Nursing expertise and self-efficacy following high fidelity simulation-based training

MD ThesisThe use of simulation in healthcare education has dramatically increased in popularity over the last two decades. It is thought to provide a standardised way of exposing learners to clinical situations where they can safely learn from mistakes. However, there is a lack of evidence to suggest whether simulation-based training offers significant benefits for clinical care over more traditional educational techniques, especially when the objective is a clinical judgement or diagnosis rather than a practical skill. This thesis explores whether the use of a high-fidelity patient simulator during training has an effect on the self-efficacy beliefs and clinical practice of learners, and whether this varies according to learners’ prior experience with simulation training or the clinical topic. Data were collected through semi-structured interviews with 16 qualified nurses, all of whom had attended a simulation-based training programme designed to improve clinical judgement skills. Analysis and data collection were iterative. Using a social constructionist epistemology, a thematic analysis approach was employed. High-fidelity simulation was perceived to be valuable by participants, who reported that it helped them to contextualize their knowledge and feel more confident about relevant clinical judgements. The reported impact on self-efficacy varied according to how much personal experience learners had in either the relevant clinical domain or with simulation as a training technique. However, greater belief in personal clinical judgement skills did not necessarily change reported clinical behaviour. The need for psychological fidelity during training appeared to be inversely related to clinical experience, reflecting the importance of contextual sensitivity in the planning of simulation-assisted training. Future research should examine whether these findings are reproducible in other settings, and consider whether simulation fidelity should be tailored to specific learner profiles

The Dynamics of Sonic Hedgehog Function in Salamander Limb Development

Sonic hedgehog (Shh) is a diffusible morphogen that is expressed in the posterior of tetrapod limbs and patterns the anterior-posterior axis of the limb. Reduction of Shh signaling has been implicated as a likely mechanism in evolved loss of digits in many tetrapod species that have digit numbers fewer than those in the most recent common ancestor of tetrapods. Much is known about the effects of Shh-based digit reduction on skeletal morphology, but little work has been done on the effect of Shh-based digit reduction on muscle development. It is unknown whether muscle morphology and identity is determined moreso by the position of the developing muscle aniage, or by the location of the muscle relative to the digits. Here we use short exposures to cyclopamine, which blocks a cell-surface protein that functions in sensing and transmitting the Shh signal. We seek to experimentally remove a single digit from the forelimbs and hindlimbs of the salamander Ambystoma mexicanum, with the intention of subsequently analyzing multiple stages of the development of limb muscle morphology and identity

An effective, secure and efficient tagging method for integrity protection of outsourced data in a public cloud storage

Data Integrity Auditing (DIA) is a security service for checking the integrity of data stored in a PCS (Public Cloud Storage), a third-party based storage service. A DIA service is provided by using integrity tags (hereafter referred to tags). This paper proposes a novel tagging method, called Tagging of Outsourced Data (TOD), for generating and verifying tags of files. TOD has a number of unique properties: (i) it supports both public and private verifiability, and achieves this property with a low level of overhead at the user end, making it particularly attractive to mobile users with resource-constrained devices, (ii) it protects data confidentiality, supports dynamic tags and is resilient against tag forgery and tag tampering (i.e. by authorised insiders) at the same time in more secure and efficient, making the method more suited to the PCS environment, (iii) it supports tags deduplication, making it more efficient, particularly for the user who has many files with data redundancy. Comprehensive security analysis and performance evaluation have been conducted to demonstrate the efficacy and efficiency of the approach taken in the design

Synthesising qualitative research findings: what are they, where are they and what should I do with them?

Ruth Garside makes a presentation on synthesizing qualitative research findings and the different methods for qualitative evidence synthesi

Images in cardiovascular medicine : multiphoton microscopy for three-dimensional imaging of lymphocyte recruitment into apolipoprotein-E-deficient mouse carotid artery

Two recent elegant studies have shown that in apolipoprotein-E– deficient mice, the lamina adventitia is a major site of arterial wall inflammation associated with lymphocyte infiltration into atherosclerotic arteries and with formation of adventitial lymphoid-like tissues.1,2 These results suggest that lymphocyte responses in the lamina adventitia may play a crucial role in atherosclerosis development.1,

The impact of malaria parasites on dendritic cell–T cell interaction

Malaria is caused by apicomplexan parasites of the genus Plasmodium. While infection continues to pose a risk for the majority of the global population, the burden of disease mainly resides in Sub-Saharan Africa. Although immunity develops against disease, this requires years of persistent exposure and is not associated with protection against infection. Repeat infections occur due to the parasite's ability to disrupt or evade the host immune responses. However, despite many years of study, the mechanisms of this disruption remain unclear. Previous studies have demonstrated a parasite-induced failure in dendritic cell (DCs) function affecting the generation of helper T cell responses. These T cells fail to help B cell responses, reducing the production of antibodies that are necessary to control malaria infection. This review focuses on our current understanding of the effect of Plasmodium parasite on DC function, DC-T cell interaction, and T cell activation. A better understanding of how parasites disrupt DC-T cell interactions will lead to new targets and approaches to reinstate adaptive immune responses and enhance parasite immunity

Suppression of adaptive immunity to heterologous antigens during Plasmodium infection through hemozoin-induced failure of dendritic cell function

BACKGROUND: Dendritic cells (DCs) are central to the initiation and regulation of the adaptive immune response during infection. Modulation of DC function may therefore allow evasion of the immune system by pathogens. Significant depression of the host's systemic immune response to both concurrent infections and heterologous vaccines has been observed during malaria infection, but the mechanisms underlying this immune hyporesponsiveness are controversial. RESULTS: Here, we demonstrate that the blood stages of malaria infection induce a failure of DC function in vitro and in vivo, causing suboptimal activation of T cells involved in heterologous immune responses. This effect on T-cell activation can be transferred to uninfected recipients by DCs isolated from infected mice. Significantly, T cells activated by these DCs subsequently lack effector function, as demonstrated by a failure to migrate to lymphoid-organ follicles, resulting in an absence of B-cell responses to heterologous antigens. Fractionation studies show that hemozoin, rather than infected erythrocyte (red blood cell) membranes, reproduces the effect of intact infected red blood cells on DCs. Furthermore, hemozoin-containing DCs could be identified in T-cell areas of the spleen in vivo. CONCLUSION: Plasmodium infection inhibits the induction of adaptive immunity to heterologous antigens by modulating DC function, providing a potential explanation for epidemiological studies linking endemic malaria with secondary infections and reduced vaccine efficacy

A novel cellular pathway of antigen presentation and CD4 T cell activation in vivo

Dendritic cell activation of CD4 T cells in the lymph node draining a site of infection or vaccination is widely considered the central event in initiating adaptive immunity. The accepted dogma is that this occurs by stimulating local activation and antigen acquisition by dendritic cells, with subsequent lymph node migration, however the generalizability of this mechanism is unclear. Here we show that in some circumstances antigen can bypass the injection site inflammatory response, draining freely and rapidly to the lymph nodes where it interacts with subcapsular sinus (SCS) macrophages resulting in their death. Debris from these dying SCS macrophages is internalized by monocytes recruited from the circulation. This coordinated response leads to antigen presentation by monocytes and interactions with naïve CD4 T cells that can drive the initiation of T cell and B cell responses. These studies demonstrate an entirely novel pathway leading to initiation of adaptive immune responses in vivo

Being the ‘med reg’: an exploration of junior doctors’ perceptions of the medical registrar role

The role of the medical registrar is a challenging one and is acknowledged as being a disincentive to a career in medicine for some junior doctors. We set out to build a broader understanding of the role through exploration of Foundation Doctors’ and Core Medical Trainees’ perceptions of the role. Data, gathered from focus groups, were analysed using a framework approach. Six key themes were identified, which were grouped under the headings ‘perceptions of the medical registrar role’ and ‘transition into the role’. Our work builds on existing literature to inform a deeper understanding of how junior doctors perceive the medical registrar role. In light of our findings we offer suggestions on possible training initiatives to tackle the issues identified. We also highlight positive perceptions of the role and emphasise the key ambassadorial role that current medical registrars have in relation to attracting tomorrows’ medical registrars to the specialty