Development of core competencies for an international training programme in intensive care medicine

OBJECTIVE

The aim of this study was to define the core (minimum) competencies required of a specialist in adult intensive care medicine (ICM). This is the second phase of a 3-year project to develop an internationally acceptable competency-based training programme in ICM for Europe (CoBaTrICE).

METHODOLOGY

Consensus techniques (modified Delphi and nominal group) were used to enable interested stakeholders (health care professionals, educators, patients and their relatives) to identify and prioritise core competencies. Online and postal surveys were used to generate ideas. A nominal group of 12 clinicians met in plenary session to rate the importance of the competence statements constructed from these suggestions. All materials were presented online for a second round Delphi prior to iterative editorial review.

RESULTS

The initial surveys generated over 5,250 suggestions for competencies from 57 countries. Preliminary editing permitted us to encapsulate these suggestions within 164 competence stems and 5 behavioural themes. For each of these items the nominal group selected the minimum level of expertise required of a safe practitioner at the end of their specialist training, before rating them for importance. Individuals and groups from 29 countries commented on the nominal group output; this informed the editorial review. These combined processes resulted in 102 competence statements, divided into 12 domains.

CONCLUSION

Using consensus techniques we have generated core competencies which are internationally applicable but still able to accommodate local requirements. This provides the foundation upon which an international competency based training programme for intensive care medicine can be built.

An international survey of training in adult intensive care medicine

OBJECTIVE

The aim of this international survey of training in adult intensive care medicine (ICM) was to characterise current structures, processes, and outcomes to determine the potential for convergence to a common competency-based training programme across national borders. This survey is the first phase of a 3 year project which will use consensus methods to build an international competency-based training programme in ICM in Europe (CoBaTrICE).

METHODOLOGY

A survey by questionnaire, e-mail, and direct discussion was undertaken with national ICM representatives from seven geographical regions.

RESULTS

Responses were obtained from 41 countries (countries which share common training programmes were grouped together; n=38). Fifty-four different training programmes were identified, 37 within the European region; three (6%) were competency-based. Twenty (53%) permitted multidisciplinary access to a common training programme; in nine (24%) training was only available within anaesthesia. The minimum duration of ICM training required for recognition as a specialist varied from 3 months to 72 months (mode 24 months). The content of most (75%) ICM programmes was standardised nationally. Work-based assessment of competence was formally documented in nineteen (50%) countries. An exam was mandatory in twenty-nine (76%).

CONCLUSION

There are considerable variations in the structures and processes of ICM training worldwide. However, as competency-based training is an outcome strategy rather than a didactic process, these differences should not impede the development of a common international competency-based training programme in ICM.

279. A dynamic model of the control of pulsatile luteinizing hormone secretion by gonadotrophin-releasing hormone

Infusion of GnRH in a continuous manner or with a very high pulse frequency initially stimulates but then downregulates LH secretion.1,2 This phenomenon is caused by the slow rate of internalisation of the GnRH receptor (GnRH-R) and the subsequent slow return of receptors to the plasma membrane of the gonadotroph.3 Pulsatile release of GnRH overcomes this problem by allowing a delay between successive stimulations. It is difficult to determine the relative importance of critical control points in this process in an animal model because GnRH activity reflects integrated inputs from many internal and external factors. We are therefore using SAAM II software to develop a compartmental model of the relationship between GnRH-R availability and LH responses following changes in GnRH pulse frequency. The model has three receptor states (free, bound, and internalised) and one LH compartment (Fig. 1). We assumed LH release is a function of the amount of receptor that binds GnRH. Following GnRH binding, receptors are rapidly lost as they enter the internalised state and then slowly returned to the membrane surface. We further assumed that the slow rate of receptor return explains the decrease in LH response with very high frequencies of GnRH pulses. The values for parameters were based on data obtained from experiments with sheep. In our current version of the model, downregulation is observed when gonadotrophs are stimulated with GnRH pulses every 15 min (Fig. 1), but not with pulses every 30 or 60 min, at a slow recycling rate (0.004 min–1). In contrast, LH secretion increases when GnRH is pulsed every 15 min and recycling rate is increased to 0.04 min–1. This suggests that, in sheep, a recycling rate between 0.004 and 0.04 min–1 is a critical aspect of the intracellular control of the process. Future work will include steroid feedback loops.

Evaluation of Podophyllum peltatum accessions for podophyllotoxin production

In an effort to develop a sustainable source of podophyllotoxin for the production of anticancer drugs such as etoposide, teniposide and etopophos, Podophyllum peltatum accessions with podophyllotoxin-rich leaf biomass were identified and transplanted to different growing conditions by vegetative cuttings. Results indicate that the lignan profile in leaves does not change over time or due to environment conditions. Podophyllotoxin and alpha-peltatin content in the blades seems to be stable with an inverse relationship of concentration between these compounds. A podophyllotoxin-rich leaf accession showed low biosynthetic capability to synthesize alpha- and beta-peltatin and the converse was also true, indicating that selection and cultivation of high-yielding podophyllotoxin leaf biomass may reduce production costs.

Metabolic modes of action of the statins in the hyperlipoproteinemias

Conflicting results have been published during the past few years regarding the physiologic modes of action of the hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitors, generally referred to as statins, using standard doses. Three mechanisms have been described: increased LDL catabolic rate, increased removal of LDL precursors resulting in decreased LDL production and decreased VLDL production. The physiologic effects of statins seem to depend on the underlying pathology of the disorders under therapy. More recent data using either the more potent atorvastatin or larger doses of previously available statins (e.g. simvastatin 80-160 mg/day), suggest that both the potency of the statins and the underlying pathopHysiology are important in determining the predominant physiologic responses of patients. To understand physiologic responses more completely, drug-dose-physiologic response curves of apo B kinetics in various groups of patients are needed. Simultaneous studies of apo B, triglycerides and cholesterol metabolism are also needed and are currently feasible.

Production rate determines plasma concentration of large high density lipoprotein in non-human primates

Large LpAI HDL particles, containing only apoA-I without apoA-II, are reported to be the major anti-atherogenic portion of HDL and to be increased in individuals with low risk for coronary heart disease. To determine whether the plasma concentration of large LpAI is modulated by the rate of production or catabolism of apolipoprotein A-I (apoA-I) in large LpAI, kinetic studies of large LpAI were performed in African green monkeys consuming an atherogenic diet with either high plasma HDL concentration (120 +/- 36 mg/dl, mean +/- SD, n = 3) or low plasma HDL concentration (40 +/- 13 mg/dl, n = 3). Large LpAI was isolated, without ultracentrifugation, by immunoaffinity and gel filtration and radiolabeled. After injection, the specific activity of apoA-I in large HDL, consisting of both LpAI and LpAI:AII particles, was followed. A multicompartmental model was developed for the kinetics of apoA-I in large HDL, which indicated that a portion of large HDL is distributed to a sequestered pool, outside the circulating plasma, and reenters circulating plasma approximately 3 h after injection. There was no conversion of large LpAI to smaller HDL particles or transfer of radiolabeled apoA-I to smaller HDL particles. Although the mean fractional catabolic rate was not different comparing the high and low HDL group, the mean production rate of apoA-I in large HDL was 4-fold greater in the high HDL group compared with the low HDL group. These data support the hypothesis that the plasma concentration of large HDL is controlled primarily by the rate of production of apoA-I in large HDL.

Bounds on null functions of linear digital imaging systems

Any linear digital imaging system produces a finite amount of data from a continuous object. This means that there are always null functions, so a reconstruction of the object, even without noise in the system, will differ from the actual object. With positivity constraints, the size of a null function is limited, provided that size is measured by the integral of the absolute value of the null function. When smoothing is used in reconstruction, then smoothed null functions become relevant. There are bounds on various measures of the size of smoothed null functions, and these bounds can be quite small. Smoothing will decrease the effects of null functions in object reconstructions, and this effect is greater if the smoothing operator is well matched to the system operator.

Symmetry properties of an imaging system and consistency conditions in image space

A general definition for a symmetry group of an imaging system is given. A key requirement is that the operators that represent the symmetries in data space are conformal. The result is that the space of consistency conditions is invariant under the action of the given symmetry group. Via the theory of group representations, this fact provides information about the possible forms that these consistency conditions can take. The theory is illustrated by example for the 2D and 3D Radon transforms, the cone-beam transform on a circular orbit and the 2D attenuated Radon transform.

Decomposition of images and objects into measurement and null components

We derive and discuss an algorithm for separating measurement-and null-space components of an object with respect to a given imaging system. This algorithm requires a discrete-to-discrete approximation of a typically continuous-to-discrete imaging system, and problems associated with such an approximation are examined. Situations where knowledge of the measurement and null spaces is crucial for analyzing imaging systems are discussed. We conclude with two examples demonstrating the usefulness of this algorithm, even in the discrete-to-discrete approximation.

Introduction

This issue of Optics Express provides a snapshot of current theoretical research in the area of tomographic image reconstruction. The topics have been chosen to illustrate some important principles that arise not only in medical imaging but also in the broader arena of indirect imaging. All of the papers were invited by the editors, and all underwent independent peer review.

How young children cope with separation: toward a new conceptualization

In this paper, it is argued that 'separation protest' and the protest-despair-detachment (PDD) pattern, having passed into folklore and become an almost undebated cornerstone in the literature on separation and attachment, continue to have a potent influence which needs to be reexamined, disputed and replaced. Three arguments are advanced: first, that the evidence for the PDD pattern was never substantial; second, that there is now and has for some time been ample evidence for alternative accounts of separation responses; third, that the PDD account, being premised on a model of the very young child as far less socially competent than recent research has indicated, stands in need of refinement.

A bound on null functions for digital imaging systems with positivity constraints

There is an upper bound for the L(1) norm of the difference of two nonnegative object functions when they both produce the same data in a digital imaging system. This bound is achieved for a certain class of systems and an arbitrary nonnegative object. For the L(2) norm of the difference, with the same conditions on the object functions, there is no upper bound.

Plasma kinetics of cholesteryl ester transfer protein in the rabbit. Effects of dietary cholesterol

The plasma kinetics of recombinant human cholesteryl ester transfer protein (rCETP) were studied in six rabbits before and after cholesterol feeding (0.5% wt/wt). The rCETP, labeled with the use of the Bolton Hunter reagent, was shown to retain neutral lipid transfer activity. After intravenous infusion, labeled rCETP associated with rabbit lipoproteins to an extent similar to endogenous rabbit CETP (62% to 64% HDL associated). The plasma kinetics of CETP, modeled with the use of SAAM-II, conformed to a two-pool model, likely representing free and loosely HDL-associated CETP (fast pool) and a tightly apo (apolipoprotein) AI-associated (slow pool) CETP. The plasma residency time (chow diet) of the fast pool averaged 7.1 hours and of the slow pool, 76.3 hours. The production rate (PR) into and the fractional catabolic rate (FCR) of the fast pool were 20 and 10 times the PR and FCR, respectively, of the slow pool. In response to cholesterol feeding, CETP PR, FCR, and plasma mass increased by 416%, 60%, and 230%, respectively. There was a strong correlation (r = .95, P = .003) between the increase in rabbit plasma CETP and the modeled increase in CETP PR in response to cholesterol feeding, suggesting that labeled human rCETP is a satisfactory tracer for rabbit plasma CETP. CETP is catabolized by distinct pools, likely corresponding to an apo AI-associated (slow) pool and a free and/or loosely HDL-associated (fast) pool. Factors that alter the affinity of CETP for HDL would be predicted to result in altered CETP catabolism. The effect of dietary cholesterol on plasma CETP mass can be explained largely by the effects on CETP synthesis, consistent with the observed effects of cholesterol on tissue mRNA levels.

Health, hygiene and maternal education: evidence from The Gambia

The paper explores the ways in which women's education influences domestic hygiene practices and use of health care services in a traditional agricultural village in The Gambia. The "environment of health" is one of poverty, high morbidity and low levels of female literacy. A detailed household survey was undertaken in the rainy season when agricultural work is demanding of people's time and energy and morbidity rates are high. Mothers with and without formal education and with at least one child under 5 were included in the study. Small differences were found between the educated and uneducated group in the knowledge and practice of household hygiene. The healthcare services in the village were utilised by all women regardless of whether or not they had been to school, but educated mothers appeared to have a better understanding of health education messages. The case study illustrates the synergy between health, hygiene and maternal education and discusses the implications of the findings.