Training to proficiency in surgery using simulation: is there a moral obligation?

A deontological approach to surgical ethics advocates that patients have the right to receive the best care that can be provided. The ‘learning curve’ in surgical skill is an observable and measurable phenomenon. Surgical training may therefore carry risk to patients. This can occur directly, through inadvertent harm, or indirectly through theatre inefficiency and associated costs. Trainee surgeon operating, however, is necessary from a utilitarian perspective, with potential risk balanced by the greater societal need to train future independent surgeons.New technology means that the surgical learning curve could take place, at least in part, outside of the operating theatre. Simulation-based deliberate practice could be used to obtain a predetermined level of proficiency in a safe environment, followed by simulation-based assessment of operative competence. Such an approach would require an overhaul of the current training paradigm and significant investment in simulator technology. This may increasingly be viewed as necessary in light of well-discussed pressures on surgical trainees and trainers.This article discusses the obligations to trainees, trainers and training bodies raised by simulation technology, and outlines the current arguments both against and in favour of a simulation-based training-to-proficiency model in surgery. The significant changes to the current training paradigm that would be required to implement such a model are also discussed.

Design new voltage balancing control series connected for HV-IGBT`s

<span>The insulated gate bipolar transistors (IGBTs) are widely used in various applications as they require low gate drive power and gate voltage. This paper proposes an active gain circuit to maintain voltage stability of series-connected IGBTs for high voltage applications. The novel gate driver circuit with closed-loops control amplifies the gate signal while restricting the IGBT emitter voltage below a predetermined level. With the proposed circuit, serial-connected IGBTs can replace high-voltage IGBTs (HV-IGBTs) for high-voltage applications through the active control of the gate signal time delay. Closed-loop controls function is to charged current to the gate to restrict the IGBT emitter voltage to a predetermined level. This paper also presents the experiment on the gate driver capability based on a series-connected IGBTs with three IGBTs and a snubber circuit. The experimental results show a voltage offset with active control with a wide variation in load and imbalance conditions. Lastly, the experimental results are validated with the simulation results, where the simulation results agree with the experimental results.</span>

A new warranty policy for heterogeneous items subject to monotone degradation processes

A new renewable warranty policy is suggested that increases the probability of its success and can decrease the corresponding costs for certain ranges of parameters. It deals with heterogeneous populations of items from two subpopulations (‘weak’ and ‘strong’) and is aimed at elimination and further replacement of weak items after screening at some optimal time. This elimination is performed when degradation described by the corresponding mixed degradation process reaches some optimally predetermined level. Probabilistic and cost analyses of the model are performed and the illustrative example is presented. It is shown that the proposed warranty policy with inspection outperforms the conventional one in a probabilistic sense. Furthermore, the proposed policy becomes economically beneficial especially when the additional penalty cost caused by a sudden failure is large.

Development and validation of an algorithm to assist in the interpretation of the electrocardiogram

Funding Acknowledgements Type of funding sources: None. Background and Purpose Interpretation of the electrocardiogram (ECG) is often poorly performed, affecting time critical patient care. There are no reliable methods that consistently bridge the gap between novices and competency. However, the development of a framework allowing a step-wise approach to interpret the ECG based on relevant signals might help. Indeed, in addition to expert teaching, a pilot study of this algorithm significantly improves sustained ECG interpretation in medical students. This study aimed to validate the ECG algorithm tool by confirming the appropriateness of its step-wise components through expert cardiologists. Methods A Modified Delphi Exercise protocol was used. Cardiologists were invited to participate in a questionnaire through an online survey tool. Expert participants evaluated each stage of the ECG algorithm through multiple levels of agreement and explained their decision making with the option of free-text comments. These were collated and analysed by the four authors and changes subsequently made. The process was repeated, with evaluation of the changes from each round until a predetermined level of agreement was achieved. Results This Modified Delphi Exercise produced two rounds. Overall, 55 responses from experts was achieved (first round = 33, round two = 22). The average agreement in round one was 85.8% with 25 changes from 124 comments. Round two achieved 93.4% agreement with 12 changes from 57 comments. After discussion by four authors, a consensus was reached and a final algorithm was achieved. Figure 1 shows the bradycardia section of the final algorithm (tachycardia and ST/T-wave/ischaemia sections not shown). Conclusions We have validated an ECG algorithm through a rigorous development and review process in a multi-institutional and multi-national Modified Delphi study. The completed expert reviewed algorithm may be a safe, informative tool for novice users to improve ECG interpretation. However, further validation in user groups is now mandated to refine the tool. Abstract Figure 1- Algorithm one of three

Patellar Tendon Imbrication

Background: Patella alta is a common cause of patellar instability. Patellar tendon imbrication is a successful surgery addressing the deformity by shortening the patellar tendon without necessitating an osteotomy. Indications: Symptomatic patella alta causing patellar instability in both skeletally immature and adult patients. Technique Description: The patellar tendon is exposed, and levels of imbrication as determined preoperatively by radiographic measurements are outlined on the tendon with a marking pen. A third line is then made proximal to the level of dissection that is half the distance of the lengthening. From the distal marking, a flap of tendon, the anterior half, is elevated by sharp dissection using a fresh No. 15 blade proximal to the predetermined level. Next, “redundancy-reducing” 2-0 vicryl sutures are placed and left untied by entering at the proximal marking, passing deep to the tendon, and emerging at the middle of the intact posterior section of tendon, followed by placement of 3 structural #2 Ethibond/Ti-Cron horizontal sutures into the patellar tendon that will create and maintain the imbrication. These sutures are then tied proximally while applying downward pressure to the patella to avoid tying under tension. Next, the “redundancy-reducing” sutures are tied thus imbricating the redundant posterior section of tendon. In a “pants over vest” fashion, the distal end of the anterior section of isolated tendon is repaired with ‘‘0’’ absorbable suture. The knee is then flexed beyond 90° to assess competence of the suture lines and to assess the need for quadriceps lengthening. Results: Radiographic shortening is maintained at a minimum of 2 years on 27 patients/32 knees. There were no complications directly related to the technique. Discussion/Conclusion: Patellar tendon imbrication is a safe and effective procedure to correct patella alta in the setting of lateral patellar instability. On average, the technique allowed 1 cm of patellar tendon shortening and maintained the correction at a minimum 2-year follow-up. In the skeletally immature patient, this technique allows correction of patella alta by avoidance of a tibial tuberosity osteotomy.

Vision-Based Road Rage Detection Framework in Automotive Safety Applications

Drivers’ road rage is among the main causes of road accidents. Each year, it contributes to more deaths and injuries globally. In this context, it is important to implement systems that can supervise drivers by monitoring their level of concentration during the entire driving process. In this paper, a module for Advanced Driver Assistance System is used to minimise the accidents caused by road rage, alerting the driver when a predetermined level of rage is reached, thus increasing the transportation safety. To create a system that is independent of both the orientation of the driver’s face and the lighting conditions of the cabin, the proposed algorithmic pipeline integrates face detection and facial expression classification algorithms capable of handling such non-ideal situations. Moreover, road rage of the driver is estimated through a decision-making strategy based on the temporal consistency of facial expressions classified as “anger” and “disgust”. Several experiments were executed to assess the performance on both a real context and three standard benchmark datasets, two of which containing non-frontal-view facial expression and one which includes facial expression recorded from participants during driving. Results obtained show that the proposed module is competent for road rage estimation through facial expression recognition on the condition of multi-pose and changing in lighting conditions, with the recognition rates that achieve state-of-art results on the selected datasets.

Design and Implementation of MQTT Load Test System

In this paper, we design and implement an MQTT load test tools for evaluating the performance of an MQTT appliance system which is capable of handling large amounts of MQTT traffic. The implemented system consists of a master that can centrally control the performance evaluation process and a set of clients that creates virtual MQTT devices and generates MQTT traffic. The MQTT Load Test system was developed using the Java language and the Jpcap library. We developed a GUI version load test and also developed a console mode system that can be executed in an environment where GUI is not available. Using the MQTT Load Test system implemented in this paper, we were able to effectively evaluate the performance of a high-performance MQTT Appliance, another important research topic. Since MQTT Load Test Master and Slave have developed not only the GUI version but also the Console version, it is possible to test the performance even in a remote connection situation where GUI is not supported. The experiment could be conducted in various scenarios, and the number of virtual clients that had to be created per a computer could be confirmed so that the computers participating in the experiment could generate or receive MQTT message traffic of a predetermined level. Applications: The MQTT Load Test system implemented in this paper can be used as a tool for performance evaluation of high-performance MQTT Appliances.

ON DEGRADATION-BASED REMAINING LIFETIME

The new reliability notion describing the remaining lifetime is introduced for items with monotonically increasing degradation. We consider the remaining lifetime of an item (to be called, the predicted remaining lifetime) after its degradation reaches the predetermined level. The prediction is executed at inception of an item into operation. For the nonhomogeneous stochastic processes of degradation, this characteristic depends on the random first passage time of a degradation process. Some properties of the predicted remaining lifetime and the corresponding stochastic comparisons are discussed for items from homogeneous and heterogeneous populations, and a generalization to the case of the n-component coherent system is outlined. The problem of regime switching is described, and the new notion of the corresponding virtual age after the switching is proposed.

Determination of Optimal MR&R Strategy and Inspection Intervals to Support Infrastructure Maintenance Decision Making

In the commonly used approach to maintenance scheduling for infrastructure facilities, maintenance decisions are made under the assumptions that inspection frequency is periodical and fixed, and that the true state of a facility is revealed through inspections. This research addresses these limitations by proposing a decision-making approach for determining optimal maintenance, repair, and rehabilitation (MR&R) strategy and inspection intervals for infrastructure facilities that can explicitly take into account non-periodical inspections as well as previously considered periodical inspections. Four transition probabilities are proposed to represent four different MR&R strategies. Then, an optimization program is suggested to minimize MR&R and inspection costs of a bridge element network over a given time period, while keeping the condition states of the element network above a predetermined level. A case study was applied to illustrate the proposed approach. The results show that the proposal approach can support decision making in situations where non-periodical inspections and MR&R actions are incorporated into the model development. If employed properly, this may allow agencies to maintain their infrastructure more effectively, resulting in cost savings and reducing unnecessary waste of resources.

Process Treatment of Heavy Metal Waste from Various Types of Adosorbents ( clay, flay ash, and natural zeolite) : A Review

Development of the industry, especially the palm oil mill industry, it will have an impact with tangible evidence that makes the environment polluted. Heavy metals will be produced from the palm oil mill industry and will pollute the environment. Zn metal is one of the heavy metal waste produced from the mustard coconut factory industry. Zn heavy metal waste will be very dangerous if it exceeds a predetermined level and will have an impact on humans, animals and the environment. One effort to reduce heavy metals using the adsorption method. Adsorption has advantages over a variety of other methods. Adsorban that is used from materials found in nature and the resulting waste can be used as an adsorbent. The type and type of adsorbent greatly affect the pH adsorption level of the Zn metal solution.