tray, however, failed to produce pupae and showed a fast increase of the indigenous lactobacilli to very high levels. Monitored pH trends in L. plantarum-inoculated diet showed a sharp pH decrease during the first 4 days of larval development from 5 to less than 4 units, while successful diet, producing viable D. ciliatus pupae and adults, showed a moderate pH drop during most of the larval development period. The paper discusses the possible ecological interactions between D. ciliatus larvae, the microbial content of the diet and the physical properties of the diet. The discussion also points out at the usefulness of this approach in understanding and managing mass production parameters of tephritid fruit flies industrial diets used for Sterile Insect Technique.

Values and value in simulated participant methodology: A global perspective on contemporary practices.

This article has been written for the 40th year of the publication of Medical Teacher. While we celebrate the contribution of simulated participants (SPs) to health professions education through values and value-based learning, we also offer critical reflection on elements of our practice, commencing with language. We argue for the use of the term simulated rather than standardized and acknowledge the dominant role of the SP as patient and the origins of the methodology. These shifts in terms and their implications in practice reflect changes in the conceptualization of SP-based methodology. Recently published standards for those who work with SPs (SP practitioners) are noted as an important milestone in our community's development. We consider contemporary practices addressing the complex notions of values and value in SP-based learning. We simultaneously refer to the work of SPs and SP practitioners. Phases of educational design including identifying learning objectives, scenario design, implementation, feedback and debriefing are used to illustrate methodological shifts. Within each of these phases, there are relational issues that have to date often gone unchecked and are under reported in literature. Finally, using the metaphor of a murmuration, we celebrate contemporary practices of the global SP practitioner community.

Ad hoc supervision of general practice registrars as a 'community of practice': analysis, interpretation and re-presentation.

General practice registrars in Australia undertake most of their vocational training in accredited general practices. They typically see patients alone from the start of their community-based training and are expected to seek timely ad hoc support from their supervisor. Such ad hoc encounters are a mechanism for ensuring patient safety, but also provide an opportunity for learning and teaching. Wenger's (Communities of practice: learning, meaning, and identity. Cambridge University Press, New York, 1998) social theory of learning ('communities of practice') guided a secondary analysis of audio-recordings of ad hoc encounters. Data from one encounter is re-presented as an extended sequence to maintain congruence with the theoretical perspective and enhance vicariousness. An interpretive commentary communicates key features of Wenger's theory and highlights the researchers' interpretations. We argue that one encounter can reveal universal understandings of clinical supervision and that the process of naturalistic generalisation allows readers to transfer others' experiences to their own contexts. The paper raises significant analytic, interpretive, and representational issues. We highlight that report writing is an important, but infrequently discussed, part of research design. We discuss the challenges of supporting the learning and teaching that arises from adopting a socio-cultural lens and argue that such a perspective importantly captures the complex range of issues that work-based practitioners have to grapple with. This offers a challenge to how we research and seek to influence work-based learning and teaching in health care settings.

Laboratory longevity and competitiveness of Dacus ciliatus Loew (Diptera: Tephritidae) following sub-sterilizing gamma irradiation.

The effect of a sub-sterilizing gamma radiation dose on Dacus ciliatus adults was investigated to assess the suitability of the sterile insect technique (SIT) as an alternative method to control this pest. Late pupae (48 h prior to adult emergence) from a laboratory strain were irradiated with 120 Gy of gamma rays emitted by a 60Co source. Following adult emergence, the mortality of irradiated and non-irradiated cohorts was recorded. Over a period of 50 days after emergence, no significant negative effects of irradiation upon the longevity of male or female laboratory flies were observed. A laboratory competitiveness study (Fried test), using irradiated laboratory and wild males at a ratio of 3:1 was conducted to assess the ability of irradiated males to reduce the egg hatch rates of a wild population. The overall competitiveness was found to be ca. 0.32, suggesting a reduced, but satisfactory, quality of irradiated laboratory as compared with wild males. Based on the above findings, we calculated and proposed effective male release ratios for field application of SIT against D. ciliatus.

Larval nutritional-stress and tolerance to extreme temperatures in the peach fruit fly, Bactrocera zonata (Diptera: Tephritidae).

Within the factors affecting insect tolerance to extreme environmental conditions, insect nutrition, particularly of immature stages, has received insufficient attention. In the present study, we address this gap by investigating the effects of larval nutrition on heat and cold tolerance of adult Bactrocera zonata - an invasive, polyphagous fruit fly pest. We manipulated the nutritional content in the larval diet by varying the amount of added yeast (2-10% by weight), while maintaining a constant sucrose content. Adults derived from the different larval diets were tested for their tolerance to extreme heat and cold stress. Restricting the amount of yeast reduced the efficacy of the larval diet (i.e. number of pupae produced per g of diet) as well as pupal and adult fresh weight, both being significantly lower for yeast-poor diets. Additionally, yeast restriction during the larval stage (2% yeast diet) significantly reduced the amount of protein but not lipid reserves of newly emerged males and females. Adults maintained after emergence on granulated sugar and water for 10 days were significantly more tolerant to extreme heat (i.e. knock-down time at 42 oC) when reared as larvae on yeast-rich diets (8% and 10% yeast) compared to counterparts developing on a diet containing 2% yeast. Nevertheless, the composition of the larval diet did not significantly affect adult survival following acute cold stress (exposure to -3°C for 2 hrs.). These results are corroborated by previous findings on Drosophilid flies. Possible mechanisms leading to nutrition-based heat-tolerance in flies are discussed.

Role of patient-specific virtual reality rehearsal in carotid artery stenting.

BACKGROUND: Recent advances in simulation science permit patient-specific rehearsal of endovascular stenting procedures. This study aimed to evaluate how effectively real interventions are replicated by patient-specific rehearsal technology, and to assess its value as a preparatory tool for the interventionalist and the operating team. METHODS: All patients deemed candidates for carotid artery stenting procedures with suitable computed tomography images were enrolled. Each team member rehearsed the virtual procedure in the laboratory, simulated operating theatre or angiography suite environment immediately before treating the real patient. Dexterity and qualitative metrics were recorded. Subjective questionnaires used a Likert scale from 1 (poor) to 5 (excellent). RESULTS: Of 18 patients, three were excluded. In 11 of 15 and 13 of 15 patients respectively endovascular tool use and fluoroscopy angles were identical during rehearsal and the real procedure. In a third of patients, the simulator did not adequately predict difficulties in cannulating the stenotic internal or common carotid arteries. The procedure realism, value in evaluating the case, increase in efficiency in tool use, and potential to increase communication, confidence and team performance were all rated highly (4 of 5). CONCLUSION: Patient-specific rehearsal was rated highly for both face and content validity. Access strategy, endovascular material use and angiographic imaging were all replicated effectively, although certain biomechanical vessel properties seemed to be replicated to a lesser degree. Patient-specific rehearsal constitutes a unique tool that may help tailor endovascular material choice, and optimize the preoperative preparation of the interventionalist and team.

Cytogenetic analysis of the Ethiopian fruit fly Dacus ciliatus (Diptera: Tephritidae).

The Ethiopian fruit fly, Dacus ciliatus, is an important pest of cucurbits, which recently invaded the Middle East. The genetics and cytogenetics of D. ciliatus have been scarcely studied. Such information is, however, an essential basis for understanding the biology of insect pests, as well as for the design of modern control strategies. We report here the mitotic karyotype and detailed photographic maps of the salivary gland polytene chromosomes of this species. The mitotic metaphase complement consists of six pairs of chromosomes, including one pair of heteromorphic sex (XX/XY) chromosomes. The heterogametic sex is ascribed to the male. The analysis of the salivary gland polytene complement shows a total number of five long chromosomes (10 polytene arms), which correspond to the five autosomes of the mitotic nuclei, and a heterochromatic mass corresponding to the sex chromosomes. Banding patterns, as well as the most characteristic features and prominent landmarks of each polytene chromosome are presented and discussed. Chromosomal homologies between D. ciliatus and Bactrocera oleae are proposed by comparing chromosome banding patterns and by in situ hybridization of the hsp70 gene.

Efficient implementation of patient-specific simulated rehearsal for the carotid artery stenting procedure: part-task rehearsal.

OBJECTIVE(S): Patient-specific simulated rehearsal (PsR) is a technological advance within the domain of endovascular virtual reality (VR) simulation. It allows incorporation of patient-specific computed tomography Digital Imaging and Communications in Medicine (CT DICOM) data into the simulation and subsequent rehearsal of real patient cases. This study aimed to evaluate whether a part-task rehearsal (PTr) of a carotid artery stenting procedure (CAS) on a VR simulator is as effective as a full-task (FTr) preoperative run through. METHODS: Medical trainees were trained in the CAS procedure and randomised to a PTr or FTr of a challenging CAS case (Type-II arch). PTr consisted of 30 min of repeated catheterisations of the common carotid artery (CCA). Thereafter, both groups performed the CAS procedure in a fully functional simulated operating suite (SOS) with an interventional team. Technical performances were assessed using simulator-based metrics and expert ratings. Other aspects of performance were assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring. RESULTS: Twenty trainees were evenly randomised to either PTr or FTr. No differences in performance were seen except for the total time the embolic protection device (EPD) was deployed (9.4 min for the PT vs. 8.1 min for the FT, p = 0.02). Total time (26.3 vs. 25.5 min, p = 0.94), fluoroscopy time (15.8 vs. 14.4 min, p = 0.68), number of roadmaps (10.5 vs. 11.0, p = 0.54), amount of contrast (53.5 vs. 58.0 ml, p = 0.33), time to deploy the EPD (0.9 vs. 0.8 min, p = 0.31) and time to catheterise the CCA (9.2 vs. 8.9 min, p = 0.94) were similar. Qualitative performances as measured by expert ratings (score 24 vs. 24, p = 0.49) and NOTSS (p > 0.05 for all categories) were also comparable. CONCLUSIONS: Part- and full-task rehearsals are equally effective with respect to the operative performance of a simulated CAS intervention. This finding makes a patient-specific rehearsal more efficient and may increase the feasibility of implementation of this technology into medical practice.

Assessment of surgical competence at carotid endarterectomy under local anaesthesia in a simulated operating theatre.

BACKGROUND: Methods of surgical training that do not put patients at risk are desirable. A high-fidelity simulation of carotid endarterectomy under local anaesthesia was tested as a tool for assessment of vascular surgical competence, as an adjunct to training. METHODS: Sixty procedures were performed by 30 vascular surgeons (ten junior trainees, ten senior trainees and ten consultants) in a simulated operating theatre. Each performed in a non-crisis scenario followed by a crisis scenario. Performance was assessed live by means of rating scales for technical and non-technical skills. RESULTS: There was a significant difference in technical skills with ascending grade for both generic and procedure-specific technical skill scores in both scenarios (P < 0.001 for all comparisons). Similarly, there was also a significant difference in non-technical skill with ascending grade for both scenarios (P < 0.001). There was a highly significant correlation between technical and non-technical performance in both scenarios (non-crisis: r(s) = 0.80, P < 0.001; crisis: r(s) = 0.85, P < 0.001). Inter-rater reliability was high (alpha > or = 0.80 for all scales). CONCLUSION: High-fidelity simulation offers competency-based assessment for all grades and may provide a useful training environment for junior trainees and more experienced surgeons.

Simulated participant methodology in paediatric surgical training: Exploring contemporary practices.

Surgical training is long and complex. At the core of clinical practice is communication. Voice is central to relationships of care. Communication and other person-centred competencies are well articulated in surgical training programs. Simulated participant (SP) methodology has seen significant development over its contemporary history. Most commonly in paediatrics SPs portray the roles of parents. However, children and adolescents as SPs are increasingly employed to support the development and assessment of the complex concept of voice. There are specific considerations in all phases of SP-based work, and these are heightened for children and adolescents. This article explores contemporary SP practices in health professional education with a focus on paediatric surgery training.

Diel rhythm of volatile emissions of males and females of the peach fruit fly Bactrocera zonata.

Fruit flies in the genus Bactrocera are among the most destructive insect pests of fruits and vegetables throughout the world. A number of studies have identified volatiles from fruit flies, but few reports have demonstrated behavioral effects or sensitivities of fly antennae to these compounds. We applied a recently developed method of automated headspace analysis using SPME (Solid Phase Microextraction) fibers and GC-MS (gas chromatography mass spectrometry), termed SSGA, to reveal volatiles specific to each sex of B. zonata that are emitted in a diel periodicity. The volatiles released primarily at dusk were identified by GC-MS and chemical syntheses as several spiroacetals, pyrazines, and ethyl esters. Solvent extraction of male rectal glands or airborne collections from each sex, followed by GC-MS, showed that certain of the volatiles increase or decrease in quantity sex-specifically with age of the flies. Electroantennographic (EAG) analysis of dose-response indicates differences in sensitivities of male and female antenna to the various volatiles. Our study provides a comprehensive analysis of the volatile chemicals produced and released by B. zonata and their antennal responses. The possible pheromone and semiochemical roles of the various volatiles released by each sex and the difficulties of establishing behavioral functions are discussed.

Gaining consent for carotid surgery: a simulation-based study of vascular surgeons.

AIM: Despite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA). METHODS: Thirty-two surgeons [Group 1: junior surgical trainees--performed 0 CEA's (n=11); 2: senior vascular trainees--1-50 CEA's (n=11); 3: consultant vascular surgeons - > 50 CEA's (n=10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors. RESULTS: There was no difference in performance between the junior and senior trainees (1: median 91 range 64-121; 2: median 100.5 range 66-125; p=0.118 1 vs. 2 Mann-Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89-1 142; p=0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (alpha=0.832). Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p<0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p<0.0001) than their junior counterparts. They were less likely to discuss infection (p<0.0001). CONCLUSION: Senior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.

Training and assessment of procedural skills in context using an Integrated Procedural Performance Instrument (IPPI).

The use of simulation in the training and assessment of procedural skills is widely acknowledged as a powerful and necessary alternative to the traditional apprenticeship model. However advanced, simulation on its own cannot provide the necessary conditions for holistic practice. The Integrated Procedural Performance Instrument presented in this paper combines simulated patients (SPs) with inanimate models, items of medical equipment or computer generated virtual models to recreate a panel of realistic scenarios, each addressing a combination of technical and non-technical clinical challenges. The result is a safe yet authentic clinical context which can be used for training and assessment. This novel use of simulation provides a patient-centred, learner-focused approach that builds up a composite picture of technical skills, communication skills and professional behaviours across a range of challenging clinical situations.

The foraging kinetics of ground ant communities in different mexican coffee agroecosystems.

Foraging efficiency was studied by measuring the rate of tuna fish bait discovery by ants in unshaded and two types of shaded coffee systems. We also investigated the effect of weed biomass upon ant foraging efficiency. We found that the rate of discovery was faster in the coffee system with no shade than in systems with shade trees. The rate of discovery in the two types of shade systems (monospecific and polyspecific shade) was similar. Differences in the foraging rate between systems seem to be related to the composition of the ground ant community in each of the systems, and to cumulative factors such as plant diversity, microclimate and interspecific competition. No correlation was found between weed biomass and ant foraging efficiency. The results of this study support the idea of manipulating agroecosystem plant and structural diversity in order to enhance pest regulation by ants.

Teaching and learning about sexual histories during undergraduate medical education: a comparison of two approaches.

Experiential small group workshops on taking a sexual history were introduced at Imperial College School of Medicine (ICSM). With the introduction of a new curriculum and an increase in the number of students, together with a growing awareness of economic constraints in medical education, a large group session on the same topic was developed. In both sessions students identify barriers to taking a sexual history, contexts in which a sexual history is appropriate and skills necessary for an effective sexual history interview. This paper describes and contrasts the content, methodology and student evaluations of both types of sessions. The results showed that in the short term students perceived benefits from both methods of teaching. Further work is required to determine the long-term effects of such training.

An evaluation of a communication skills workshop for dentists: cultural and clinical relevance of the patient-centred interview.

The benefits for both doctors and patients of effective communication skills in medical care have been widely documented and are generally accepted. There has been less research on this topic with respect to dental care. However, based on available studies and the reported success of teaching communication skills at the undergraduate level in dental schools, a workshop was developed to improve the communication skills of dentists working in government clinics in Hong Kong. The patient-centred interview as used in medical care formed the basis for teaching communication skills in this workshop. Objective and subjective measures of dentists' knowledge, attitude and skills related to the patient-centred interview were obtained before, immediately and eight weeks after the workshops. Objective measures showed immediate gains in knowledge. However, attitudes declined during the period of study. Subjective evaluations revealed improved communication skills eight weeks after the workshop and that the patient-centred interview was considered relevant to the practices of these dentists. Participants made specific reference to the concept of empathy as a means of promoting more effective communication between dentists and patients.

Communication challenges in surgical oncology.

In this essay we set out clinical communication challenges in surgical oncology. We draw directly on relevant examples where they are available. Otherwise, we refer to the more generic surgical and medical literature. We offer 'macro' and 'micro' perspectives on clinical communication. That is, exploring communication challenges at the level of the organization and between individuals, doctors and patients and interprofessionally across different settings. Training content and methods are reported that address the complex communication challenges associated with surgical oncology. Innovations in simulation-based education offer exciting new opportunities for formative and summative assessment. We outline limitations of the essay and finally propose the content of a surgical oncology communication program.

Management of protein intake in the fruit fly Anastrepha fraterculus.

This work tested if carbohydrates and proteins ingestion is regulated in the South American fruit fly, Anastrepha fraterculus, to optimize survival and reproduction. Adult food treatments were established by providing sugar and hydrolyzed yeast in various combinations either alone or mixed at a standard 3:1 ratio (sugar:hydrolyzed yeast). Individual food consumption was assessed and related to survival patterns. The effects of adult feeding on fecundity and fertility patterns were investigated in groups of flies. Sugar consumption was the lowest in the treatment where it was provided with hydrolyzed yeast at a fixed 3:1 ratio. Consumption of hydrolyzed yeast did not differ between this treatment and the one in which this solution was complemented with one solution of sugar. It seems that a mixture of sugar and hydrolyzed yeast at a fixed ratio of 3:1, respectively, restricts extra ingestion of sugar; most probably because of negative response of the fly to overconsumption of protein. Survival was affected by the treatments, being lower in those cases where protein was at the fixed ratio. Group experiments revealed that protein restriction expanded longevity and decreased egg production. In contrast, egg production was enhanced when flies were kept continuously with a mixture of yeast and sugar plus an extra source of sugar, and this was not in detriment of survival. Our results suggest that fixed sugar-protein ratios in which protein is in excess affects fitness components such as longevity and reproduction. These findings are discussed from a theoretical and applied perspective in the context of pest control by means of the sterile insect technique.

Patient-specific simulation for endovascular procedures: qualitative evaluation of the development process.

BACKGROUND: Recent advancements in simulation permit patient-specific rehearsal of carotid artery stenting procedures. This study evaluates the feasibility of transferring patient-specific CT data into the simulator, creating a 3D reconstruction and performing a rehearsal. The face validity of the model was assessed. METHODS/RESULTS: By thematic analysis of qualitative data, an algorithm was generated, focusing on simulation set-up, time of data transfer, software/compatibility issues and problem-solving strategies. The face validity of the simulated case was evaluated by 15 expert interventionalists: realism (median 4/5), training potential (median 4/5) and pre-procedure rehearsal potential for challenging CAS cases (median 4/5) were rated highly. CONCLUSIONS: Setting up a procedure rehearsal is feasible and reproducible for different patients in different hospital settings without major software compatibility issues. The time to create a 3D reconstruction of patient-specific CT data is a major factor in the total time necessary to set up a rehearsal. The face validity is highly rated by experts.