Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative-evidence synthesis

Background:
Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions.

Objectives:
1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used.

Search methods:
We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.

We reran the search on 3rd July 2016 and found three studies, which are awaiting classification.

Selection criteria:
We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation.

Data collection and analysis:
At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews.

Main results:
We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.

The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as ‘low’, 13 as ‘moderate’ and five as ‘high’ confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents.

Authors' conclusions:
There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of ‘ownership’. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.

Mitigating the Impact of Faults in Unreliable Memories for Error-Resilient Applications

Inherently error-resilient applications in areas such as signal processing, machine learning and data analytics provide opportunities for relaxing reliability requirements, and thereby reducing the overhead incurred by conventional error correction schemes. In this paper, we exploit the tolerable imprecision of such applications by designing an energy-efficient fault-mitigation scheme for unreliable data memories to meet target yield. The proposed approach uses a bit-shuffling mechanism to isolate faults into bit locations with lower significance. This skews the bit-error distribution towards the low order bits, substantially limiting the output error magnitude. By controlling the granularity of the shuffling, the proposed technique enables trading-off quality for power, area, and timing overhead. Compared to error-correction codes, this can reduce the overhead by as much as 83% in read power, 77% in read access time, and 89% in area, when applied to various data mining applications in 28nm process technology.

Impact of age, various forms of cataract, and visual acuity on whole-field scotopic sensitivity screening for glaucoma in rural Taiwan.

OBJECTIVE: To evaluate the impact of age, various forms of cataract, and visual acuity on whole-field scotopic sensitivity screening for glaucoma in a rural population. DESIGN: Clinic-based study with population-based recruitment. SETTING: Jin Shan Township near Taipei, Taiwan. SUBJECTS: Three hundred forty-six residents (ages, > or = 40 years) of Jin Shan Township. INTERVENTIONS: Whole-field scotopic testing, ophthalmoscopy with dilation of the pupils, cataract grading against photographic standards, and screening visual field testing in a random one-third subsample. MAIN OUTCOME MEASURES: Whole-field scotopic sensitivity (in decibels) and diagnostic status as a case of glaucoma, glaucoma suspect, or normal. RESULTS: Participants in Jin Shan Township did not differ significantly in the rate of blindness, low visual acuity, or family history of glaucoma from a random sample of nonrespondents. Scotopic sensitivity testing detected 100% (6/6) of subjects with open-angle glaucoma at a specificity of 80.2%. The mean +/- SE scotopic sensitivity for six subjects with open-angle glaucoma (32.78 +/- 1.51 dB) differed significantly from that of 315 normal individuals (38.51 +/- 0.22 dB), when adjusted for age and visual acuity (P = .05, t test). With linear regression modeling, factors that correlated significantly with scotopic sensitivity were intraocular pressure, screening visual field, best corrected visual acuity, presence of cortical cataract, and increasing age. CONCLUSIONS: Although cataract affects the whole-field scotopic threshold, it appears that scotopic testing may be of value in field-based screening for glaucoma.

Reversal in gender valuations of cataract surgery after the implementation of free screening and low-priced high-quality surgery in a rural population of southern China.

PURPOSE: To assess the impact of community outreach and the availability of low-cost surgeries [500 Renminbi (RMB) or 65 United States dollars (US$) per surgery] on the willingness to pay for cataract surgery among male and female rural-dwelling Chinese.METHODS: Cross-sectional willingness-to-pay surveys were conducted at the initiation of a cataract outreach programme in June 2001 and then again in July 2006. Respondents underwent visual acuity testing and provided socio-demographic data.RESULTS: In 2001 and 2006, 325 and 303 subjects, respectively, were interviewed. On average the 2006 sample subjects were of similar age, more likely to be female (p < 0.01), illiterate (p < 0.01), and less likely to come from a household with annual income of less than US$789 (62% vs. 87%, p < 0.01). Familiarity with cataract surgery increased from 21.2% to 44.4% over the 5 years for male subjects (p < 0.01) and 15.8%-44.4% among females (p < 0.01). The proportion of respondents willing to pay at least 500 RMB for surgery increased from 67% to 88% (p < 0.01) among male subjects and from 50% to 91% (p < 0.01) among females.CONCLUSIONS: Five years of access to free cataract testing and low-cost surgery programmes appears to have improved the familiarity with cataract surgery and increased the willingness to pay at least 500 RMB (US$65) for it in this rural population. Elderly women are now as likely as men to be willing to pay at least 500 RMB, reversing gender differences present 5 years ago.

The impact of hydrogeology on the instability of a road cutting through a drumlin in the North of Ireland

This paper describes the hydrogeological processes which caused unexpected instability and quick conditions during the excavation of a 25m deep cutting through a drumlin in County Down, Northern Ireland. A conceptual hydrogeological model of the cutting, based on pore pressures monitored during and after the excavation demonstrates how quick conditions at the toe of the cutting caused liquefaction of the till. Stability of the cutting was re-established by draining the highly permeable, weathered Greywacke which underlies the drumlin, through the use of a deep toe drain. In spite of this drainage, the cutting was only marginally stable due to the presence of a low permeability zone in the till above the bedrock which limits the reduction of elevated pore pressures within the upper to mid-depths of the drumlin. The factor of safety has been further improved by the addition of vertical relief drains at the crest and berm of the cutting to relieve the pore-pressures within the upper till by intercepting the weathered bedrock. The paper also highlights the importance of carrying out an adequate site investigation compliant with Eurocode 7 and additional monitoring in excavations in stiff, low permeability till.

Inexact-aware architecture design for ultra-low power bio-signal analysis

This study introduces an inexact, but ultra-low power, computing architecture devoted to the embedded analysis of bio-signals. The platform operates at extremely low voltage supply levels to minimise energy consumption. In this scenario, the reliability of static RAM (SRAM) memories cannot be guaranteed when using conventional 6-transistor implementations. While error correction codes and dedicated SRAM implementations can ensure correct operations in this near-threshold regime, they incur in significant area and energy overheads, and should therefore be employed judiciously. Herein, the authors propose a novel scheme to design inexact computing architectures that selectively protects memory regions based on their significance, i.e. their impact on the end-to-end quality of service, as dictated by the bio-signal application characteristics. The authors illustrate their scheme on an industrial benchmark application performing the power spectrum analysis of electrocardiograms. Experimental evidence showcases that a significance-based memory protection approach leads to a small degradation in the output quality with respect to an exact implementation, while resulting in substantial energy gains, both in the memory and the processing subsystem.

Heterogeneous error-resilient scheme for spectral analysis in ultra-low power wearable electrocardiogram devices

Wearable devices performing advanced bio-signal analysis algorithms are aimed to foster a revolution in healthcare provision of chronic cardiac diseases. In this context, energy efficiency is of paramount importance, as long-term monitoring must be ensured while relying on a tiny power source. Operating at a scaled supply voltage, just above the threshold voltage, effectively helps in saving substantial energy, but it makes circuits, and especially memories, more prone to errors, threatening the correct execution of algorithms. The use of error detection and correction codes may help to protect the entire memory content, however it incurs in large area and energy overheads which may not be compatible with the tight energy budgets of wearable systems. To cope with this challenge, in this paper we propose to limit the overhead of traditional schemes by selectively detecting and correcting errors only in data highly impacting the end-to-end quality of service of ultra-low power wearable electrocardiogram (ECG) devices. This partition adopts the protection of either significant words or significant bits of each data element, according to the application characteristics (statistical properties of the data in the application buffers), and its impact in determining the output. The proposed heterogeneous error protection scheme in real ECG signals allows substantial energy savings (11% in wearable devices) compared to state-of-the-art approaches, like ECC, in which the whole memory is protected against errors. At the same time, it also results in negligible output quality degradation in the evaluated power spectrum analysis application of ECG signals.

Relativistic radiatively damped R -matrix calculations of the electron-impact excitation of helium-like iron and krypton

Electron-impact excitation data for He-like ions are of significant importance for diagnostic applications to both laboratory and astrophysical plasmas. Here we report on the first fully relativistic R -matrix calculations with radiation damping for the He-like ions Fe 24+ and Kr 34+ . Effective collision strengths for these two ions have been determined with and without damping over a wide temperature range for all transitions between the 49 levels through n = 5. We find that damping has a pronounced effect on the effective collision strengths for excitation to some of the low-lying levels, but its effect on excitation to the vast majority of levels is small. At the energy of a resonance peak, we also investigate the effect of radiation damping on the angular distribution of scattered electrons. Finally, we compare our results for Fe 24+ with an earlier intermediate coupling frame transformation R -matrix calculation with radiation damping by Whiteford et al ( J. Phys. B: At. Mol. Opt. Phys. 34 3179) and find good agreement, especially for excitation to the lower levels.

Electron-impact excitation of Fe2: a comparison of intermediate coupling frame transformation, Breit-Pauli and Dirac R-matrix calculations

Modeling the spectral emission of low-charge iron group ions enables the diagnostic determination of the local physical conditions of many cool plasma environments such as those found in H II regions, planetary nebulae, active galactic nuclei etc. Electron-impact excitation drives the population of the emitting levels and, hence, their emissivities. By carrying-out Breit-Pauli and intermediate coupling frame transformation (ICFT) R-matrix calculations for the electron-impact excitation of Fe$^{2+}$ which both use the exact same atomic structure and the same close-coupling expansion, we demonstrate the validity of the application of the powerful ICFT method to low-charge iron group ions. This is in contradiction to the finding of Bautista et al. [Ap.J.Lett, 718, L189, (2010)] who carried-out ICFT and Dirac R-matrix calculations for the same ion. We discuss possible reasons.

Electron-impact excitation of Fe 4+ : an intermediate-coupling R -matrix calculation

For a number of years, there has been a major effort to calculate electron-impact excitation data for every ion stage of iron embodied by the ongoing efforts of the IRON project by Hummer et al (1993 Astron. Astrophys. 279 298). Due to the complexity of the targets, calculations for the lower stages of ionization have been limited to either intermediate-coupling calculations within the ground configurations or LS -coupling calculations of the ground and excited configurations. However, accurate excitation data between individual levels within both the ground and excited configurations of the low charge-state ions are urgently required for applications to both astrophysical and laboratory plasmas. Here we report on the results of the first intermediate-coupling R -matrix calculation of electron-impact excitation for Fe 4+ for which the close-coupling (CC) expansion includes not only those levels of the 3d 4 ground configuration, but also the levels of the 3d 3 4s, 3d 3 4p, 3d 3 4d and 3d 2 4s 2 excited configurations. With 359 levels in the CC expansion and over 2400 scattering channels for many of the J Π partial waves, this represents the largest electron–ion scattering calculation to date and it was performed on massively parallel computers using a recently developed set of relativistic parallel R -matrix programs.

Electron-impact excitation of Li to high principal quantum numbers

The time-dependent close-coupling method is used to calculate electron-impact excitation cross sections for the Li(2s)--{\textgreater}Li(nl) and Li(2p)--{\textgreater}Li(nl) transitions at incident energies just above the ionization threshold. The implementation of the time-dependent close-coupling method on a nonuniform lattice allows the study of continuum-coupling effects in excitations to high principal quantum number, i.e., n{\textless}=10. Good agreement is found with R-matrix with pseudostates calculations, which also include continuum-coupling effects, for excitations to low principal quantum number, i.e., n{\textless}=4. Poor agreement is found with standard distorted-wave calculations for excitations to all principal quantum numbers, with differences still at the 50% level for n=10. We are able to give guidance as to the accuracy expected in the n3 extrapolation of nonperturbative close-coupling calculations of low n cross sections and rate coefficients.

Collisional-radiative calculations of He line emission in low-temperature plasmas

We present spectral modeling results for neutral helium. Our underlying atomic data contains radiative transition rates that are generated from atomic structure calculations and electron-impact excitation rates, that are determined from both the standard R-matrix method and the R-matrix with pseudostates RMPS method. In this paper, we focus on transitions of particular importance to diagnostic line ratios. For example, our calculated rate coefficient for the electron-impact transition 1s3s 1S→1s3p 1P, which has a pronounced effect on the 728.1 nm diagnostic spectral line, is found to be in good agreement with previous experimental mea- surements. We also consider transitions from the 1s2 1S ground and 1s2s 3S terms to terms of the n=4 shell. They are found to be affected significantly by coupling of the bound states to the target continuum continuum coupling, which is included in our RMPS calculation, but not in our standard R-matrix calculation. We perform collisional-radiative calculations to determine spectral line intensity ratios for three ratios of particular interest, namely the 504.8 nm/471.3 nm, 492.2 nm/471.3 nm, and 492.2 nm/504.8 nm line ratios. Comparing our results determined from the RMPS excitation rates with those from the standard R-matrix excitation rates, we find that continuum coupling affects the rate coefficients significantly, leading to different values for all three line ratios. We also compare our modeling results with spectral measurements taken recently on the Auburn Helicon plasma device, finding that the ground and metastable populations are not in equilibrium, and that the experimental measurements are more consistent with the 1s2s 3S metastable term populations being short lived in the plasma.

Assessment of the impact speed and angle conditions for the EN1317 barrier tests

Roadside safety barriers designs are tested with passenger cars in Europe using standard EN1317 in which the impact angle for normal, high and very high containment level tests is 20°. In comparison to EN1317, the US standard MASH has higher impact angles for cars and pickups (25°) and different vehicle masses. Studies in Europe (RISER) and the US have shown values for the 90th percentile impact angle of 30°–34°. Thus, the limited evidence available suggests that the 20° angle applied in EN 1317 may be too low.
The first goal of this paper is to use the US NCHRP database (Project NCHRP 17–22) to assess the distribution of impact angle and collision speed in recent ROR accidents. Second, based on the findings of the statistical analysis and on analysis of impact angles and speeds in the literature, an LS-DYNA finite element analysis was carried out to evaluate the normal containment level of concrete barriers in non-standard collisions. The FE model was validated against a crash test of a portable concrete barrier carried out at the UK Transport Research Laboratory (TRL).
The accident data analysis for run-off road accidents indicates that a substantial proportion of accidents have an impact angle in excess of 20°. The baseline LS-DYNA model showed good comparison with experimental acceleration severity index (ASI) data and the parametric analysis indicates a very significant influence of impact angle on ASI. Accordingly, a review of European run-off road accidents and the configuration of EN 1317 should be performed.

Modeling the Rossiter-McLaughlin Effect: Impact of the Convective Center-to-limb Variations in the Stellar Photosphere

bservations of the Rossiter–McLaughlin (RM) effect provide information on star–planet alignments, which can inform planetary migration and evolution theories. Here, we go beyond the classical RM modeling and explore the impact of a convective blueshift that varies across the stellar disk and non-Gaussian stellar photospheric profiles. We simulated an aligned hot Jupiter with a four-day orbit about a Sun-like star and injected center-to-limb velocity (and profile shape) variations based on radiative 3D magnetohydrodynamic simulations of solar surface convection. The residuals between our modeling and classical RM modeling were dependent on the intrinsic profile width and v sin i; the amplitude of the residuals increased with increasing v sin i and with decreasing intrinsic profile width. For slowly rotating stars the center-to-limb convective variation dominated the residuals (with amplitudes of 10 s of cm s−1 to ~1 m s−1); however, for faster rotating stars the dominant residual signature was due a non-Gaussian intrinsic profile (with amplitudes from 0.5 to 9 m s−1). When the impact factor was 0, neglecting to account for the convective center-to-limb variation led to an uncertainty in the obliquity of ~10°–20°, even though the true v sin i was known. Additionally, neglecting to properly model an asymmetric intrinsic profile had a greater impact for more rapidly rotating stars (e.g., v sin i = 6 km s−1) and caused systematic errors on the order of ~20° in the measured obliquities. Hence, neglecting the impact of stellar surface convection may bias star–planet alignment measurements and consequently theories on planetary migration and evolution.

Electron-impact excitation of open d-shell ions

Astrophysics is driven by observations, and in the present era there are a wealth of state-of-the-art ground-based and satellite facilities. The astrophysical spectra emerging from these are of exceptional quality and quantity and cover a broad wavelength range. To meaningfully interpret these spectra, astronomers employ highly complex modelling codes to simulate the astrophysical observations. Important input to these codes include atomic data such as excitation rates, photoionization cross sections, oscillator strengths, transition probabilities and energy levels/line wavelengths. Due to the relatively low temperatures associated with many astrophysical plasmas, the accurate determination of electron-impact excitation rates in the low energy region is essential in generating a reliable spectral synthesis. Hence it is these atomic data, and the main computational methods used to evaluate them, which we focus on in this publication. We consider in particular the complicated open d- shell structures of the Fe-peak ions in low ionization stages. While some of these data can be obtained experimentally, they are usually of insufficient accuracy or limited to a small number of transitions.