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Manikin selection: general principles Training requirements The growing number of different manikins available today can make choosing which manikin to purchase a complex process purchase 80 mg super cialis fast delivery. Manikins are vital for learning practical cardiopulmonary resuscitation skills The most important question to ask initially is: which skills need to be acquired? This will obviously depend on the class under instruction; the requirements of a lay class will be quite different from those of professional hospital staff learning advanced life support skills purchase 80mg super cialis overnight delivery. For large classes it may be better to maximise the practical hands-on exposure by investing in several cheaper With all manikins super cialis 80mg, realistic appearance buy cheap super cialis 80mg, manikins rather than rely on one or two expensive buy super cialis 80mg online, more accurate anatomical landmarks, and an appropriate response to any attempted complex models. Models vary greatly in sophistication, but most provide some qualitative indication that technique is adequate, such as audible clicks when the depth of chest compression is correct. Some manikins incorporate sensors that recognise the correct hand position and the rescuer’s attempts at shaking, opening the airway, and Resuscitation skills that can be practised palpation of a pulse. The depths of ventilation and chest on manikins compression may also be recorded. An objective assessment of Basic life support performance may be communicated to the student or ● Manual airway control with or without instructor by means of flashing lights, meters, audible signals, simple airway adjuncts or graphical display on a screen. A permanent record may be ● Pulse detection obtained for subsequent study or certification. A score, indicating the number of correct ● Precordial thump manoeuvres, may form the basis of a test of competence. A minimum score of 70% correct ● Defibrillation and cardioversion ● Intravenous and intraosseous access cardiac compressions and ventilations may be taken to (with or withoutadministration of drugs) represent effective life support. This score on a Skillmeter Related skills Resusci Anne manikin is acceptable to the Royal College of ● Management of haemorrhage, fractures, etc. General Practitioners of the United Kingdom as part of the ● Treatment of pneumothorax MRCGP examination. Some care is required, however, and the “skin” should not be permanently marked by lipstick or pens or allowed to become stained with extensive use. Many currently available manikins have replacements available for those components subject to extensive wear and tear. This is particularly true for the face, which bears the brunt of damage and where discoloration or wear will make the manikin aesthetically unattractive. A carrying case (preferably rigid and fitted with castors for heavier manikins) is essential for safe storage and transport. Cross infection and safety To minimise the risk of infection occurring during the conduct of simulated mouth-to-mouth ventilation the numbers of Manikins can be students using each manikin should be kept low and careful used for a attention should be paid to hygiene. Students should be free of variety of communicable infection, particularly of the face, mouth, or training exercises respiratory tract. Faceshields or other barrier devices (see Chapter 18) should be used when appropriate. Manikins should be disinfected during and after each training session according to the manufacturer’s instructions. Preparations incorporating 70% alcohol and chlorhexidine are often used. Hypochlorite solutions containing 500ppm chlorine (prepared by adding 20ml of domestic bleach to 1l of water) are effective but unpleasant to use. They are best reserved for the thorough cleaning of manikins between classes. Moulded hair has now replaced stranded or artificial hair and is much easier to keep clean. Many modern manikins feature a disposable lower airway consisting of plastic lungs and connecting tubes. Expired air passes through a non-return valve in the side of the manikin during expiration. All disposable parts should be replaced in accordance with the manufacturer’s recommendations. Other manikins use a clean mouthpiece and disposable plastic bag insert for each student. Cost Some manikins Cost will depend on the skills to be practised and the number produce printed of manikins required for a class. Sophisticated skills, such as reports on performance monitoring, recording, and reporting facilities, increase cost further. Any budget should include an allowance for cleaning, provision of disposable items, and replacement parts. Another consideration is the ease with which the manikins can be updated when resuscitation guidelines and protocols change.

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Buchholz HW generic 80mg super cialis free shipping, Baars G purchase super cialis 80 mg fast delivery, Dahmen G (1985) Frueherfahrungen mit der Mini- Hueftgelenkstotalendoprothese (Modell “St Georg-Mini”) bei Dysplasie-Coxarthrose cheap 80mg super cialis mastercard. Matsuno T (1989) Long-term follow-up study of total hip replacement with bone graft purchase super cialis 80mg online. Paavilainen T super cialis 80mg overnight delivery, Hoikka V, Solonen KA (1990) Cementless replacement for severely dysplastic or dislocated hip. Charnley J, Feagin JA (1973) Low-friction arthroplasty in congenital subluxation of hip. Kinoshita I, Hirano N (1985) Some problems about indication of total arthroplasty for secondary coxarthrosis (in Japanese). Kuroki Y (1986) Total hip arthroplasty for high dislocation of the hip joint (in Japanese). Kerboull M, Hamadouche M, Kerboull L (2001) Total hip arthroplasty for Crowe type IV developmental hip dysplasia. Inoue S (1983) Total hip arthroplasty for painful high dislocation of the hip in the adult (in Japanese). Kanehara, Tokyo, pp 257–266 A Biomechanical and Clinical Review: The Dall–Miles Cable System Desmond M. The Dall–Miles Cable System (Stryker Orthopaedics, Mahwah, NJ, USA) has been in clinical use since 1983. It was initially developed for reattachment of the greater trochanter in low-friction arthroplasty of the hip. It is now used largely as a cerclage system, par- ticularly in revision total hip arthroplasty (THA). A biomechanical review includes a comparison of the mechanical strength of different cerclage systems. The relationship between tensile strength and fatigue per- formance is analyzed, and comparative data are presented. A review of the clinical use of cable cerclage is presented, including fixation of the greater trochanter in various trochanteric osteotomy approaches to the hip, the use of the system in revi- sion THA, femoral allografts, its use in fixation of periprosthetic fractures of the femur in THA, and the use of the system in augmentation of other forms of fracture fixation, emphasizing its value in the treatment of fractures in soft bone. Dall–Miles, Cable, Biomechanical, Clinical Introduction Cerclage systems have been used in many clinical situations, mainly to provide, or assist in, fixation of bony fragments and occasionally of long bones. Materials have included stainless steel, chrome cobalt, titanium alloy, and nylon. Monofilament wires or bands have been used for many decades, but it was not until the late 1970s that Dall and Miles were the first to use multifilament cable in the fixation of the greater trochanter when osteotomized as an approach to the hip in total hip arthroplasty. Emeritus Professor of Clinical Orthopaedics, University of Southern California, Los Angeles, CA, USA 239 240 D. Dall The Strength of Cerclage Systems It is important to appreciate that the stress–strain curves of different cerclage systems (e. However, the load-deflection curves will be different because of the structural differences even in the same material. Thus, yield and break- ing loads are the most useful measurement of mechanical strength. The other impor- tant aspect of strength in cerclage systems is that of fatigue strength, which I discuss later. Figure 1a shows the comparative yield and ultimate tensile strengths of different systems in the same material, and Fig. Strength of Fastening Methods in Different Cerclage Systems There are great variations in the method of fastening used in cerclage systems. There is also great variation in the measurements used, and these could include measure- ments of displacement, slip or yield, and failure loads. Comparative yield and ultimate tensile strength of different geometric structures made of the same materials (a) and different geometric structures made of different materials (b). Dark gray bars represent yield strength; light gray bars represent ultimate strength The Dall–Miles Cable System 241 a b Fig. There is therefore a plethora of comparative data, sometimes comparing apples with oranges.

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Ames worked He found that tris (2 quality 80mg super cialis,3-dibromopropyl) phosphate proven 80 mg super cialis, the chemi- at the National Institutes of Health super cialis 80 mg with mastercard, primarily in the National cal that was used as a flame retardant on children’s pajamas 80 mg super cialis sale, Institute of Arthritis and Metabolic Diseases order 80mg super cialis with amex, from 1953 to was a mutagen in the Ames test; he was instrumental in get- 1967. Similarly he found that some hair dyes con- and Molecular Biology at the University of California at tained mutagens. He was Chairman of the regulations that forced manufacturers to reformulate their Department from 1984 to 1989. In his position on the regulation of synthetic chemi- Director of the National Institute of Environmental Health cals, he was a natural ally of environmentalists. However, in the early 1980s Ames reversed his position, In the 1960s and early 1970s Ames developed a test arguing that there is no scientific evidence that small doses of that measured the degree to which synthetic chemicals cause most synthetic chemicals cause human cancers; he also argued gene mutation (a change in the deoxyribonucleic acid, or that, in the absence of such evidence, they should not be con- DNA, the molecule that carries genetic information). This about-face was partly a result of a growing body began by deliberately mutating a Salmonella bacterium. The of knowledge concerning the mutagenic properties of numer- changed bacterium could not produce an amino acid called ous chemicals found in nature. Ames began arguing against histidine that normal bacteria produce and that they need to the existing large public expenditures for pollution control and survive. The next step was to add just enough histidine to the regulation of synthetic chemicals, noting that cancer might allow the bacteria to live, and to add, as well, the synthetic just as plausibly be caused by the chemicals in plants. If the added chemical caused genetic arguments were based primarily on three factors: his argument mutation, the abnormal gene of the Salmonella bacteria that more scientific evidence should be required before con- would mutate and again be able to produce histidine. When trols are implemented; his attitude toward the setting of prior- 13 Amino acid chemistry WORLD OF MICROBIOLOGY AND IMMUNOLOGY ities, which he argued should be centered on basic research AMINO ACID CHEMISTRY Amino acid chemistry rather than regulation; and finally his belief that the large pub- lic expenditures incurred by the regulatory process hurt Amino acids are the building blocks of proteins and serve American economic competitiveness. The prime function Ames and his colleague Gold have also argued that the of DNA is to carry the information needed to direct the proper use of bioassays (animal tests) of chemicals to predict their sequential insertion of amino acids into protein chain during carcinogenic potential in humans should be abandoned. The approximately 20 amino acids (plus a few the animal can be given without immediately becoming ill or derivatives) that have been identified as protein constituents dying. At the end of the time period, the number of animals are alpha-amino acids in which the -NH2 group is attached to that have developed cancers is tabulated as an indicator of the the alpha-carbon next to the -COOH group. Thus, their basic cancer causing potential of the chemical being tested. This side suggested that it is often the large dosage itself, rather than the chain, which uniquely characterizes each alpha-amino acid, nature of the particular chemical that induces the rat cancers. There are hundreds of alpha-amino acids, such large doses, the assays were not valid for predicting both natural and synthetic. The amino acids that receive the most attention are the Ames’s arguments have some support both within and alpha-amino acids that genes are codes for, and that are used outside scientific communities. These amino acids include glycine NH2CH2COOH, alanine CH3CH (NH2) COOH, valine ous critics. Those taking issue with his positions have noted (CH3)2CHCH (NH2)COOH, leucine (CH3)2CHCH2CH(NH2) that pollution control, for example, involves far more than just COOH, isoleucine CH3CH2CH(CH3)CH(NH2)COOH, methi- carcinogenicity. These critics suggest that Ames has not onine CH3SCH2CH2CH(NH2)COOH, phenylalanine C6H5CH2 offered a substitute for animal assays (the Ames test has not CH(CH2)COOH, proline C4H8NCOOH, serine HOCH2CH proved to be such a substitute), and that neither he nor they (NH2)COOH, threonine CH3CH(OH)CH(NH2)COOH, cys- have a good idea of what goes on at low dosages. Some argue teine HSCH2CH(NH2)COOH, asparagine, glutamine H2NC that Ames has an over-simplified view of the regulatory (O)(CH2)2CH(NH2)COOH, tyrosine C6H4OHCH2CHNH2 process, which is based on a consideration of animal assays COOH, tryptophan C8H6NCH2CHNH2COOH, aspartate but also on other factors. It has also been argued that the dis- COOHCH2CH(NH2)COOH, glutamate COOH(CH2)2CH covery that many naturally occurring chemicals have a high (NH2)COOH, histidine HOOCCH(NH2)CH2C3H3H2, lysine mutagenic rate (just as synthetic chemicals) should not lead to NH2(CH2)4CH(NH2)COOH, and arginine (NH2)C(NH) the conclusion that synthetic chemicals pose less risk than was HNCH CH CH CH(NH )COOH. Such an assumption places too much Proteins are one of the most common types of mole- emphasis on mutagenic rate as a sole indicator of carcino- cules in living matter. There are countless members of this genicity, ignoring the complex, multi-stage developmental class of molecules. One Yet the disagreements between Ames and his critics are thing that all proteins have in common is that they are com- based on several points of commonality—that cancer is a posed of amino acids. The protein’s secondary structure is the fixed arrange- made and carried out in spite of this deficiency of knowledge. The hobby, and he has noted that his recent scientific work secondary structure is strongly influenced by the nature of the includes studies in the biochemistry of aging. Side chains also contribute to the pro- Ames has received many awards, including the Eli Lilly tein’s tertiary structure, i. The twists and folds in the protein chain Prize of the General Motors Cancer Research Foundation result from the attractive forces between amino acid side (1983), and the Gold Medal of the American Institute of chains that are widely separated from each other within the Chemists (1991). Some proteins are composed of two of more chains of 250 scientific articles. The subunits can be structurally the same, but in many See also Chemical mutagenesis; Molecular biology and cases differ. The protein’s quaternary structure refers to the molecular genetics spatial arrangement of the subunits of the protein, and 14 WORLD OF MICROBIOLOGY AND IMMUNOLOGY Amino acid chemistry The twenty most common amino acids.

For the content validity to be high cheap super cialis 80mg overnight delivery, the assessment must sample the students’ abilities on each objective order 80mg super cialis with visa. As these objectives are likely to cover a wide range of knowledge discount 80 mg super cialis free shipping, skills and attitudes buy super cialis 80 mg fast delivery, it will immediately become apparent that no single test method is likely to provide a valid assessment order 80mg super cialis overnight delivery. For instance, a multiple-choice test will hardly be likely to provide valid information about clinical skills. Some objectives, particularly those in the attitudinal area will be hard to assess validly in examination settings and alternative forms of assessment may have to be sought. Other forms of validity exist but generally speaking you will not be in a position to evaluate them so they will not be discussed further. If you are interested, you should consult the Guided Reading at the end of the chapter. Reliability The reliability of any assessment is a measure of the consistency and precision with which it tests what it is supposed to test. Though its importance is initially less vital than validity, you should remember that an unreliable assessment cannot be valid. The degree of reliability varies with the assessment format itself, the quality of its administration and the marking. Theoretically, a reliable assessment should produce the same result if administered to the same student on two separate occasions. Various methods are available which provide statistical indices of reliability and you should seek expert advice on these. A common approach used in 129 multiple-choice tests is to produce a measure of internal consistency. Another key component in determining the reliability of an assessment is the consistency of the marking. The absence of consistency is a major reason for the unacceptable levels of reliability in most forms of direct assessment, in clinical examinations and in written tests of the essay type. However, methods are available to help you minimise this problem and these will be discussed later in this chapter. It has become widely recognised in recent years that an even more important contributor to unreliability is inadequate content or performance sampling. This is a particular problem for assessments of clinical competence which need to be much longer than is usually the case if high levels of reliability (generalisability) are to be achieved. You must explore this issue further if you are involved in developing a ‘high stakes’ clinical examination such as ones to be used for certification purposes. Improving validity and reliability of assessments Validity can be improved by: carefully matching an assessment with the learning objectives, content and teaching methods; increasing the sample of objectives and content areas included in any assessment; producing an examination blueprint (see Figure 8. Reliability can be improved by: ensuring that questions are clear and suitable for the level of the students; checking to make sure time limits are realistic; writing instructions that are simple, clear, and unambiguous; developing a marking scheme of high quality (e. You may decide to use a scheme that is potentially highly valid and reliable but find that it is not practical to do so in your circumstances. Some questions you might consider here are: 131 Do I have the skills to administer, mark and grade the assessment? If appropriate, can I combine less reliable methods with more reliable methods? Obviously, there will be other considerations of a practical nature that are peculiar to your own circumstances and that you will have to consider before implementing any particular scheme. Norm-referenced versus criterion-referenced assessment Before we finish dealing with some of the basic principles of educational measurement, we wish to introduce the difference between norm- and criterion-referenced assessment. You are likely to be familiar with norm- referenced assessment, as this reflects the traditional approach to testing. Any assessment which uses the results of all the students to determine the standard is of this type. In such tests the pass level is often set by predetermining the proportion of students given each grade or ‘grading on the curve’ as it is often called. Some assumptions made are not appropriate to assessing learning in universities, and the approach can be shown to lack an educational justification. For example, do we seriously set out in our teaching to ensure that, no matter how well students achieve the objectives, because of our grading on the curve policy, some will fail? Surely, our task is to help all students to achieve the objectives and reduce gaps between them rather than getting a ‘spread of scores’.

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