The Advanced Modular Manikin Open Source Platform for Healthcare Simulation.

INTRODUCTION: Current thinking in healthcare education stipulates a holistic approach with a focus on patient management, bringing together technical skills, decision-making, and team performance. In parallel, training opportunities with actual patients have diminished, and the number of different interventions to master has increased. Training on simulators has become broadly accepted; however, requirements for such training devices have outpaced the development of new simulators. The Department of Defense (DoD) targeted this gap with a development challenge. This article introduces the Advanced Modular Manikin (AMM) platform and describes the path followed to address the challenge. MATERIALS AND METHODS: Under Contract # W81XWH-14-C-0101, our interdisciplinary team of healthcare providers, educators, engineers, and scientists, together with partners in industry and the government collaborated to establish a set of comprehensive requirements and develop an overarching system architecture and specifications to meet healthcare simulation needs. In order to instantiate the architecture and investigate usability of the platform, a demonstration modular manikin was created that incorporated physical and digital peripherals. RESULTS: The system architecture and corresponding data models have been completed and published as open source. A developer's tool kit has been created, including instructional materials and required hardware and software for interested parties to develop AMM-compatible modules. A reference manikin was created based on the platform specifications and successfully supported a usability study that was performed by the American College of Surgeons, Education Division at the Naval Medical Center San Diego. CONCLUSIONS: The formal release of a functional modular, interoperable open-source healthcare simulation platform is complete. Next steps involve a strategy for maintaining the open standards and verification of AMM-compatibility for modules. Increasing awareness of this powerful tool and prioritization of module-development to address the wide range of healthcare education needs could lead to a renaissance in military and civilian healthcare simulation-based training.

Skill Transference of a Probe-Tube Placement Training Simulator.

BACKGROUND: Probe-tube placement is a necessary step in hearing aid verification which needs ample hands-on experience and confidence before performing in clinic. To improve the methods of training in probe-tube placement, a manikin-based training simulator was developed consisting of a 3D-printed head, a flexible silicone ear, and a mounted optical tracking system. The system is designed to provide feedback to the user on the depth and orientation of the probe tube, and the time required to finish the task. Although a previous validation study was performed to determine its realism and teachability with experts, further validation is required before implementation into educational settings. PURPOSE: This study aimed to examine the skill transference of a newly updated probe-tube placement training simulator to determine if skills learned on this simulator successfully translate to clinical scenarios. RESEARCH DESIGN: All participants underwent a pretest in which they were evaluated while performing a probe-tube placement and real-ear-to-coupler difference (RECD) measurement on a volunteer. Participants were randomized into one of two groups: the simulator group or the control group. During a two-week training period, all participants practiced their probe-tube placement according to their randomly assigned group. After two weeks, each participant completed a probe-tube placement on the same volunteer as a posttest scenario. STUDY SAMPLE: Twenty-five novice graduate-level student clinicians. DATA COLLECTION AND ANALYSIS: Participants completed a self-efficacy questionnaire and an expert observer completed a questionnaire evaluating each participant's performance during the pre- and posttest sessions. RECD measurements were taken after placing the probe tube and foam tip in the volunteer's ear. Questionnaire results were analyzed through nonparametric t-tests and analysis of variance, whereas RECD results were analyzed using a nonlinear mixed model method. RESULTS: Results suggested students in the simulator group were less likely to contact the tympanic membrane when placing a probe tube, appeared more confident, and had better use of the occluding foam tip, resulting in more improved RECD measurements. CONCLUSIONS: The improved outcomes for trainees in the simulator group suggest that supplementing traditional training with the simulator provides useful benefits for the trainees, thereby encouraging its usage and implementation in educational settings.

Digital Health Professions Education in the Field of Pediatrics: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration.

BACKGROUND: Reducing childhood morbidity and mortality is challenging, particularly in countries with a shortage of qualified health care workers. Lack of trainers makes it difficult to provide the necessary continuing education in pediatrics for postregistration health professionals. Digital education, teaching and learning by means of digital technologies, has the potential to deliver medical education to a large audience while limiting the number of trainers needed. OBJECTIVE: The goal of the research was to evaluate whether digital education can replace traditional learning to improve postregistration health professionals' knowledge, skills, attitudes, and satisfaction and foster behavior change in the field of pediatrics. METHODS: We completed a systematic review of the literature by following the Cochrane methodology. We searched 7 major electronic databases for articles published from January 1990 to August 2017. No language restrictions were applied. We independently selected studies, extracted data, and assessed risk of bias, and pairs of authors compared information. We contacted authors of studies for additional information if necessary. All pooled analyses were based on random effects models. We included individually or cluster randomized controlled trials that compared digital education with traditional learning, no intervention, or other forms of digital education. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. RESULTS: Twenty studies (1382 participants) were included. Participants included pediatricians, physicians, nurses, and midwives. Digital education technologies were assessed including high-fidelity mannequins (6 studies), computer-based education (12 studies), mobile learning (1 study), and virtual reality (1 study). Most studies reported that digital education was either as effective as or more effective than the control intervention for outcomes including skill, knowledge, attitude, and satisfaction. High-fidelity mannequins were associated with higher postintervention skill scores compared with low-fidelity mannequins (standardized mean difference 0.62; 95% CI 0.17-1.06; moderate effect size, low-quality evidence). One study reported physician change in practicing behavior and found similar effects between offline plus online digital education and no intervention. The only study that assessed impact on patient outcome found no difference between intervention and control groups. None of the included studies reported adverse or untoward effects or economic outcomes of the digital education interventions. The risk of bias was mainly unclear or high. The quality of evidence was low due to study inconsistencies, limitations, or imprecision across the studies. CONCLUSIONS: Digital education for postregistration health professions education in pediatrics is at least as effective as traditional learning and more effective than no learning. High-fidelity mannequins were found to be more effective at improving skills than traditional learning with low-fidelity mannequins. Computer-based offline/online digital education was better than no intervention for knowledge and skill outcomes and as good as traditional face-to-face learning. This review highlights evidence gaps calling for more methodologically rigorous randomized controlled trials on the topic. TRIAL REGISTRATION: PROSPERO CRD42017057793; https://tinyurl.com/y5q9q5o6.

Promoting experiential learning through the use of high-fidelity human patient simulators in midwifery: A qualitative study.

BACKGROUND:  The need to use innovative teaching and learning strategies in the nursing pedagogy is important in the 21st century. The challenges of clinical sites and opportunities for nursing students to gain clinical experience are a growing concern for many nurse educators. High-fidelity human patient simulators (HFHPS) are computerised mannequins that replicate a real-life patient, and when integrated into classroom teaching they allow students to become fully immersed into an almost real-life scenario. OBJECTIVES:  The aim of this study was to describe how HFHPS can promote experiential learning following the management of postpartum haemorrhage as a midwifery clinical emergency. METHOD:  A descriptive qualitative research approach was carried out in this study. The research setting was a local university in KwaZulu-Natal. The total population included all (N = 43) fourth-year baccalaureate of nursing undergraduate student midwives who participated as observers and/or role-players of a scenario role-play. An all-inclusive sampling was performed. There were 43 student midwives involved in the simulation teaching session with 6 of these students actively participating in each role-play at a time, while the remaining 37 observed. This occurred in two separate sessions and all the student midwives were involved in a debriefing session. These student midwives were then followed up and asked to participate in a focus group. The data in this article came from two separate focus groups which comprised 20 student midwives in total. Data were analysed using content analysis. RESULTS:  Four categories emerged from the data, namely HFHPS offers a unique opportunity for student midwives to manage complex real-life emergencies; promotes reflection by allowing student midwives to reflect or review their roles, decisions and skills; allows student midwives to learn from their own experiences and encourages student midwives to try out what they learnt in a real-life situation. CONCLUSION:  High-fidelity human patient simulators can be used in a complex case scenario to promote experiential learning of a clinical emergency.

Local anaesthesia training for undergraduate students - how big is the step from model to man?

BACKGROUND: Local anesthesia is an important skill and a prerequisite for most dental treatments. However, the step from theory to application on the patient is huge for the novice. Hence, a mannequin training model course was developed and implemented into the existing local anesthesia curriculum in undergraduate dental students. It was the aim of this study to evaluate the relation between training-model and real-life anesthesia performance and to measure whether a gain in skill on the model translates to the actual patient situation. METHODS: Thirty-six third-year students (14 males, 22 females, age 24 years±2.98) attended the four-day course comprising each 4 h of lectures and practical training. The student cohort gave subjective ratings about the didactical components of the course after attendance by using the TRIL questionnaire (TRIL-mod; University of Trier). At the end of the course the performance of each student in administering an inferior alveolar nerve (IAN) block on the training model as well as on a fellow dental student was investigated using a standardized checklist. To evaluate the successful performance, the in vivo IAN-block was assessed using subjective patient-feeling, the sharp-blunt test and an objective pain- and thermal sensitivity tester (PATH). RESULTS: The course was rated with an average score of 5.25 ± 0.44 (range 1-6; 6 = best). On the training model, 69.4% of the students successfully performed an IAN-block. The in vivo assessment, objectified by the PATH test, showed a successful anesthesia in 36.9% of the cases. The assessment of local anesthesia by using the sharp blunt test and the subjective patient feeling significantly correlated with these findings (k = 0.453-0.751, p < 0.05). The model performance did not correlate with the performance on the patient (k = 0.137, p = 0.198). CONCLUSIONS: Although subjective ratings of the course were high, the anesthesia success rate on mannequin models did not imply an equal performance on the in vivo setting. As local anesthesia training models are a valuable didactic complement, the focus of the training should be on to the actual real life situation. Chair side feedback should be offered to the students using one of the presented evaluation methods.

The effect of mannequin fidelity on the achievement of learning outcomes for nursing, midwifery and allied healthcare practitioners: Systematic review and meta-analysis.

BACKGROUND: Simulation has demonstrated superiority over purely didactic instruction in multiple contexts, and educationalists have embraced this modality for enhancing access to clinical skills. However, there remains uncertainty if increasing the realism (fidelity) of simulation equipment heightens performance. To address this within nursing and allied health, this review examines if increasing equipment fidelity improves learning outcomes. METHODS: A systematic search of; CINAHL, Academic Search Complete, AMED; British Education Index, ERIC, MEDLINE, PsycARTICLES, PsycINFO, Maternity and Infant Care, INTERMID, Google Scholar, American Doctoral Dissertations, EThOS, ClinicalTrials.gov and ISRCTN registers was conducted for trials comparing two or more fidelity levels for knowledge, psychomotor or affective/non-technical outcomes. Data extraction and quality appraisal were performed and independently verified. Subgroup meta-analyses were undertaken (where viable), at post-intervention, intermediate, and long-term assessment time-frames. RESULTS: 18 RCTs and quasi-experimental trials containing ~1192 participants met the inclusion criteria. Almost ¾ of included trials exhibited high risk-of-bias. Training on higher-fidelity mannequins was associated with improved performance immediately post-intervention when compared with training on lower-fidelity mannequins for knowledge (p < 0.00001) and psychomotor outcomes (p < 0.00001). A similar directional effect for affective/non-technical skills was considered less robust due to substantial weaknesses in available studies. During follow-up testing at intermediate (1-3 weeks) and long-term (1-6 months) data points, there was insufficient evidence to determine any advantage in the use of higher fidelity mannequins. Repeated-intervention training was also insubstantially reported. CONCLUSION: Higher-fidelity mannequins exhibited modest advantages when testing closely followed training. However results need to be confirmed using a larger number of high quality RCTs. A greater body of research using repeated-interventions and extended time-frames is also required before the influence of sustained training with alternative mannequins can be fully elucidated.

[Study on the white channel system carved on the wooden acupoint figurine of Laoguanshan: comments on lacquer-coating acupoint figure].

There are two systems as the red channel system and the white channel system carved or painted on the wooden figurine of Laoguanshan of Benque school. The two systems are horizontally staggered each other without overlapped. The red channel system, similar to Shuangbaoshan wooden figurine, have channels, but without points. For the white channel system, the running courses of channels result from the sensation distributions of the points after optional stimulation. The Laoguanshan wooden figurine focuses on the illustration of the white channel system, named as white channel figurine. Compared with the Shuangbaoshan red channel figurine, together with examples, such as the running course of the white channel related to the meridian of heart-transfer-point, the white channel related to the belt vessel linking to lung-transfer-point, stomach-transfer-point and kidney-transfer-point, as well as the corresponding photographs. It is indicated that the Laoguanshan white channel figurine is a training aid for testing the sensation marching along channel (SMC) caused by transfer-point stimulation. The white channel system is a flexible way of channel. The study aims to observe the QI/SMC reaching the affected area and contributes to clinical practice. This discovery is not related to the "intermediate link theory" in the Yellow Emperor meridian system.

Training student pharmacists to administer emergency pediatric influenza vaccine: A comparison of traditional vs. just-in-time training.

INTRODUCTION: This study compared traditional training (TT) and just-in-time training (JITT) of P3 student pharmacists regarding interest, confidence, and comfort pre- and post-training (primary objective); and assessment and administration competency (secondary objective) during a simulated influenza vaccination clinic. METHODS: Student pharmacists were randomized 1:1 to receive either TT or JITT, completed pre- and post-training surveys assessing interest, confidence and comfort; and evaluated on performance during a simulated emergency infant vaccination. An infant manikin simulated a child <1 year of age, and an actor role-played the mother. All students received a briefing about the simulated mass vaccination prior to their performance assessment. Survey differences between groups were analyzed by ANOVA. The competency assessment was analyzed by a Chi-square or Fisher's exact test for individual steps and Student t-test for mean scores. RESULTS: Pre-training interest was high and maintained post-training. Pre-training confidence and comfort levels were low and improved in both groups. Mean competency scores were comparable between the TT and JITT groups. Comparing groups, TT students more commonly missed proper injection site selection and care; while JITT missed distracting the infant and administration documentation. DISCUSSION AND CONCLUSIONS: JITT for student pharmacists to learn skills required to immunize infants elicits similar outcomes (interest, confidence, comfort, and administration competency) as TT for emergency pediatric influenza vaccination.

Team Size and Stretching-Exercise Effects on Simulated Chest Compression Performance and Exertion.

INTRODUCTION: Investigators conducted a prospective experimental study to evaluate the effect of team size and recovery exercises on individual providers' compression quality and exertion. Investigators hypothesized that 1) larger teams would perform higher quality compressions with less exertion per provider when compared to smaller teams; and 2) brief stretching and breathing exercises during rest periods would sustain compressor performance and mitigate fatigue. METHODS: In Phase I, a volunteer cohort of pre-clinical medical students performed four minutes of continuous compressions on a Resusci-Anne manikin to gauge the spectrum of compressor performance in the subject population. Compression rate, depth, and chest recoil were measured. In Phase II, the highest-performing Phase I subjects were placed into 2-, 3-, and/or 4-compressor teams; 2-compressor teams were assigned either to control group (no recovery exercises) or intervention group (recovery exercises during rest). All Phase II teams participated in 20-minute simulations with compressor rotation every two minutes. Investigators recorded compression quality and real-time heart rate data, and calculated caloric expenditure from contact heart rate monitor measurements using validated physiologic formulas. RESULTS: Phase I subjects delivered compressions that were 24.9% (IQR1-3: [0.5%-74.1%]) correct with a median rate of 112.0 (IQR1-3: [103.5-124.9]) compressions per minute and depth of 47.2 (IQR1-3: [35.7-55.2]) mm. In their first rotations, all Phase II subjects delivered compressions of similar quality and correctness (p=0.09). Bivariate analyses of 2-, 3-, and 4-compressor teams' subject compression characteristics by subsequent rotation did not identify significant differences within or across teams. On multivariate analyses, only subjects in 2-compressor teams exhibited significantly lower compression rates (control subjects; p<0.01), diminished chest release (intervention subjects; p=0.03), and greater exertion over successive rotations (both control [p≤0.03] and intervention [p≤0.02] subjects). CONCLUSION: During simulated resuscitations, 2-compressor teams exhibited increased levels of exertion relative to 3- and 4-compressor teams for comparable compression delivery. Stretching and breathing exercises intended to assist with compressor recovery exhibited mixed effects on compression performance and subject exertion.

Motor imagery of body movements that can't be executed on Earth.

BACKGROUND: Before participating in a space mission, astronauts undergo parabolic-flight and underwater training to facilitate their subsequent adaptation to weightlessness. A quick, simple and inexpensive alternative could be training by motor imagery (MI). OBJECTIVE: An important prerequisite for this training approach is that humans are able to imagine movements which are unfamiliar, since they can't be performed in the presence of gravity. Our study addresses this prerequisite. METHODS: 68 young subjects completed a modified version of the CMI test (Schott, 2013). With eyes closed, subjects were asked to imagine moving their body according to six consecutive verbal instructions. After the sixth instruction, subjects opened their eyes and arranged the segments of a manikin into the assumed final body configuration. In a first condition, subjects received instructions only for moving individual body segments (CMIground). In a second condition, subjects received instructions for moving body segments or their full body (CMIfloat). After each condition, subjects were asked to rate their subjective visual and kinesthetic vividness of MI. RESULTS: Condition differences emerged for the CMI scores and for the duration of correct trials with better performance in the CMIground condition. Condition differences were also represented for the subjective MI performance. CONCLUSION: Motor imagery is possible but degraded when subjects are asked to imagine body movements while floating. This confirms that preflight training of MI while floating might be beneficial for astronauts' mission performance.

Talk to the Hand: U.S. Army Biophysical Testing.

BACKGROUND: Many people are unaware of the science underlying the biophysical properties of Soldier clothing and personal protective equipment, yet there is a well-refined biomedical methodology initiated by Army physiologists in World War II. This involves a methodical progression of systematic material testing technologies, computer modeling, and human testing that enables more efficient development and rapid evaluation of new concepts for Soldier health and performance. Sophisticated manikins that sweat and move are a central part of this testing continuum. This report briefly summarizes the evolution and use of one specialized form of the manikin technologies, the thermal hand model, and its use in research on Soldier hand-wear items that sustain dexterity and protect the hand in extreme environments. METHODS: Thermal manikin testing methodologies were developed to provide an efficient and consistent analytical tool for the rapid evaluation of new clothing concepts. These methods have been upgraded since the original World War II and Korean War eras to include articulation and sweating capabilities, as characterized and illustrated in this article. The earlier "retired" versions of thermal hand models have now been transferred to the National Museum of Health and Science. FINDINGS: The biophysical values from manikin testing are critical inputs to the U.S. Army Research Institute of Environmental Medicine mathematical models that provide predictions of soldier comfort, duration of exposure before loss of manual dexterity, and time to significant risk of freezing (skin temperature <-1°C) and nonfreezing cold injuries (skin temperature <5°C). The greater thickness of better insulated handwear reduces dexterity and also increases surface area which makes added insulation increasingly less effective in retaining heat. Measurements of both thermal resistance (insulation) and evaporative resistance (permeability) collectively characterize the biophysical properties and enable mathematical modeling of the human thermophysiological responses. This information can help guide the hand-wear development and selection process which often requires trade-offs between factors such as material, cost, and sizing. IMPACT: Soldier hands provide fine motor dexterity in tactical functions, ranging from pulling a trigger to pulling a parachute ripcord; thus, protecting hand function is critical to soldier readiness. Also, the importance of protection against nonbattle cold injuries was highlighted during World War II in northern Europe, in the Aleutian Islands, and later in Korea. The U.S. Army has been on the forefront of the biophysical analysis of clothing including gloves since environmental research was established at the Armored Medical Research Laboratory and Climatic Research Laboratory during World War II. U.S. Army Research Institute of Environmental Medicine does not make the equipment but works with their Natick Soldier Research, Development, and Engineering Center partners to make the equipment better.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists.

BACKGROUND: We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. METHODS: A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant's technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. RESULTS: Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. CONCLUSIONS: Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Thrust Magnitudes, Rates, and 3-Dimensional Directions Delivered in Simulated Lumbar Spine High-Velocity, Low-Amplitude Manipulation.

OBJECTIVES: The purpose of this study was to measure faculty performance of simulated spinal manipulation on a mannequin to help identify teaching standards. METHODS: We measured 3-dimensional transmitted loads using a force plate mounted in the table. Thrusts were delivered through a compliant, jointed mannequin by faculty members along predefined "listings" as taught in lumbopelvic technique courses. RESULTS: Eleven chiropractic faculty members participated, delivering 9 thrusts at 3 loads (light, moderate, and heavy) along 9 different prone and side-posture listings, totaling 81 thrusts per participant. Single-hand Gonstead-style thrusts had variability in magnitude across participants and loads: light thrusts averaged 365 N (95% confidence interval [CI] 327-402), moderate thrusts 454 N (421-487), and heavy thrusts 682 N (623-740). All faculty members could easily distinguish the loads within their performances, but there was some crossover of load levels between participants. Thrust rates averaged 3.55 N/ms (95% CI 3.29-3.82). The dominant vector of prone thrusts was in the z direction (vertically downward), but side-to-side and inferior-to-superior vector components occurred. CONCLUSION: Faculty member performance of simulated spinal manipulation indicated that they are able to control the thrust magnitude and rate as well as direction. In this sample, there was significant variability in peak loads between participants, which needs to be considered in student learning standards. These findings may be useful in translating the understanding of force characteristics to the technique teaching lab.

Temperature measurements in a capacitive system of deep loco-regional hyperthermia.

Hyperthermia has been shown to be a medically useful procedure applicable for different indications. For the connection between clinical effects and heat, it is important to understand the actual temperatures achieved in the tissue. There are limited temperature data available when using capacitive hyperthermia devices even though this is worldwide the most widespread method for loco-regional heating. Hence, this study examines temperature measurements using capacitive heating. Bioequivalent phantoms were used for the measurements, which, however, do not consider perfusion in live tissue. In general, the required temperature impact for an effective cancer therapy should need an increase of 0.2°C/min, which has been achieved. In the described tests on the non-perfused dummy, on average, the temperature increases by approximately 2°C in the first 12 min. The temperature difference relative to the starting temperature was 10-12°C within a therapy time of 60 min (rising from the initial room temperature between 20-24°C and 32-34°C). The average deviation with three individual measurements each on different days in a specified localization was 2°C. The minimum temperature difference was 4.2°C, and the maximum value was reached in the liver with 10.5°C. These values were achieved with a moderate energy input of 60-150 watts, with much higher performance outputs still available. These results show that the tested capacitive device is capable of achieving quick temperature increase with a sufficient impact into the depth of a body.

Manipulation Peak Forces Across Spinal Regions for Children Using Mannequin Simulators.

OBJECTIVE: The purpose of this work was to create an exploratory database of manipulation treatment force variability as a function of the intent of an experienced clinician sub-specializing in the care of children to match treatment to childhood category. Data of this type are necessary for realistic planning of dose-response and safety studies on therapeutic benefit. METHODS: The project evaluated the transmitted peak forces of procedures applied to mannequins of different stature for younger and older children. Common procedures for the cervical, thoracic, and lumbar spine and sacroiliac joint were administered to estimate variability by a single experienced practitioner and educator in pediatric manipulation attempting to modulate for childhood category. Results described for peak components in the cardinal axes and for peak total forces were cataloged and compared with consensus estimates of force from the literature. RESULTS: Mean force values for both components and total force peaks monotonically increased with childhood category analogous to consensus expectations. However, a mismatch was observed between peak values measured and consensus predictions that ranged by a factor of 2 to 3.5, particularly in the upper categories. Quantitative data permit a first estimate of effect size for future clinical studies. CONCLUSIONS: The findings of this study indicate that recalibration of spinal manipulation performance of experienced clinicians toward arbitrary target values similar to consensus estimates is feasible. What is unclear from the literature or these results is the identity of legitimate target values that are both safe and clinically effective based on childhood categories in actual practice.

Training effect of a stationary preprogrammed target dummy on visual response time and contest performance of karate athletes.

BACKGROUND: Response time (RT) is crucial in karate athletes and can be trained. The aim of this study was to compare standing eye-hand RT and contest performance in nonelite karate athletes who underwent 6 weeks of training using either a stationary preprogrammed target dummy (experimental group) or traditional karate instruction (control group). METHODS: Forty male nonelite karate athletes (20 in each group) were recruited. Standing RT and contest performance was assessed before and after training. Attack RT (eye-hand or eye-leg) and success rate were measured in the experimental group only during training. RESULTS: Age, years of karate practice, Body Mass Index, and standing RT before training did not significantly differ between groups. In the control group, standing RT was significantly improved in the dominant hand after training (25.62±24.18 ms, P=0.0003), but there was no significant improvement in standing RT of the nondominant hand and karate contest score. In the experimental group, standing RT was significantly faster after training (improvement in dominant hand: 69.84±50.85 ms, P<0.0001; improvement in nondominant hand: 68.94±59.43 ms, P<0.0001), and the karate contest score was significantly improved (P=0.0234). During the training period, mean attack RT improved from 1047.4 ms in week1 to 944.9 ms in week6 (P<0.001). However, the success rate gradually decreased from 89.3% (week 1) to 62.4% (week 6) (P<0.001). CONCLUSIONS: A 6-week training using a stationary preprogrammed target dummy improved contest performance and standing RT in both the dominant and nondominant hands of nonelite karate athletes. Improvements of RT in the dominant hand were also seen in the control group.

The Predictive Value of Ultrasound Learning Curves Across Simulated and Clinical Settings.

OBJECTIVES: The aim of the study was to explore whether learning curves on a virtual-reality (VR) sonographic simulator can be used to predict subsequent learning curves on a physical mannequin and learning curves during clinical training. METHODS: Twenty midwives completed a simulation-based training program in transvaginal sonography. The training was conducted on a VR simulator as well as on a physical mannequin. A subgroup of 6 participants underwent subsequent clinical training. During each of the 3 steps, the participants' performance was assessed using instruments with established validity evidence, and they advanced to the next level only after attaining predefined levels of performance. The number of repetitions and time needed to achieve predefined performance levels were recorded along with the performance scores in each setting. Finally, the outcomes were correlated across settings. RESULTS: A good correlation was found between time needed to achieve predefined performance levels on the VR simulator and the physical mannequin (Pearson correlation coefficient .78; P < .001). Performance scores on the VR simulator correlated well to the clinical performance scores (Pearson correlation coefficient .81; P = .049). No significant correlations were found between numbers of attempts needed to reach proficiency across the 3 different settings. A post hoc analysis found that the 50% fastest trainees at reaching proficiency during simulation-based training received higher clinical performance scores compared to trainees with scores placing them among the 50% slowest (P = .025). CONCLUSIONS: Performances during simulation-based sonography training may predict performance in related tasks and subsequent clinical learning curves.

Research: Testing of a Novel Portable Body Temperature Conditioner Using a Thermal Manikin.

A battery-operated active cooling/heating device was developed to maintain thermoregulation of trauma victims in austere environments while awaiting evacuation to a hospital for further treatment. The use of a thermal manikin was adopted for this study in order to simulate load testing and evaluate the performance of this novel portable active cooling/heating device for both continuous (external power source) and battery power. The performance of the portable body temperature conditioner (PBTC) was evaluated through cooling/heating fraction tests to analyze the heat transfer between a thermal manikin and circulating water blanket to show consistent performance while operating under battery power. For the cooling/heating fraction tests, the ambient temperature was set to 15°C ± 1°C (heating) and 30°C ± 1°C (cooling). The PBTC water temperature was set to 37°C for the heating mode tests and 15°C for the cooling mode tests. The results showed consistent performance of the PBTC in terms of cooling/heating capacity while operating under both continuous and battery power. The PBTC functioned as intended and shows promise as a portable warming/cooling device for operation in the field.