Increased sedation requirements in patients receiving extracorporeal membrane oxygenation for respiratory and cardiorespiratory failure

Critically ill patients receiving extracorporeal membrane oxygenation (ECMO) are often noted to have increased sedation requirements. However, data related to sedation in this complex group of patients is limited. The aim of our study was to characterise the sedation requirements in adult patients receiving ECMO for cardiorespiratory failure. A retrospective chart review was performed to collect sedation data for 30 consecutive patients who received venovenous or venoarterial ECMO between April 2009 and March 2011. To test for a difference in doses over time we used a regression model. The dose of midazolam received on ECMO support increased by an average of 18 mg per day (95% confidence interval 8, 29 mg, P=0.001), while the dose of morphine increased by 29 mg per day (95% confidence interval 4, 53 mg, P=0.021) The venovenous group received a daily midazolam dose that was 157 mg higher than the venoarterial group (95% confidence interval 53, 261 mg, P=0.005). We did not observe any significant increase in fentanyl doses over time (95% confidence interval 1269, 4337 µg, P=0.94). There is a significant increase in dose requirement for morphine and midazolam during ECMO. Patients on venovenous ECMO received higher sedative doses as compared to patients on venoarterial ECMO. Future research should focus on mechanisms behind these changes and also identify drugs that are most suitable for sedation during ECMO.

Dying in hospital: medical failure or natural outcomes?

The purpose of this study was to describe patterns of medical and nursing practice in the care of patients dying of oncological and hematological malignancies in the acute care setting in Australia. A tool validated in a similar American study was used to study the medical records of 100 consecutive patients who died of oncological or hematological malignancies before August 1999 at The Canberra Hospital in the Australian Capital Territory. The three major indicators of patterns of end-of-life care were documentation of Do Not Resuscitate (DNR) orders, evidence that the patient was considered dying, and the presence of a palliative care intention. Findings were that 88 patients were documented DNR, 63 patients' records suggested that the patient was dying, and 74 patients had evidence of a palliative care plan. Forty-six patients were documented DNR 2 days or less prior to death and, of these, 12 were documented the day of death. Similar patterns emerged for days between considered dying and death, and between palliative care goals and death. Sixty patients had active treatment in progress at the time of death. The late implementation of end-of-life management plans and the lack of consistency within these plans suggested that patients were subjected to medical interventions and investigations up to the time of death. Implications for palliative care teams include the need to educate health care staff and to plan and implement policy regarding the management of dying patients in the acute care setting. Although the health care system in Australia has cultural differences when compared to the American context, this research suggests that the treatment imperative to prolong life is similar to that found in American-based studies.

A non-linear dynamic analysis of heavy haul track line sleepers under wheel flat

Significant wheel-rail dynamic forces occur because of imperfections in the wheels and/or rail. One of the key responses to the transmission of these forces down through the track is impact force on the sleepers. Dynamic analysis of nonlinear systems is very complicated and does not lend itself easily to a classical solution of multiple equations. Trying to deduce the behaviour of track components from experimental data is very difficult because such data is hard to obtain and applies to only the particular conditions of the track being tested. The finite element method can be the best solution to this dilemma. This paper describes a finite element model using the software package ANSYS for various sized flat defects in the tread of a wheel rolling at a typical speed on heavy haul track. The paper explores the dynamic response of a prestressed concrete sleeper to these defects.

A dynamic wheel-rail impact analysis of railway track under wheel flat by Finite Element Analysis

Wheel–rail interaction is one of the most important research topics in railway engineering. It involves track impact response, track vibration and track safety. Track structure failures caused by wheel–rail impact forces can lead to significant economic loss for track owners through damage to rails and to the sleepers beneath. Wheel–rail impact forces occur because of imperfections in the wheels or rails such as wheel flats, irregular wheel profiles, rail corrugations and differences in the heights of rails connected at a welded joint. A wheel flat can cause a large dynamic impact force as well as a forced vibration with a high frequency, which can cause damage to the track structure. In the present work, a three-dimensional (3-D) finite element (FE) model for the impact analysis induced by the wheel flat is developed by use of the finite element analysis (FEA) software package ANSYS and validated by another validated simulation. The effect of wheel flats on impact forces is thoroughly investigated. It is found that the presence of a wheel flat will significantly increase the dynamic impact force on both rail and sleeper. The impact force will monotonically increase with the size of wheel flats. The relationships between the impact force and the wheel flat size are explored from this finite element analysis and they are important for track engineers to improve their understanding of the design and maintenance of the track system.

A lawyer's duty of care : beware the failure to advise of contingencies and foreseeable risks

It is trite law that a lawyer owes their client a duty of care requiring the lawyer to take reasonable steps to avoid their client suffering foreseeable economiic loss: Hawkins v Clayton. In the context of a property transaction this will include a duty to warn the client of anything that is unusual or anything which may affect the client obtaining the full benefit of the contract entered into: Macindoe v Parbery.

International entrepreneurship for SME business growth : a resource and dynamic capability view of the firm : an internet context

This research explores the relationship between international business Internet capabilities and international entrepreneurial characteristics. It has been suggested, that the accumulation of a firms Internet capability can assist international operations, especially when operating in fast changing dynamic environments. However, the international entrepreneurial characteristics which are seen as a precursor to leveraging such capabilities are still vague. Given this finding a conceptual framework is constructed and research issues are then developed in order to focus attention on the relationship between the Internet and a firm’s resource base, dynamic capabilities and international market performance.

A dynamic mapping of the UK's creative industries

This paper argues that, despite its strengths, the UK Department of Culture, Media and Sport (DCMS) classification of the creative industries contains inconsistencies which need to be addressed to make it fully fit for purpose. It presents an improved methodology which retains the strengths of the DCMS's approach while addressing its deficiencies. We focus on creative intensity: the proportion of total employment within an industry that is engaged in creative occupations.

Building shared situational awareness in surgery through distributed dialogue

Background Failure to convey time-critical information to team members during surgery diminishes members’ perception of the dynamic information relevant to their task, and compromises shared situational awareness. This research reports the dialog around clinical decisions made by team members in the time-pressured and high-risk context of surgery, and the impact of these communications on shared situational awareness. Methods Fieldwork methods were used to capture the dynamic integration of individual and situational elements in surgery that provided the backdrop for clinical decisions. Nineteen semi structured interviews were performed with 24 participants from anaesthesia, surgery, and nursing in the operating rooms of a large metropolitan hospital in Queensland, Australia. Thematic analysis was used. Results: The domain “coordinating decisions in surgery” was generated from textual data. Within this domain, three themes illustrated the dialog of clinical decisions, i.e., synchronizing and strategizing actions, sharing local knowledge, and planning contingency decisions based on priority. Conclusion Strategies used to convey decisions that enhanced shared situational awareness included the use of “self-talk”, closed-loop communications, and “overhearing” conversations that occurred at the operating table. Behaviours’ that compromised a team’s shared situational awareness included tunnelling and fixating on one aspect of the situation.

Dynamic lifecycle strategies for target date retirement funds

Target date retirement funds have gained favor with retirement plan investors in recent years. Typically, these funds initially have a high allocation to stocks but move towards less volatile assets, such as bonds and cash, as the target retirement date approaches. Empirical research has generally found that a switch to low-risk assets prior to retirement can reduce the risk of confronting the most extreme negative outcomes. This article questions the rationale for lifecycle switching based solely on age or target retirement date as is the prevalent practice among target date funds. The authors argue that a dynamic switching strategy, which takes into consideration achieved investment returns, will produce superior returns for most investors compared to conventional lifecycle switching. In this article, the authors put forward a dynamic lifecycle switching strategy that is conditional on the attainment of the plan member's wealth accumulation objective at every stage of switching.

STALKERBOT : learning to navigate dynamic human environments by following people

Service robots that operate in human environments will accomplish tasks most efficiently and least disruptively if they have the capability to mimic and understand the motion patterns of the people in their workspace. This work demonstrates how a robot can create a humancentric navigational map online, and that this map re ects changes in the environment that trigger altered motion patterns of people. An RGBD sensor mounted on the robot is used to detect and track people moving through the environment. The trajectories are clustered online and organised into a tree-like probabilistic data structure which can be used to detect anomalous trajectories. A costmap is reverse engineered from the clustered trajectories that can then inform the robot's onboard planning process. Results show that the resultant paths taken by the robot mimic expected human behaviour and can allow the robot to respond to altered human motion behaviours in the environment.

A prototype system dynamic model for assessing the sustainability of construction projects

There is a worldwide demand for an increasingly sustainable built environment. This has resulted in the need for a more accurate evaluation of the level of sustainability of construction projects. To do this it involves the development of better measurement and benchmarking methods. One approach is to use a theoretical model to assess construction projects in terms of their sustainable development value (SDV) and sustainable development ability (SDA) for implementation in the project life cycle, where SDA measures the contribution of a project to development sustainability and as a major criterion for assessing its feasibility. This paper develops an improved SDA prototype model that incorporates the effects of dynamical factors on project sustainability. This involves the introduction of two major factors concerning technological advancement and changes in people's perceptions. A case study is used to demonstrate the procedures involved in simulation and modeling, one outcome of which is to demonstrate the greater influence of technological advancement on project sustainability than changes in perception.

Dynamic performance characteristics of an innovative Hybrid Composite Floor Plate System under human-induced loads

This study explored the dynamic performance of an innovative Hybrid Composite Floor Plate System (HCFPS), composed of Polyurethane (PU) core, outer layers of Glass–fibre Reinforced Cement (GRC) and steel laminates at tensile regions, using experimental testing and Finite Element (FE) modelling. Experimental testing included heel impact and walking tests for 3200 mm span HCFPS panels. FE models of the HCFPS were developed using the FE program ABAQUS and validated with experimental results. HCFPS is a light-weight high frequency floor system with excellent damping ratio of 5% (bare floor) due to the central PU core. Parametric studies were conducted using the validated FE models to investigate the dynamic response of the HCFPS and to identify characteristics that influence acceleration response under human induced vibration in service. This vibration performance was compared with recommended acceptable perceptibility limits. The findings of this study show that HCFPS can be used in residential and office buildings as a light-weight floor system, which does not exceed the perceptible thresholds due to human induced vibrations.