Twelve tips for developing and implementing an effective critical care simulation programme

Simulation training in healthcare settings has become a valuable training tool. It provides an ideal formative assessment for interdisciplinary teaching. It provides a high fidelity and highly immersive environment where healthcare staff and students can practice developing their skills in a safe and controlled manner. Simulation training allows staff to practice skills that better prepare them for clinical emergencies, therefore possibly optimising clinical care. While the benefits of simulation education are well understood, establishing a programme for use by critical care staff is complex. Complexities include the highly specialised scenarios that are not typically encountered in non-critical care areas, as well as the need for advanced monitoring equipment, ventilation equipment etc. These 12 tips are intended to assist healthcare educators in navigating the complexities in the establishment of a critical care simulation programme, providing advice on selecting target audiences, learning outcomes, creating a critical care simulation environment and recommendations on evaluation and development of the programme.

Detection of herpesvirus capsids in transmission electron microscopy images using transfer learning

The detailed analysis of secondary envelopment of the Human betaherpesvirus 5/human cytomegalovirus (HCMV) from transmission electron microscopy (TEM) images is an important step towards understanding the mechanisms underlying the formation of infectious virions. As a step towards a software-based quantification of different stages of HCMV virion morphogenesis in TEM, we developed a transfer learning approach based on convolutional neural networks (CNNs) that automatically detects HCMV nucleocapsids in TEM images. In contrast to existing image analysis techniques that require time-consuming manual definition of structural features, our method automatically learns discriminative features from raw images without the need for extensive pre-processing. For this a constantly growing TEM image database of HCMV infected cells was available which is unique regarding image quality and size in the terms of virological EM. From the two investigated types of transfer learning approaches, namely feature extraction and fine-tuning, the latter enabled us to successfully detect HCMV nucleocapsids in TEM images. Our detection method has outperformed some of the existing image analysis methods based on discriminative textural indicators and radial density profiles for virus detection in TEM images. In summary, we could show that the method of transfer learning can be used for an automated detection of viral capsids in TEM images with high specificity using standard computers. This method is highly adaptable and in future could be easily extended to automatically detect and classify virions of other viruses and even distinguish different virion maturation stages.

The construction of customized nucleosomal arrays

A simple, efficient, and reliable method is demonstrated for cloning long tandem arrays of the 601 nucleosomal positioning sequence. In addition, it is shown that such long arrays can be ligated together in vitro with high efficiency. By combining these two procedures it becomes straightforward to synthesize customized arrays that contain different (or variable) nucleosomal repeat lengths (NRLs) and monosome units bearing chemical modifications such as fluorophores, methyl groups, and reaction sites. This is, therefore, an enabling technology for the in vitro study of chromatin structure and function.

Case of the month: Dislodged tracheo-oesophageal valve: importance of rapid replacement or stenting

Dislodgement of a tracheo-oesophageal prosthesis needs prompt action to ensure patency and prevent aspiration in patients with total laryngectomy. Failure to do so may lead to an unnecessary repeat tracheo-oesophageal puncture. This case report is about a patient who needed a repeat procedure under general anaesthetic. It highlights the need for emergency physicians to be aware of this not uncommon event in a patient with a laryngectomy and to refer them immediately for ENT review.

Genotypes of Cryptosporidium from Sydney water catchment areas

AIMS

Currently cryptosporidiosis represents the major public health concern of water utilities in developed nations and increasingly, new species and genotypes of Cryptosporidium are being identified in which the infectivity for humans is not clear. The complicated epidemiology of Cryptosporidium and the fact that the majority of species and genotypes of Cryptosporidium cannot be distinguished morphologically makes the assessment of public health risk difficult if oocysts are detected in the raw water supplies. The aim of this study was to use molecular tools to identify sources of Cryptosporidium from the Warragamba catchment area of Sydney, Australia.

METHODS AND RESULTS

Both faecal and water samples from the catchment area were collected and screened using immunomagnetic separation (IMS) and immunofluorescence microscopy. Samples that contained Cryptosporidium oocysts were genotyped using sequence and phylogenetic analysis of the 18S rDNA, and the heat-shock (HSP-70) gene. Analysis identified five Cryptosporidium species/genotypes including C. parvum (cattle genotype), C. suis, pig genotype II, the cervid genotype and a novel goat genotype.

CONCLUSIONS

Monitoring and characterization of the sources of oocyst contamination in watersheds will aid in the development and implementation of the most appropriate watershed management policies to protect the public from the risks of waterborne Cryptosporidium.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study has shown that quantification by IMS analysis can be combined with the specificity of genotyping to provide an extremely valuable tool for assessing the human health risks from land use activities in drinking water catchments.

CRYPTOSPORIDIUM SUIS N. SP. (APICOMPLEXA: CRYPTOSPORIDIIDAE) IN PIGS (SUS SCROFA)

Molecular and biological characteristics of a new species of Cryptosporidium from the feces of pigs (Sus scrofa) is described. Oocysts are structurally indistinguishable from those of Cryptosporidium parvum; they are passed fully sporulated, lack sporocysts, and measure 4.9-4.4 microm (mean = 4.6 microm) x 4.0-4.3 microm (mean = 4.2 microm); length to width ratio 1.1 (n = 50). Cryptosporidium suis is not transmissible to nude mice and is poorly infectious for cattle. Molecular and phylogenetic analyses at the 18S ribosomal RNA, heat shock protein 70, and actin gene loci demonstrate C. suis to be genetically distinct from all known species and genotypes of Cryptosporidium, and thus is named as Cryptosporidium suis.

Gastrointestinal parasites of domestic cats in Perth, Western Australia

A study was conducted to determine the prevalence of gastrointestinal parasites in a sample of domestic cats in Perth and the knowledge of their owners about the control and potential for zoonotic transmission of these parasites. Faecal samples (418), collected from cats originating from five sources, were examined by microscopy and questionnaires administered to cat owners. Forty randomly selected samples were also screened using PCR in order to detect cysts of Giardia and oocysts of Cryptosporidium that may have been present in a faecal sample at very low levels. The overall prevalence of gastrointestinal parasites in domestic cats by microscopy was 8.6%. Pet shop kittens had the highest parasite prevalence (34.3%), followed by cats and kittens from breeding establishments (15.8%), refuge cats and kittens (8.3%), privately owned cats (2.3%), and boarding cats and kittens (1.6%). Surprisingly, 80% of the 40 cats tested by PCR were positive for Giardia duodenalis and 10% for Cryptosporidium. None of these cats were positive on microscopy. After adjusting for other factors with multiple logistic regression, kittens less than 6 months of age, and cats living in households with more than one cat or with a dog were significantly more likely to be parasitised. In the logistic regression model, the presence of parasitism was also significantly influenced by the number of anthelmintic doses administered in the 12 month period prior to the study. The majority (64.5%) of cat owners were aware that feline parasites could be transmitted to humans, however less than half (42.8%) were aware of the modes of transmission to humans.

DNA binding of a non-sequence-specific HMG-D protein is entropy driven with a substantial non-electrostatic contribution

The thermal properties of two forms of the Drosophila melanogaster HMG-D protein, with and without its highly basic 26 residue C-terminal tail (D100 and D74) and the thermodynamics of their non-sequence-specific interaction with linear DNA duplexes were studied using scanning and titration microcalorimetry, spectropolarimetry, fluorescence anisotropy and FRET techniques at different temperatures and salt concentrations. It was shown that the C-terminal tail of D100 is unfolded at all temperatures, whilst the state of the globular part depends on temperature in a rather complex way, being completely folded only at temperatures close to 0 degrees C and unfolding with significant heat absorption at temperatures below those of the gross denaturational changes. The association constant and thus Gibbs energy of binding for D100 is much greater than for D74 but the enthalpies of their association are similar and are large and positive, i.e. DNA binding is a completely entropy-driven process. The positive entropy of association is due to release of counterions and dehydration upon forming the protein/DNA complex. Ionic strength variation showed that electrostatic interactions play an important but not exclusive role in the DNA binding of the globular part of this non-sequence-specific protein, whilst binding of the positively charged C-terminal tail of D100 is almost completely electrostatic in origin. This interaction with the negative charges of the DNA phosphate groups significantly enhances the DNA bending. An important feature of the non-sequence-specific association of these HMG boxes with DNA is that the binding enthalpy is significantly more positive than for the sequence-specific association of the HMG box from Sox-5, despite the fact that these proteins bend the DNA duplex to a similar extent. This difference shows that the enthalpy of dehydration of apolar groups at the HMG-D/DNA interface is not fully compensated by the energy of van der Waals interactions between these groups, i.e. the packing density at the interface must be lower than for the sequence-specific Sox-5 HMG box.

A REDESCRIPTION OF CRYPTOSPORIDIUM GALLI PAVLASEK, 1999 (APICOMPLEXA: CRYPTOSPORIDIIDAE) FROM BIRDS

Cryptosporidium galli Pavlasek, 1999, described from the feces of birds, is redescribed with additional molecular and biological data. Oocysts are ellipsoidal, are passed fully sporulated, lack sporocysts, and measure 8.25 x 6.3 microm (range 8.0-8.5 x 6.2-6.4 microm) with a length-width ratio of 1.30 (n = 50). Oocysts are structurally similar to those of Cryptosporidium baileyi described from chickens, but in addition to being considerably larger than oocysts of C. baileyi, these oocysts infect the proventriculus in a variety of birds and not the respiratory tract. Oocysts were successfully transmitted from chickens to chickens, and morphologically similar oocysts also were observed in a variety of exotic and wild birds (Order Passeriformes, Phasianidae, Fringillidae, and Icteridae). Molecular and phylogenetic analyses at the 18S rRNA, HSP70, and actin gene loci demonstrate that this species is genetically distinct from all known species and genotypes of Cryptosporidium and, thus, was named C. galli.

Identification of a novel Cryptosporidium genotype in pigs

Over a 3-year period, a total of 646 fecal samples from pigs in 22 indoor and outdoor herds from Western Australia were screened for Cryptosporidium spp. by microscopy. Results revealed that 39 of 646 samples (6.03%) were positive for Cryptosporidium. Cryptosporidium was much more common in outdoor herds (17.2%) than in indoor herds (0.5%) and was more common in animals between the ages of 5 and 8 weeks (69.2%) than in younger animals (P < 0.0001). Molecular characterization of the positive samples at the 18S ribosomal DNA locus identified two distinct genotypes of Cryptosporidium: the previously identified pig genotype I and a novel pig genotype (pig genotype II), both of which warrant species status.

Barriers to uptake of services for coronary heart disease: qualitative study

OBJECTIVES

To identify factors within the South Yorkshire coalfields that influence use of health services by people with angina.

DESIGN

Qualitative study using semistructured individual and group interviews.

SETTING

General practice and community settings in Barnsley and Rotherham health authorities.

PARTICIPANTS

14 patients with stable angina and nine primary care staff had individual interviews plus five community groups and one group of general practitioners.

MAIN OUTCOME MEASURES

Barriers to accessing health services.

RESULTS

A complex web of factors was identified that prevented, delayed, or facilitated referral to secondary care. Delay, denial, and self management by patients meant that the full extent of symptoms often remained hidden from general practitioners, resulting in a delayed or missed referral. Barriers identified fell into six categories: structural, personal, social and cultural, past experience and expectations, diagnostic confusion, and knowledge and awareness.

CONCLUSIONS

Many of the factors influencing referral operate before general practitioners become involved. Community development could be one way of tackling inequalities and promoting sustainable change. Structural changes are needed to improve access and increase the acceptability of general practice services. Primary care staff should be educated to detect underreporting of symptoms and promote appropriate referral.

An unusual case of subdural haematoma presenting to the accident and emergency department

A case of subdural haematoma associated with an intracranial arachnoid cyst is reported. The pathogenesis, clinical presentation and treatment options of intracranial arachnoid cysts is discussed.

Transfer of radioactivity to fruit: significant radionuclides and speciation

One of the roles of the BIOMASS Theme 3 Fruit Working Group was to identify significant radionuclides to support its work programme. This paper provides a short review of radionuclide emissions to atmosphere together with comments on their relative dosimetric impacts to identify those radionuclides most relevant to the Fruit Working Group. Speciation of the identified radionuclides is also discussed to identify the most likely chemical forms to which fruits might be exposed. It is noted that no information currently exists on radionuclide speciation in regard to the uptake and retention of radionuclides in fruit crops.

Outbreak of meningococcal disease in Rotherham illustrates the value of coordination, communication, and collaboration in management

On New Year's Eve 1998, two teenagers from the same school in Rotherham died of serogroup C meningococcal septicaemia. A third linked case occurred three days later. Over eight days starting on New Year's Eve, a further five cases of meningococcal disease arose across Rotherham district, four of whom were severely ill with serogroup C meningococcal septicaemia. Intense media interest, high levels of public concern, and anxieties caused by several 'false alarm' cases added to the challenge faced by a small health district. This article describes the epidemiology of the incident and policy decisions made, but focuses on the operational aspects of outbreak management (coordination, communication, and collaboration), an area often neglected in outbreak reports.

Patients' information needs in intensive care and surgical wards

Meeting the information and psychosocial support needs of surgical patients who have been in intensive care can contribute significantly to their recovery. In this article, the author examines the nursing opportunities for meeting these needs and suggests how they can be addressed.

A Study of the Housing Needs of Disabled Applicants to the Nottingham City Council Housing Department and the Problems Faced by Local Housing Providers in Meeting These Needs

This study of the housing needs of disabled people and the problems faced by housing providers in Nottingham was carried out with a view to establishing a data base of adapted properties and disabled people. A small survey of 47 disabled people, with 22 respondents, reported problems when trying to find a new home. Less than a quarter of those who replied had been assessed prior to looking for a new home by an occupational therapist, while over half said that they would like help from an occupational therapist when choosing a new home. A survey of 42 housing providers found that, of the 26 respondents, over half had disabled people waiting for a property and a third had adapted properties that they were unable to let.

These findings supported local concern about housing problems for disabled people and led to the development of the Disabled People and Adapted Properties Register (DPAPR). This register holds a computerised list of disabled people looking for a new home and of the adapted properties in Nottingham, for sale or for rent.

Early discharge schemes for hysterectomy patients

This review looks at the needs of hysterectomy patients discharged early from hospital. The author explores the concept of early discharge schemes and evaluates whether they can be safe, cost effective and provide quality care. Reflection on these factors suggests that an early discharge scheme could be a way to provide choice, and fulfill expectations of quality, holistic care and cost effectiveness, while allowing the nurse to work as an expert practitioner.

Recognition of the Xenopus ribosomal core promoter by the transcription factor xUBF involves multiple HMG box domains and leads to an xUBF interdomain interaction

The interaction of the ribosomal transcription factor xUBF with the RNA polymerase I core promoter of Xenopus laevis has been studied both at the DNA and protein levels. It is shown that a single xUBF-DNA complex forms over the 40S initiation site (+1) and involves at least the DNA sequences between -20 and +60 bp. DNA sequences upstream of +10 and downstream of +18 are each sufficient to direct complex formation independently. HMG box 1 of xUBF independently recognizes the sequences -20 to -1 and +1 to +22 and the addition of the N-terminal dimerization domain to HMG box 1 stabilizes its interaction with these sequences approximately 10-fold. HMG boxes 2/3 interact with the DNA downstream of +22 and can independently position xUBF across the initiation site. The C-terminal segment of xUBF, HMG boxes 4, 5 or the acidic domain, directly or indirectly interact with HMG box 1, making the core promoter sequences between -11 and -15 hypersensitive to DNase. This interaction also requires the DNA sequences between +17 and +32, i.e. the HMG box 2/3 binding site. The data suggest extensive folding of the core promoter within the xUBF complex.

High resolution studies of the Xenopus laevis ribosomal gene promoter in vivo and in vitro

The first high resolution maps of the Xenopus laevis ribosomal promoter and its flanking regions (-179 to +14) have been created by assaying point mutants both in oocyte and in vitro. Within the promoter boundaries (-141(-145) to +3(+4)), domains analogous to the Core Promoter and "Upstream Control Element" (UCE) were clearly detected. The base pairs at -133, within the UCE, and -20, -10, -7, and +3, within the Core, were all shown to be especially important for promotion. Between the Core and UCE, two central promoter elements (CPEs) were also resolved. Surprisingly, these CPEs did not correspond to the highly conserved enhancer homology (approximately -70 to -110), but to CCCGGCC motifs immediately flanking it. Although xUBF was shown to be a limiting component for in vitro transcription, none of the point mutations was found to affect the interaction of this factor with the promoter.

The hospital trauma team: a model for trauma management

A triage system was established as the initiating mechanism for a trauma team response to assist the assessment and early management of patients presenting to an accident and emergency department. A checklist of triage criteria was used. During a 6-month period, 342 patients (29.7% of trauma admissions) satisfied the triage criteria, which should have resulted in an average of 1.9 trauma team calls per day. Staff compliance with the triage tool was 75.4%. The overtriage rate for the checklist criteria was 52.7%. The triage tool identified patients with severe injuries who were not initially considered sufficiently injured to justify initiation of the trauma team response. The sensitivity of the triage tool in identifying patients with serious injury was 95.0%. Comparison of the review with a similar review performed 12 months earlier demonstrated that staff compliance with initiating the trauma team response had improved. Using data from 564 patients from both series, logistic regression analysis of the power of the triage criteria to predict serious injury contributed to a revision of the triage criteria. This trauma triage tool and trauma team response constitute a valid approach to the early hospital management of trauma patients. This system may be more appropriate or achievable in many hospitals than the construction of dedicated trauma reception units or permanent surgical staffing of general Accident and Emergency departments.

Point mutation analysis of the Xenopus laevis RNA polymerase I core promoter

The core region of the Xenopus laevis pre-ribosomal RNA promoter was subjected to point mutation analysis. A total of 27 point mutants within a 78 base pair region from -64 to +14, (relative to the start of transcription at +1), were assayed by oocyte microinjection. The results locate the 3' boundary of the core promoter at +4 and the 5' boundary at between -33 and -39 and suggest that this region of the Xenopus promoter is generally similar in organisation to mammalian core promoters. In particular, the conserved guanidine nucleotides at -7 and -16 are clearly essential for promoter function. The data suggest that interactions between the transcription machinery and the promoter occur in four distinct regions around +2 to +4, -7, -17 to -20 and -28 to -33. This particular periodicity of functionally important nucleotides is consistent with a model in which all protein-DNA interactions take place from predominantly one side of the DNA helix.

The Xenopus laevis ribosomal gene terminator contains sequences that both enhance and repress ribosomal transcription

A DNA segment approximately 200 base pairs upstream of the Xenopus laevis ribosomal promoter acts both as an upstream promoter element that augments transcription and as a transcription terminator. It is, however, unclear to what extent these two activities are related. A segment of the X. laevis ribosomal DNA, containing the terminator and the upstream promoter element, was subjected to point mutation, and the effects of the resulting mutations were investigated by oocyte microinjection. Analysis of 26 point mutants revealed not only sequences that augment 40S transcription but also those that repress it. The sequences that augmented transcription lay within the T3 homology box and also near the site of 3'-end formation. These sequences also played a role in termination. The sequences that repressed transcription lay within the G+C-rich DNA flanking the T3 box. It can be concluded that termination is probably essential but may not be sufficient for the activity of the upstream promoter element.

Implementation of a trauma team

A team approach to the initial assessment, investigation and management of potentially seriously injured patients has been instituted. Team members are alerted through an emergency paging system which is activated when a patient fulfills one of a predetermined list of criteria relating to the injury incident, physiological status of the patients and anatomic injuries. Medical members of the team include surgical, intensive care, anaesthetic, and accident and emergency staff. The surgical representative acts as team co-ordinator. Aspects of the function of the trauma team system were assessed over 4 months during which time 721 injured patients were admitted, 240 patients satisfied the trauma team criteria, and the team was called 152 times. The observed 'false alarm' rate was 38% but the true false alarm rate would have been 46%. Injuries sustained by some patients, who satisfied the criteria but who were not evaluated by the team, were of sufficient severity to justify a greater compliance with the system than was observed at this early stage after its implementation. Although a false alarm rate of 46% is higher than desirable, the number of calls per day would still only average 2 in a hospital with a high trauma patient load. The checklist criteria were highly sensitive (97%) in identifying those patients who should have been evaluated by the trauma team. Although hospitals differ in workload and staffing, this trauma team model is recommended for more widespread use and for further evaluation and modification.

The management of injuries--a review of deaths in hospital

A prospective review was undertaken of the management of 111 consecutive patients who died in hospital after admission for treatment of injuries. A standard set of data relating to each patient was reviewed by each member of a trauma death audit committee and then by the whole committee. Autopsy reports were available on all patients. Conclusions were drawn concerning defective aspects of patient management and possible avoidance of each death. Injury severity was assessed using the Trauma Score (TS) and Injury Severity Score (ISS). The possibly avoidable death (PAD) rate was 17%. The most common defects in management were related to inadequate fluid resuscitation and delays in definitive management. The greatest contributions to the PAD rate were from inadequate fluid resuscitation, delays and inadequate perception of the severity of injuries or significance of clinical deterioration. Increasing age was related to a higher frequency of PAD. PAD rate in the presence of severe head injury was 8%, but was 63% in the absence of a severe head injury. It is concluded that review of all trauma deaths is an achievable, beneficial and essential part of a hospital-based integrated trauma service. TS and ISS are not sufficiently sensitive to justify their use in selecting deaths for review. Improved blood volume replacement, earlier and more direct management and supervision by senior specialist staff, and elimination of causes of delay in patient management should all decrease the death rate from injuries particularly in patients without severe head injury.