Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards

BACKGROUND: Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence. OBJECTIVES: The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events. SEARCH STRATEGY: The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study. MAIN RESULTS: Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group. AUTHORS' CONCLUSIONS: The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.

Evidence for on-line visual guidance during saccadic gaze shifts.

Rapid orientating movements of the eyes are believed to be controlled ballistically. The mechanism underlying this control is thought to involve a comparison between the desired displacement of the eye and an estimate of its actual position (obtained from the integration of the eye velocity signal). This study shows, however, that under certain circumstances fast gaze movements may be controlled quite differently and may involve mechanisms which use visual information to guide movements prospectively. Subjects were required to make large gaze shifts in yaw towards a target whose location and motion were unknown prior to movement onset. Six of those tested demonstrated remarkable accuracy when making gaze shifts towards a target that appeared during their ongoing movement. In fact their level of accuracy was not significantly different from that shown when they performed a 'remembered' gaze shift to a known stationary target (F-3,F-15 = 0.15, p > 0.05). The lack of a stereotypical relationship between the skew of the gaze velocity profile and movement duration indicates that on-line modifications were being made. It is suggested that a fast route from the retina to the superior colliculus could account for this behaviour and that models of oculomotor control need to be updated.

Inter-Frame Contextual Modelling For Visual Speech Recognition

In this paper, we present a new approach to visual speech recognition which improves contextual modelling by combining Inter-Frame Dependent and Hidden Markov Models. This approach captures contextual information in visual speech that may be lost using a Hidden Markov Model alone. We apply contextual modelling to a large speaker independent isolated digit recognition task, and compare our approach to two commonly adopted feature based techniques for incorporating speech dynamics. Results are presented from baseline feature based systems and the combined modelling technique. We illustrate that both of these techniques achieve similar levels of performance when used independently. However significant improvements in performance can be achieved through a combination of the two. In particular we report an improvement in excess of 17% relative Word Error Rate in comparison to our best baseline system.

Regarding the Real: Cinema, Documentary, and the Visual Arts

Regarding the Real: Cinema, Documentary, and the Visual Arts develops an interdisciplinary approach to documentary film, focusing on its cultural and formal relations to other visual arts, such as animation, assemblage, photography, painting, sculpture, and architecture. The book considers the work of figures whose preferred film language is associative and fragmentary, and for whom the documentary is an endlessly open form, an unstable expressive phenomenon that cannot but interrogate the validity of its own narratives and representational modes. Combining close analysis with cultural history, Regarding the Real calls for a re-assessment of the influence of the modern arts in subverting the structures of realism typically associated with documentary filmmaking.

Music, Magic, and the Mythic: The Dynamics of Visual and Aural Discourse in Souleymane Cissé’s Yeelen

The 1980s saw a wave of African films that aimed to represent, on both local and international screens, a sophisticated pre-colonial Africa, thus debunking notions of the continent as primitive. Toward this aim the films inscribed the conventions of oral performance within their visual styles, denying spectator identification with the protagonists and emphasising the presence of the narrator. However, some critics argued that these films exoticised Africa, while their use of oral performance’s distancing effect echoed the ‘scientific’ distance structured by the ethnographic film, in which African societies were represented as ‘the other’. Souleymane Cissé’s Yeelen exemplifies this tension, transposing into cinematic form oral storytelling techniques in the depiction of a power struggle within the covert cult of the komo, a Bambara initiation society unfamiliar to most non-Bambara viewers. This paper demonstrates how the film negotiates this tension via music, which interpellates the international spectator by eliciting a greater identification with the protagonists than that determined at a visual level, while encoding a verisimilitude to rituals that may otherwise be read as the superstitious practices of ‘the other’. In this way, music and image in Yeelen operate as parallel, though often overlapping, discourses, bridging the gap between the film’s culturally specific narrative and formal components, and its international spectators.

Correctable visual impairment in stroke rehabilitation patients

Background: after stroke, visual impairment may exacerbate the impact of other impairments on overall disability and negatively influence rehabilitation.