A randomised, controlled trial of conventional versus automated weaning from mechanical ventilation using SmartcareTM/PS

Objective
Preliminary assessment of an automated weaning system (SmartCare™/PS) compared to usual management of weaning from mechanical ventilation performed in the absence of formal protocols.


Design and setting
A randomised, controlled pilot study in one Australian intensive care unit.


Patients
A total of 102 patients were equally divided between SmartCare/PS and Control.

Interventions
The automated system titrated pressure support, conducted a spontaneous breathing trial and provided notification of success (“separation potential”).

Measurements and results
The median time from the first identified point of suitability for weaning commencement to the state of “separation potential” using SmartCare/PS was 20 h (interquartile range, IQR, 2–40) compared to 8 h (IQR 2–43) with Control (log-rank P = 0.3). The median time to successful extubation was 43 h (IQR 6–169) using SmartCare/PS and 40 (14–87) with Control (log-rank P = 0.6). Unadjusted, the estimated probability of reaching “separation potential” was 21% lower (95% CI, 48% lower to 20% greater) with SmartCare/PS compared to Control. Adjusted for other covariates (age, gender, APACHE II, SOFAmax, neuromuscular blockade, corticosteroids, coma and elevated blood glucose), these estimates were 31% lower (95% CI, 56% lower to 9% greater) with SmartCare/PS. The study groups showed comparable rates of reintubation, non-invasive ventilation post-extubation, tracheostomy, sedation, neuromuscular blockade and use of corticosteroids.

Conclusions
Substantial reductions in weaning duration previously demonstrated were not confirmed when the SmartCare/PS system was compared to weaning managed by experienced critical care specialty nurses, using a 1:1 nurse-to-patient ratio. The effect of SmartCare/PS may be influenced by the local clinical organisational context.

A Scalable and Programmable Modular Traffic Manager Architecture

A key issue in the design of next generation Internet routers and switches will be provision of traffic manager (TM) functionality in the datapaths of their high speed switching fabrics. A new architecture that allows dynamic deployment of different TM functions is presented. By considering the processing requirements of operations such as policing and congestion, queuing, shaping and scheduling, a solution has been derived that is scalable with a consistent programmable interface. Programmability is achieved using a function computation unit which determines the action (e.g. drop, queue, remark, forward) based on the packet attribute information and a memory storage part. Results of a Xilinx Virtex-5 FPGA reference design are presented.

Time domain wave separation using multiple microphones

Methods of measuring the acoustic behavior of tubular systems can be broadly characterized as steady state measurements, where the measured signals are analyzed in terms of infinite duration sinusoids, and reflectometry measurements which exploit causality to separate the forward and backward going waves in a duct. This paper sets out a multiple microphone reflectometry technique which performs wave separation by using time domain convolution to track the forward and backward going waves in a cylindrical source tube. The current work uses two calibration runs (one for forward going waves and one for backward going waves) to measure the time domain transfer functions for each pair of microphones. These time domain transfer functions encode the time delay, frequency dependent losses and microphone gain ratios for travel between microphones. This approach is applied to the measurement of wave separation, bore profile and input impedance. The work differs from existing frequency domain methods in that it combines the information of multiple microphones within a time domain algorithm, and differs from existing time domain methods in its inclusion of the effect of losses and gain ratios in intermicrophone transfer functions.

The Global Financial Crisis and UK PPPs

Purpose – This paper seeks to examine how Public Private Partnerships (PPPs) have been affected by the global financial crisis (GFC). After briefly discussing PPPs and the GFC, the paper considers whether the latter has been a contributing factor in the declining number of projects reaching financial close.

Design/methodology/approach – The paper employs document content analysis to compare the time between notification of a project in the Official Journal of the European Union and its financial close in order to assess whether this period has increased since the beginning of the GFC. Two case studies are also presented.

Findings – Apart from a very small number of projects, the time between official project notification and financial close is lengthening, with the case studies providing some possible explanations for this.

Originality/value – Whilst Burger et al. provide some general statistics on the impact of the GFC on PPPs in a number of countries, this paper examines over 600 PPPs in the UK and supplements this analysis with two case studies, in order to assess whether the GFC has led to delays in projects reaching financial close.

Stability of dust lattice modes in the presence of charged dust grain polarization in plasmas

We discuss the effect of the attractive force associated with overlapping Debye spheres on the dispersion properties of the longitudinal and transverse dust lattice waves in strongly coupled dust crystals. The dust grain attraction is shown to contribute to a destabilization of the longitudinal dust lattice oscillations. The (optic-like) transverse mode dispersion law is shown to change. due to the Debye sphere dressing effect, from the known inverse-dispersive ("backward wave") form into a normal dispersive law (i.e. the group velocity changes sign). The stability of one-dimensionless bi-layers, consisting of (alternating) negatively and positively charged dust particles, is also discussed. The range of parameter values (mainly in terms of the lattice parameter kappa) where the above predictions are valid, are presented. (c) 2005 Elsevier B.V. All rights reserved.

Modulated transverse off-plane dust-lattice wave packets in hexagonal two-dimensional dusty plasma crystals

The propagation of nonlinear dust-lattice waves in a two-dimensional hexagonal crystal is investigated. Transverse (off-plane) dust grain oscillatory motion is considered in the form of a backward propagating wave packet whose linear and nonlinear characteristics are investigated. An evolution equation is obtained for the slowly varying amplitude of the first (fundamental) harmonic by making use of a two-dimensional lattice multiple scales technique. An analysis based on the continuum approximation (spatially extended excitations compared to the lattice spacing) shows that wave packets will be modulationally stable and that dark-type envelope solitons (density holes) may occur in the long wavelength region. Evidence is provided of modulational instability and of the occurrence of bright-type envelopes (pulses) at shorter wavelengths. The role of second neighbor interactions is also investigated and is shown to be rather weak in determining the modulational stability region. The effect of dissipation, assumed negligible in the algebra throughout the article, is briefly discussed.

Existence and stability of multisite breathers in honeycomb and hexagonal lattices

We study the existence and stability of multisite discrete breathers in two prototypical non-square Klein-Gordon lattices, namely a honeycomb and a hexagonal one. In the honeycomb case we consider six-site configurations and find that for soft potential and positive coupling the out-of-phase breather configuration and the charge-two vortex breather are linearly stable, while the in-phase and charge-one vortex states are unstable. In the hexagonal lattice, we first consider three-site configurations. In the case of soft potential and positive coupling, the in-phase configuration is unstable and the charge-one vortex is linearly stable. The out-of-phase configuration here is found to always be linearly unstable. We then turn to six-site configurations in the hexagonal lattice. The stability results in this case are the same as in the six-site configurations in the honeycomb lattice. For all configurations in both lattices, the stability results are reversed in the setting of either hard potential or negative coupling. The study is complemented by numerical simulations which are in very good agreement with the theoretical predictions. Since neither the form of the on-site potential nor the sign of the coupling parameter involved have been prescribed, this description can accommodate inverse-dispersive systems (e. g. supporting backward waves) such as transverse dust-lattice oscillations in dusty plasma (Debye) crystals or analogous modes in molecular chains.

A similarity measure for graphs with low computational complexity

We present and analyze an algorithm to measure the structural similarity of generalized trees, a new graph class which includes rooted trees. For this, we represent structural properties of graphs as strings and define the similarity of two Graphs as optimal alignments of the corresponding property stings. We prove that the obtained graph similarity measures are so called Backward similarity measures. From this we find that the time complexity of our algorithm is polynomial and, hence, significantly better than the time complexity of classical graph similarity methods based on isomorphic relations. (c) 2006 Elsevier Inc. All rights reserved.

Causality, apparent 'superluminality' and reshaping in barrier penetration

We consider tunneling of a nonrelativistic particle across a potential barrier. It is shown that the barrier acts as an effective beam splitter which builds up the transmitted pulse from the copies of the initial envelope shifted in the coordinate space backward relative to the free propagation. Although along each pathway causality is explicitly obeyed, in special cases reshaping can result an overall reduction of the initial envelope, accompanied by an arbitrary coordinate shift. In the case of a high barrier the delay amplitude distribution (DAD) mimics a Dirac delta function, the transmission amplitude is superoscillatory for finite momenta and tunneling leads to an accurate advancement of the (reduced) initial envelope by the barrier width. In the case of a wide barrier, initial envelope is accurately translated into the complex coordinate plane. The complex shift, given by the first moment of the DAD, accounts for both the displacement of the maximum of the transmitted probability density and the increase in its velocity. It is argued that analyzing apparent

Methods to increase response to postal and electronic questionnaires

Background: Postal and electronic questionnaires are widely used for data collection in epidemiological studies but non-response reduces the effective sample size and can introduce bias. Finding ways to increase response to postal and electronic questionnaires would improve the quality of health research. Objectives: To identify effective strategies to increase response to postal and electronic questionnaires. Search strategy: We searched 14 electronic databases to February 2008 and manually searched the reference lists of relevant trials and reviews, and all issues of two journals. We contacted the authors of all trials or reviews to ask about unpublished trials. Where necessary, we also contacted authors to confirm methods of allocation used and to clarify results presented. We assessed the eligibility of each trial using pre-defined criteria. Selection criteria: Randomised controlled trials of methods to increase response to postal or electronic questionnaires. Data collection and analysis: We extracted data on the trial participants, the intervention, the number randomised to intervention and comparison groups and allocation concealment. For each strategy, we estimated pooled odds ratios (OR) and 95% confidence intervals (CI) in a random-effects model. We assessed evidence for selection bias using Egger's weighted regression method and Begg's rank correlation test and funnel plot. We assessed heterogeneity among trial odds ratios using a Chi 2 test and the degree of inconsistency between trial results was quantified using the I 2 statistic. Main results: Postal We found 481 eligible trials.The trials evaluated 110 different ways of increasing response to postal questionnaires.We found substantial heterogeneity among trial results in half of the strategies. The odds of response were at least doubled using monetary incentives (odds ratio 1.87; 95% CI 1.73 to 2.04; heterogeneity P < 0.00001, I 2 = 84%), recorded delivery (1.76; 95% CI 1.43 to 2.18; P = 0.0001, I 2 = 71%), a teaser on the envelope - e.g. a comment suggesting to participants that they may benefit if they open it (3.08; 95% CI 1.27 to 7.44) and a more interesting questionnaire topic (2.00; 95% CI 1.32 to 3.04; P = 0.06, I 2 = 80%). The odds of response were substantially higher with pre-notification (1.45; 95% CI 1.29 to 1.63; P < 0.00001, I 2 = 89%), follow-up contact (1.35; 95% CI 1.18 to 1.55; P < 0.00001, I 2 = 76%), unconditional incentives (1.61; 1.36 to 1.89; P < 0.00001, I 2 = 88%), shorter questionnaires (1.64; 95%CI 1.43 to 1.87; P < 0.00001, I 2 = 91%), providing a second copy of the questionnaire at follow up (1.46; 95% CI 1.13 to 1.90; P < 0.00001, I 2 = 82%), mentioning an obligation to respond (1.61; 95% CI 1.16 to 2.22; P = 0.98, I 2 = 0%) and university sponsorship (1.32; 95% CI 1.13 to 1.54; P < 0.00001, I 2 = 83%). The odds of response were also increased with non-monetary incentives (1.15; 95% CI 1.08 to 1.22; P < 0.00001, I 2 = 79%), personalised questionnaires (1.14; 95% CI 1.07 to 1.22; P < 0.00001, I 2 = 63%), use of hand-written addresses (1.25; 95% CI 1.08 to 1.45; P = 0.32, I 2 = 14%), use of stamped return envelopes as opposed to franked return envelopes (1.24; 95% CI 1.14 to 1.35; P < 0.00001, I 2 = 69%), an assurance of confidentiality (1.33; 95% CI 1.24 to 1.42) and first class outward mailing (1.11; 95% CI 1.02 to 1.21; P = 0.78, I 2 = 0%). The odds of response were reduced when the questionnaire included questions of a sensitive nature (0.94; 95% CI 0.88 to 1.00; P = 0.51, I 2 = 0%). Electronic: We found 32 eligible trials. The trials evaluated 27 different ways of increasing response to electronic questionnaires. We found substantial heterogeneity among trial results in half of the strategies. The odds of response were increased by more than a half using non-monetary incentives (1.72; 95% CI 1.09 to 2.72; heterogeneity P < 0.00001, I 2 = 95%), shorter e-questionnaires (1.73; 1.40 to 2.13; P = 0.08, I 2 = 68%), including a statement that others had responded (1.52; 95% CI 1.36 to 1.70), and a more interesting topic (1.85; 95% CI 1.52 to 2.26). The odds of response increased by a third using a lottery with immediate notification of results (1.37; 95% CI 1.13 to 1.65), an offer of survey results (1.36; 95% CI 1.15 to 1.61), and using a white background (1.31; 95% CI 1.10 to 1.56). The odds of response were also increased with personalised e-questionnaires (1.24; 95% CI 1.17 to 1.32; P = 0.07, I 2 = 41%), using a simple header (1.23; 95% CI 1.03 to 1.48), using textual representation of response categories (1.19; 95% CI 1.05 to 1.36), and giving a deadline (1.18; 95% CI 1.03 to 1.34). The odds of response tripled when a picture was included in an e-mail (3.05; 95% CI 1.84 to 5.06; P = 0.27, I 2 = 19%). The odds of response were reduced when "Survey" was mentioned in the e-mail subject line (0.81; 95% CI 0.67 to 0.97; P = 0.33, I 2 = 0%), and when the e-mail included a male signature (0.55; 95% CI 0.38 to 0.80; P = 0.96, I 2 = 0%). Authors' conclusions: Health researchers using postal and electronic questionnaires can increase response using the strategies shown to be effective in this systematic review. Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.


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A Frequency Domain Algorithm for Wave Separation

We propose a frequency domain adaptive algorithm for
wave separation in wind instruments. Forward and backward travelling waves are obtained from the signals acquired by two microphones placed along the tube, while the
separation ?lter is adapted from the information given by a
third microphone. Working in the frequency domain has a
series of advantages, among which are the ease of design of
the propagation ?lter and its differentiation with respect to
its parameters.
Although the adaptive algorithm was developed as a ?rst
step for the estimation of playing parameters in wind instruments it can also be used, without any modi?cations, for
other applications such as in-air direction of arrival (DOA)
estimation. Preliminary results on these applications will
also be presented.

The contours of memory in post-conflict societies: enacting public remembrance of the bomb in Omagh, Northern Ireland

Drawing on the theoretical insights of Paul Ricoeur this paper investigates the geographies of public remembrance in a post-conflict society. In Northern Ireland, where political divisions have found expression through acts of extreme violence over the past 30 years, questions of memory and an amnesty for forgetting have particular resonance both at the individual and societal level, and render Ricoeur’s framework particularly prescient. Since the signing of the Belfast Agreement in 1998, initiating the Peace Process through consociational structures, discovering a nomenclature and set of practices which would aid in the rapprochement of a deeply divided society has presented a complex array of issues. In this paper I examine the various practices of public remembrance of the 1998 bombing of Omagh as a means of understanding how memory-spaces evolve in a post-conflict context. In Omagh there were a variety of commemorative practices instituted and each, in turn, adopted a different contour towards achieving reconciliation with the violence and grief of the bombing. In particular the Garden of Light project is analysed as a collective monument which, with light as its metaphysical centre, invited the populace to reflect backward on the pain of the bombing while at the same time enabling the society to look forward toward a peaceful future where a politics of hope might eclipse a politics of despair.

The Governance of Sexual Offending Across Europe: Penal Policies, Political Economies and the Institutionalization of Risk

This article examines why England and Wales have comparatively one of the most stringent systems for the governance of sexual offending within Western Europe. While England and Wales, like the USA, have adopted broadly exclusionary, managerialist penal policies based around incapacitation and targeted surveillance, many other Western European countries have opted for more inclusionary therapeutic interventions. Divergences in state approaches to sex offender risk, particularly in relation to notification and vetting schemes, are initially examined with reference to the respective theoretical frameworks of ‘policy transfer’ and differing political economies. Chiefly, however, differences in penal policies are attributed to the social and political construction of risk and its control. There may be multiple expressions of risk relating to expert, lay, moral or emotive aspects. It is argued, however, that it is the particular convergence and alignment of these dimensions on the part of the various stakeholders in the UK – government, media, public and professional – that leads to risk becoming institutionalized in the form of punitive regulatory policies for managing the dangerous.

Population-based study reveals new risk-stratification biomarker panel for Barrett's esophagus

BACKGROUND & AIMS: The risk of progression of Barrett's esophagus (BE) to esophageal adenocarcinoma (EAC) is low and difficult to calculate. Accurate tools to determine risk are needed to optimize surveillance and intervention. We assessed the ability of candidate biomarkers to predict which cases of BE will progress to EAC or high-grade dysplasia and identified those that can be measured in formalin-fixed tissues. METHODS: We analyzed data from a nested case-control study performed using the population-based Northern Ireland BE Register (1993-2005). Cases who progressed to EAC (n = 89) or high-grade dysplasia =6 months after diagnosis with BE were matched to controls (nonprogressors, n = 291), for age, sex, and year of BE diagnosis. Established biomarkers (abnormal DNA content, p53, and cyclin A expression) and new biomarkers (levels of sialyl Lewis(a), Lewis(x), and Aspergillus oryzae lectin [AOL] and binding of wheat germ agglutinin) were assessed in paraffin-embedded tissue samples from patients with a first diagnosis of BE. Conditional logistic regression analysis was applied to assess odds of progression for patients with dysplastic and nondysplastic BE, based on biomarker status. RESULTS: Low-grade dysplasia and all biomarkers tested, other than Lewis(x), were associated with risk of EAC or high-grade dysplasia. In backward selection, a panel comprising low-grade dysplasia, abnormal DNA ploidy, and AOL most accurately identified progressors and nonprogressors. The adjusted odds ratio for progression of patients with BE with low-grade dysplasia was 3.74 (95% confidence interval, 2.43-5.79) for each additional biomarker and the risk increased by 2.99 for each additional factor (95% confidence interval, 1.72-5.20) in patients without dysplasia. CONCLUSIONS: Low-grade dysplasia, abnormal DNA ploidy, and AOL can be used to identify patients with BE most likely to develop EAC or high-grade dysplasia.

MarA-mediated transcriptional repression of the rob promoter

The Escherichia coli transcriptional regulator MarA affects functions that include antibiotic resistance, persistence, and survival. MarA functions as an activator or repressor of transcription utilizing similar degenerate DNA sequences (marboxes) with three different binding site configurations with respect to the RNA polymerase-binding sites. We demonstrate that MarA down-regulates rob transcripts both in vivo and in vitro via a MarA-binding site within the rob promoter that is positioned between the -10 and -35 hexamers. As for the hdeA and purA promoters, which are repressed by MarA, the rob marbox is also in the "backward" orientation. Protein-DNA interactions show that SoxS and Rob, like MarA, bind the same marbox in the rob promoter. Electrophoretic mobility shift analyses with a MarA-specific antibody demonstrate that MarA and RNA polymerase form a ternary complex with the rob promoter DNA. Transcription experiments in vitro and potassium permanganate footprinting analysis show that MarA affects the RNA polymerase-mediated closed to open complex formation at the rob promoter.