The Effectiveness of a 'Train the Trainer' Model of Resuscitation Education for Rural Peripheral Hospital Doctors in Sri Lanka

BACKGROUND Sri Lankan rural doctors based in isolated peripheral hospitals routinely resuscitate critically ill patients but have difficulty accessing training. We tested a train-the-trainer model that could be utilised in isolated rural hospitals. METHODS Eight selected rural hospital non-specialist doctors attended a 2-day instructor course. These "trained trainers" educated their colleagues in advanced cardiac life support at peripheral hospital workshops and we tested their students in resuscitation knowledge and skills pre and post training, and at 6- and 12-weeks. Knowledge was assessed through 30 multiple choice questions (MCQ), and resuscitation skills were assessed by performance in a video recorded simulated scenario of a cardiac arrest using a Resuci Anne Skill Trainer mannequin. RESULTS/DISCUSSION/CONCLUSION Fifty seven doctors were trained. Pre and post training assessment was possible in 51 participants, and 6-week and 12-week follow up was possible for 43, and 38 participants respectively. Mean MCQ scores significantly improved over time (p<0.001), and a significant improvement was noted in "average ventilation volume", "compression count", and "compressions with no error", "adequate depth", "average depth", and "compression rate" (p<0.01). The proportion of participants with compression depth ≥40mm increased post intervention (p<0.05) and at 12-week follow up (p<0.05), and proportion of ventilation volumes between 400-1000mls increased post intervention (p<0.001). A significant increase in the proportion of participants who "checked for responsiveness", "opened the airway", "performed a breathing check", who used the "correct compression ratio", and who used an "appropriate facemask technique" was also noted (p<0.001). A train-the-trainer model of resuscitation education was effective in improving resuscitation knowledge and skills in Sri Lankan rural peripheral hospital doctors. Improvement was sustained to 12 weeks for most components of resuscitation knowledge and skills. Further research is needed to identify which components of training are most effective in leading to sustained improvement in resuscitation.This research was funded by an international collaborative research Wellcome Trust/National Health and Medical Research Council grant GR071669. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Entanglement Sharing and Decoherence in the Spin-Bath

The monogamous nature of entanglement has been illustrated by the derivation of entanglement sharing inequalities - bounds on the amount of entanglement that can be shared amongst the various parts of a multipartite system. Motivated by recent studies of decoherence, we demonstrate an interesting manifestation of this phenomena that arises in system-environment models where there exists interactions between the modes or subsystems of the environment. We investigate this phenomena in the spin-bath environment, constructing an entanglement sharing inequality bounding the entanglement between a central spin and the environment in terms of the pairwise entanglement between individual bath spins. The relation of this result to decoherence will be illustrated using simplified system-bath models of decoherence.Comment: 5 pages, 1 figure v2: 6 pages 2 figures, additional example and reference

Serendipitously Detected Galaxies in the Hubble Deep Field

We present a catalog of 74 galaxies detected serendipitously during a campaign of spectroscopic observations of the Hubble Deep Field North (HDF) and its environs. Among the identified objects are five candidate Ly-alpha emitters at z > 5, a galaxy cluster at z = 0.85, and a Chandra source with a heretofore undetermined redshift of z = 2.011. We report redshifts for 25 galaxies in the central HDF, 13 of which had no prior published spectroscopic redshift. Of the remaining 49 galaxies, 30 are located in the single-orbit HDF Flanking Fields. We discuss the redshift distribution of the serendipitous sample, which contains galaxies in the range 0.10 < z < 5.77 with a median redshift of z = 0.85, and we present strong evidence for redshift clustering. By comparing our spectroscopic redshifts to optical/IR photometric studies of the HDF, we find that photometric redshifts are in most cases capable of producing reasonable predictions of galaxy redshifts. Finally, we estimate the line-of-sight velocity dispersion and the corresponding mass and expected X-ray luminosity of the galaxy cluster, we present strong arguments for interpreting the Chandra source as an obscured AGN, and we discuss in detail the spectrum of one of the candidate z > 5 Ly-alpha emitters.Comment: 18 pages, 9 figures, accepted for publication in the Astronomical Journa

Electrophysiological correlates of respiratory failure in acute organophosphate poisoning: Evidence for differential roles of muscarinic and nicotinic stimulation

Background. Respiratory failure in acute organophosphate (OP) poisoning can occur early and also relatively late in the clinical course, and the pathophysiology of respiratory failure at these different phases may have important clinical implications. Objective. To compare the electrophysiological findings in patients with early and late respiratory failure following acute OP poisoning. Methods. A prospective observational case series of consenting symptomatic patients with acute OP poisoning were assessed with daily physical examinations and repetitive nerve stimulation (RNS) studies. RNS was done on right and left median and ulnar nerves at 1, 3, 10, 15, 20, and 30 Hz. Outcomes such as need for ventilation and development of intermediate syndrome (IMS) were noted. Early respiratory failure was defined as occurring within 24 hours of ingestion. Results. Seventy-eight patients were recruited for the clinical and electrophysiological study and of those 59 (75.6%) patients had ingested chlorpyrifos. Seven patients developed respiratory failure within 24 hours of ingestion with overt muscarinic signs. They had no electrophysiological abnormalities at median and ulnar nerves before intubation. Three of them later developed “forme fruste” IMS. Five other patients developed late respiratory failure after 24 hours of ingestion, and all of them showed progressive RNS changes indicating severe IMS prior to intubation. Conclusion. The normal RNS in all patients developing early respiratory failure suggests that it is due to a central nervous system (CNS) and muscarinic effect. This emphasizes the need for early rapid atropinisation as a priority, combating the nicotinic effects being less urgent. This is in contrast with the late respiratory failure, which has been shown to be associated with neuromuscular dysfunction. Further studies are needed to quantify CNS and muscarinic dysfunction to assist in the development of better treatments for the severe and early OP poisoning

SPICES II. Optical and Near-Infrared Identifications of Faint X-Ray Sources from Deep Chandra Observations of Lynx

We present our first results on field X-ray sources detected in a deep, 184.7 ks observation with the ACIS-I camera on Chandra. The observations target the Lynx field of SPICES, and contains three known X-ray-emitting clusters out to z=1.27. Not including the known clusters, in the 17'x17' ACIS-I field we detect 132 sources in the 0.5-2 keV (soft) X-ray band down to a limiting flux of \~1.7e-16 erg/cm2/s and 111 sources in the 2-10 keV (hard) X-ray band down to a limiting flux of ~1.3e-15 erg/cm2/s. The combined catalog contains a total of 153 sources, of which 42 are detected only in the soft band and 21 are detected only in the hard band. Confirming previous Chandra results, we find that the fainter sources have harder X-ray spectra, providing a consistent solution to the long-standing `spectral paradox'. From deep optical and near-infrared follow-up data, 77% of the X-ray sources have optical counterparts to I=24 and 71% of the X-ray sources have near-infrared counterparts to K=20. Four of the 24 sources in the near-IR field are associated with extremely red objects (EROs; I-K>4). We have obtained spectroscopic redshifts with the Keck telescopes of 18 of the Lynx Chandra sources. These sources comprise a mix of broad-lined active galaxies, apparently normal galaxies, and two late-type Galactic dwarfs. Intriguingly, one Galactic source is identified with an M7 dwarf exhibiting non-transient, hard X-ray emission. We review non-AGN mechanisms to produce X-ray emission and discuss properties of the Lynx Chandra sample in relation to other samples of X-ray and non-X-ray sources.Comment: 42 pages, 16 figures. Accepted for publication in the May 2002 Astronomical Journa

Acute impact of conventional and eccentric cycling on platelet and vascular function in patients with chronic heart failure.

Evidence-based guidelines recommend exercise therapy for patients with chronic heart failure (CHF). Such patients have increased atherothrombotic risk. Exercise can transiently increase platelet activation and reactivity and decrease vascular function in healthy participants, although data in CHF is scant. Eccentric (ECC) cycling is a novel exercise modality which may be particularly suited to patients with CHF, but the acute impacts of ECC on platelet and vascular function are currently unknown. Our null hypothesis was that ECC and concentric (CON) cycling, performed at matched external workloads, would not induce changes in platelet or vascular function in patients with CHF. Eleven patients with heart failure with reduced ejection fraction (HFrEF) took part in discrete bouts of ECC and CON cycling. Before and immediately after exercise, vascular function was assessed by measuring diameter and flow mediated dilation (FMD) of the brachial artery. Platelet function was measured by the flow cytometric determination of glycoprotein IIb/IIIa activation and granule exocytosis in the presence and absence of platelet agonists. ECC increased baseline artery diameter (pre: 4.0±0.8mm vs post: 4.2±0.7mm, P=0.04) and decreased FMD%. When changes in baseline artery diameter were accounted for the decrease in FMD post-ECC was no longer significant. No changes were apparent after CON. Neither ECC nor CON resulted in changes to any platelet function measures (all P>0.05). These results suggest both ECC and CON cycling at a moderate intensity and short duration can be performed by patients with HFrEF, without detrimental impacts on vascular or platelet function

Policymaking ‘under the radar': a case study of pesticide regulation to prevent intentional poisoning in Sri Lanka

Background Suicide in Sri Lanka is a major public health problem and in 1995 the country had one of the highest rates of suicide worldwide. Since then reductions in overall suicide rates have been largely attributed to efforts to regulate a range of pesticides. The evolution, context, events and implementation of the key policy decisions around regulation are examined. Methods This study was undertaken as part of a broader analysis of policy in two parts—an explanatory case study and stakeholder analysis. This article describes the explanatory case study that included an historical narrative and in-depth interviews. Results A timeline and chronology of policy actions and influence were derived from interview and document data. Fourteen key informants were interviewed and four distinct policy phases were identified. The early stages of pesticide regulation were dominated by political and economic considerations and strongly influenced by external factors. The second phase was marked by a period of local institution building, the engagement of local stakeholders, and expanded links between health and agriculture. During the third phase the problem of self-poisoning dominated the policy agenda and closer links between stakeholders, evidence and policymaking developed. The fourth and most recent phase was characterized by strong local capacity for policymaking, informed by evidence, developed in collaboration with a powerful network of stakeholders, including international researchers. Conclusions The policy response to extremely high rates of suicide from intentional poisoning with pesticides shows a unique and successful example of policymaking to prevent suicide. It also highlights policy action taking place ‘under the radar', thus avoiding policy inertia often associated with reforms in lower and middle income countrie

Delayed Psychological Morbidity Associated with Snakebite Envenoming

Introduction The psychological impact of snakebite on its victims, especially possible late effects, has not been systematically studied. Objectives To assess delayed somatic symptoms, depressive disorder, post-traumatic stress disorder (PTSD), and impairment in functioning, among snakebite victims. Methods The study had qualitative and quantitative arms. In the quantitative arm, 88 persons who had systemic envenoming following snakebite from the North Central Province of Sri Lanka were randomly identified from an established research database and interviewed 12 to 48 months (mean 30) after the incident. Persons with no history of snakebite, matched for age, sex, geograpical location and occupation, acted as controls. A modified version of the Beck Depression Inventory, Post-Traumatic Stress Symptom Scale, Hopkins Somatic Symptoms Checklist, Sheehan Disability Inventory and a structured questionnaire were administered. In the qualitative arm, focus group discussions among snakebite victims explored common somatic symptoms attributed to envenoming. Results Previous snakebite victims (cases) had more symptoms than controls as measured by the modified Beck Depression Scale (mean 19.1 Vs 14.4; p<0.001) and Hopkins Symptoms Checklist (38.9 vs. 28.2; p<0.001). 48 (54%) cases met criteria for depressive disorder compared to 13 (15%) controls. 19 (21.6%) cases also met criteria for PTSD. 24 (27%) claimed that the snakebite caused a negative change in their employment; nine (10.2%) had stopped working and 15 (17%) claimed residual physical disability. The themes identified in the qualitative arm included blindness, tooth decay, body aches, headaches, tiredness and weakness. Conclusions Snakebite causes significant ongoing psychological morbidity, a complication not previously documented. The economic and social impacts of this problem need further investigation