1,097 research outputs found
How do variations in Urban Heat Islands in space and time influence household water use? The case of Phoenix, Arizona
No full textabstract: This paper explores how urbanization, through its role in the evolution of Urban Heat Island (UHI), affects residential water consumption. Using longitudinal data and drawing on a mesoscale atmospheric model, we examine how variations in surface temperature at the census tract level have affected water use in single family residences in Phoenix, Arizona. Results show that each Fahrenheit rise in nighttime temperature increases water consumption by 1.4%. This temperature effect is found to vary significantly with lot size and pool size. The study provides insights into the links between urban form and water use, through the dynamics of UHI.Corresponding Author:
Rimjhim M. Aggarwal
Arizona State University
[email protected]
Innovation in surgical training and its impact on healthcare
No full textSurgical training is currently in a state of flux, with dramatic changes in the way it is structured and delivered. The greatest challenges to surgical training have come from the advent of minimally invasive surgery in the 1990’s and more recently the reduction in a doctors working hours. This has led to a significant decrease in training opportunities that are available to the surgical trainee. Simulation has been heralded as an effective adjunct to surgical training whilst ensuring high standards of patient safety. This thesis aims to investigate the factors influencing current surgical training methods and whether simulation can be used to improve the effectiveness of surgical training in a cost efficient manner.
The first part of this thesis investigates the impact that the reduction in working hours has had on surgical training, and whether the use of simulation can alleviate this. The reduction in working hours for doctors has led to a significant reduction in training opportunities. However, laboratory based simulation training can improve technical skills, provided it is used as part of a proficiency based technical skills curriculum.
The second part of this thesis investigates the impact that innovations in surgery have had on surgical training, and whether simulator technology can advance at a similar rate. The introduction of single incision laparoscopic surgery provides further challenges for the surgical trainee, and it is clear that a novice laparoscopic surgeon needs further technical skills curriculum based training before entering the operating room. In addition, advancement in simulator technology now allows senior surgeons to learn advanced techniques in the skills laboratory.
The final part of this thesis aims to assess the current costs of surgical training in the operating room, and whether simulation can improve operating room efficiency such that cost savings can be made. One of the main criticisms of simulation training is that it is expensive. However, the evidence in this thesis demonstrates that traditional training is also very expensive; and with prior training on simulation, operating times can be significantly reduced, providing sufficient cost savings that make simulation cost efficient.
Simulation works. This is clear from the literature and from evidence provided by this thesis. Although simulation alone is not sufficient to train surgeons to operating room proficiency, it can provide a useful adjunct to surgical training. It allows trainees to train in the safety of skills laboratory, and shorten the learning curve in the operating room which in turn improves patient safety. If appropriate simulators are selected and used correctly, it can provide benefits to the healthcare system by reducing costs through an improvement in operating room efficiency
Evaluation of the effect of modafinil in conditions of sleep deprivation and fatigue in the medical profession
No full textAims and objectives
This thesis aimed to investigate the use of modafinil to reverse the effects of sleep deprivation and fatigue in the medical profession. The objectives were to: (1) determine the pattern of expected cognitive and clinical psychomotor effects of sleep deprivation and fatigue in the context of the medical profession, (2) investigate the subjective and objective effects of modafinil on the performance of sleep deprived participants using a battery of carefully selected cognitive and clinical tasks, (3) investigate the subjective and objective effects of modafinil on the performance of acutely fatigued subjects using a battery of carefully selected tasks.
Methods
Objective 1: A systematic review of the sleep deprivation and fatigue literature was performed
Objective 2: Two double blind, placebo controlled, randomised trials were performed. In the first study participants were randomised to receive either modafinil or placebo following extended wakefulness. Cognitive tasks and a virtual reality laparoscopic skill simulator were used to assess performance. In the second study, participants took part in a counterbalanced crossover study in which they were allocated to all three study conditions (rest, sleep deprivation, sleep deprivation and modafinil) in a randomised order. A surgical performance monitoring task and a matched neurobehavioural task were used to assess performance and Near Infrared Spectroscopy was used to record cortical haemodynamics.
Objective 3: (i) Two studies were carried out with the aim of developing and validating a series of virtual reality intubation and extubation tasks. In the first study a battery of intubation assessment tasks was identified. Comparisons between novice and experienced colonoscopists led to the isolation of tasks that possessed construct validity. In the second study, a series of colonoscopy extubation tasks was developed and validated by comparing the performance of cohorts of experienced and novice colonoscopists. (ii) An experimentally induced acute mental fatigue protocol was developed and a single blind randomised controlled trial was performed to investigate the effect of acute mental fatigue on colonoscopy performance. (iii) Two studies were carried out to investigate strategies to ameliorate the effects of acute mental fatigue on colonoscopy performance. In the first study the acute mental fatigue protocol was administered to all participants following which they were randomly allocated to either receive no intervention or a “goal setting” psychological intervention. Performance was assessed using the colonoscopy task battery. In the second study a double blind, placebo controlled randomised trial was performed to investigate the effect of modafinil on the performance of participants following administration of the acute mental fatigue protocol. Again, performance was assessed using the colonoscopy task battery. (iv) One study was carried out to determine the pattern of effects of modafinil on sustained attention, visual perception, metacognition and working memory. In this randomised, placebo controlled, double blind study, rested participants were allocated to receive modafinil or lactose placebo and interrelated cognitive domains were assessed using a sophisticated neurocognitive task battery.
Results
Objective 1: Sleep loss was consistently associated with impaired attention, memory higher-order cognitive function and the performance of virtual reality laparoscopic skills tasks. No studies investigated the effect of acute mental fatigue.
Objective 2: In the first study, modafinil was found to improve the performance of sleep deprived participants on tests of attention, impulsivity and working memory but did not improve the performance of a laparoscopic psychomotor skills task. In the second study, modafinil administration was again associated with a pronounced improvement in attention using a classical vigilance paradigm but was only associated with a small improvement in the performance of a matched surgical clinical performance monitoring task. Improved performance on the classical vigilance paradigm in the modafinil condition was associated with activation in the right Dorsolateral Prefrontal Cortex. Modafinil also improved performance and attenuated task disengagement following a high cognitive load divided attention and working memory task.
Objective 3: (i) A comprehensive battery of valid intubation and extubation tasks was developed. (ii) An experimentally induced acute mental fatigue protocol was effective in inducing subjective feelings of fatigue. Acute mental fatigue was associated with impaired colonoscopy intubation performance but was not associated with impaired abnormality detection. (iii) The psychological “goal setting” intervention was not effective in improving intubation or extubation colonoscopy performance. Modafinil was found to be effective in improving both intubation and extubation colonoscopy performance. Participants in the modafinil group identified more abnormalities than those in the placebo group in all task conditions and this effect was predicted by Psychomotor Vigilance Task performance. (iv) Modafinil was found to improve vigilant attention and working memory in rested subjects and, in a visual perception and metacognition task, was found to improve performance without promoting over or underconfidence.
Conclusions
Sleep deprivation and fatigue impair cognitive and simulated clinical performance. Modafinil is effective in improving sustained attention, resilience to cognitive load, impulsivity and working memory in conditions of sleep deprivation but less effective in improving simulated laparoscopic performance monitoring and ineffective in improving simulated laparoscopic psychomotor skill. Simulated colonoscopy intubation performance is degraded by acute mental fatigue and impaired extubation performance is associated with subjective feelings of fatigue. Psychological “goal setting strategies are ineffective in reversing these effects. However, modafinil is effective in improving intubation and extubation performance by promoting resilience to demanding mental work by improving sustained attention and visual perception without compromising introspective accuracy.Open Acces
Improving resuscitation : the role of design and teamwork
No full textResuscitation is the process medical teams use in an attempt to save a patient’s life
when they have suffered a cardiopulmonary arrest. It is a stressful, time-pressured
procedure, and unfortunately is often futile. Care of a patient in the emergency
setting is particularly prone to errors and adverse events for a variety of reasons.
These include the time-pressured decision making, increased rate of patient
interventions, and the fact that teams are “assembled” by the emergency call that
may have never worked together, or even met each other, before. Recent analysis of
incident reports specifically from resuscitation attempts suggests that the majority of
incidents relate to issues with the resuscitation team, problems related to human
performance, and incidents relating to malfunctioning or absent equipment.
One of the aims of this thesis is to look at ways to address these issues, and reduce
rates of adverse events and critical incidents at resuscitation attempts. I will
specifically look at the areas of non-technical teamworking skills, team training with
environmental risk assessment, and the design of ergonomic equipment.
In Chapter 4 I will describe the process of development and evaluation of a tool to
assess non-technical teamworking skills in resuscitation teams. When this tool was
initially developed, no other tools had been published. However, another tool has
subsequently been made available, therefore in Chapter 5 I will compare our tool,
OSCAR, with this other tool, called TEAM. In Chapter 6 I describe the process of in situ simulation for resuscitation training. I
organised resuscitation team simulations as part of a training programme, and
gathered participant feedback on the training. I also describe some of the
unanticipated benefits of this training, such as risk assessment of the ward
environment.
In Chapters 7 and 8 I describe two studies that were undertaken to evaluate the
newly designed Resus:Station. Specifically I assessed its use during simulated
cardiac arrest scenarios, and when nursing staff performed a stock check of the
trolley
An evaluation of the quality of surgical training
No full textQuality assessment in healthcare is an essential part of governance culture. Clinical outcomes and research output are routinely assessed with national and global comparisons commonplace in a bid to continually drive up standards. While the subject of surgical training has received greater exposure in recent years, there remains no rigorous assessment of surgical training quality in the same way as clinical and research outcomes. To improve surgical training quality, high quality training must first be defined to permit evaluation of training and facilitate identification of methods to raise standards.
Variability of global surgical training programs is first identified by comparing the national surgical curricula of a sample of countries against defined standards for curricula. A questionnaire study further explores the variations between the two nations with the most contrasting surgical curricula.
Qualitative methodologies, including semi-structured interviews and a global Delphi consensus study, are subsequently employed to define high quality surgical training. The results have enabled the development of a surgical training quality assessment tool (S-QAT). The S-QAT has been piloted in the North West London training region where variability in surgical training quality has been confirmed.
Defining high quality training has facilitated the development and piloting of interventions to improve surgical training quality. The first intervention employs video-based coaching to improve surgical skills. The second intervention is an intensive, immersive week of simulation training to ease the transition from medical student to Foundation Doctor. These interventions demonstrate that improvements in training quality can be made without the need to rely on increasing the quantity or time in training.
The foundations for robust evaluation of surgical training quality have been constructed. Evidence-based medicine is the gold standard for patients; evidence-based training of surgeons will ensure standards are maintained for the next generation of patients. Open Acces
Structural and Care Process Improvement of Ward-based Postoperative Care to Optimise Surgical Outcomes
No full textMuch of the variation seen in surgical outcomes can be explained by differences in the quality of management of post-operative complications and ward-based care. The surgical ward round (WR) is critical to determining post-operative care and serves as the primary point of interaction between clinician and patient. Despite this, it is an area not subject to training or assessment at present.
This thesis demonstrates the high degree of variability which exists in the conduct of WRs. It establishes the link between suboptimal patient assessment and increased risk of preventable post-operative complications. These place patients not only at risk of short-term deterioration, but result in reduced long-term survival as well.
In order to quantify WR quality, a novel assessment tool has been developed and validated within a simulated environment. Ward simulation is a nascent branch of simulation which has been only preliminarily explored to date. A simulation environment was developed to take advantage of the known benefits of simulation such as controllability, reproducibility, and recordability, whilst maintaining a high level of fidelity and realism. An evidence-based curriculum for surgical WR training was designed and implemented in a simulation-based course. By focusing on structured generic processes of patient assessment and management, this resulted in significant improvement of trainee performance in routine WRs.
To ensure standardised and optimum management of specific conditions, checklists have proven themselves to be of great value in a number of surgical and medical disciplines. Surgical complications are common, yet their management often suboptimal. As part of this thesis, evidence-based protocols for the management of the six most common complications were designed and validated. The implementation of these in a simulation-based randomised, controlled trial has resulted in greatly increased adherence to evidence-based standards of care, as well as improved communication and clinician performance.
This thesis explores the variance currently present in surgical ward rounds, and the potentially grave consequences of this for patient outcomes. To date, WRs have been one of the last areas of surgical care still dependent on the Halstedian principle of experiential learning alone. The tools have now been developed with which to assess, improve, and standardise critical structures and care processes in the assessment and management of the post-operative surgical patient. Future implementation of these and integration into surgical curricula will benefit clinician training, patient care, and surgical outcomes alike.Open Acces
Caste, religion and power: an Indian case study
No full textReviews the book "Caste, Religion and Power: An Indian Case Study," by Pratap C. Aggarwal.; Reviews the book "Caste, Religion and Power: An Indian Case Study," by Pratap C. Aggarwal
Data mining : the textbook / Charu C. Aggarwal.
No full textcomputer bookfair2016Includes bibliographical references and index.xxix, 734 pages
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