Looking in the wrong place for healthcare improvements: a system dynamics study of an accident and emergency department

Accident and Emergency (A&E) units provide a route for patients requiring urgent admission to acute hospitals. Public concern over long waiting times for admissions motivated this study, whose aim is to explore the factors which contribute to such delays. The paper discusses the formulation and calibration of a system dynamics model of the interaction of demand pattern, A&E resource deployment, other hospital processes and bed numbers; and the outputs of policy analysis runs of the model which vary a number of the key parameters. Two significant findings have policy implications. One is that while some delays to patients are unavoidable, reductions can be achieved by selective augmentation of resources within, and relating to, the A&E unit. The second is that reductions in bed numbers do not increase waiting times for emergency admissions, their effect instead being to increase sharply the number of cancellations of admissions for elective surgery. This suggests that basing A&E policy solely on any single criterion will merely succeed in transferring the effects of a resource deficit to a different patient group.

An in vitro study of the probiotic potential of a bile-salt-hydrolyzing Lactobacillus fermentum strain, and determination of its cholesterol-lowering properties

This study evaluated the use of a bile-salt-hydrolyzing Lactobacillus fermentum strain as a probiotic with potential hypocholesterolemic properties. The effect of L. fermentum on representative microbial populations and overall metabolic activity of the human intestinal microbiota was investigated using a three-stage continuous culture system. Also, the use of galactooligosaccharides as a prebiotic to enhance growth and/or activity of the Lactobacillus strain was evaluated. Administration of L. fermentum resulted in a decrease in the overall bifidobacterial population (ca. 1 log unit). In the in vitro system, no significant changes were observed in the total bacterial, Lactobacillus, Bacteroides, and clostridial populations through L. fermentum supplementation. Acetate production decreased by 9 to 27%, while the propionate and butyrate concentrations increased considerably (50 to 90% and 52 to 157%, respectively). A general, although lesser, increase in the production of lactate was observed with the administration of the L. fermentum strain. Supplementation of the prebiotic to the culture medium did not cause statistically significant changes in either the numbers or the activity of the microbiota, although an increase in the butyrate production was seen (29 to 39%). Results from this in vitro study suggest that L.Fermentum KC5b is a candidate probiotic which may affect cholesterol metabolism. The short-chain fatty acid concentrations, specifically the molar proportion of propionate and/or bile salt deconjugation, are probably the major mechanism involved in the purported cholesterol-lowering properties of this strain.

Cancellation of siren noise from two way voice communications inside emergency vehicles

Sirens used by police, fire and paramedic vehicles have been designed so that they can be heard over large distances, but unfortunately the siren noise enters the vehicle and corrupts intelligibility of voice communications from the emergency vehicle to the control room. Often the siren needs to be turned off to enable the control room to hear what is being said. This paper discusses a siren noise filter system that is capable of removing the siren noise picked up by the two-way radio microphone inside the vehicle. The removal of the siren noise improves the response time for emergency vehicles and thus save lives. To date, the system has been trialed within a fire tender in a non-emergency situation, with good results.

Cancellation of siren noise from two-way voice communication inside emergency vehicles

The development of an adaptive filter system, capable of reducing significantly the effect of siren noise within the cab of an emergency vehicle, is described. The system is capable of removing the siren noise picked up by the radio microphone inside the vehicle, without degrading the wanted voice signal, thus allowing the siren to be used at all times.

The application of affine projection to the development of a siren noise cancellation system

Emergency vehicles use high-amplitude sirens to warn pedestrians and other road users of their presence. Unfortunately, the siren noise enters the vehicle and corrupts the intelligibility of two-way radio voice com-munications from the emergency vehicle to a control room. Often the siren has to be turned off to enable the control room to hear what is being said which subsequently endangers people's lives. A digital signal processing (DSP) based system for the cancellation of siren noise embedded within speech is presented. The system has been tested with the least mean square (LMS), normalised least mean square (NLMS) and affine projection algorithm (APA) using recordings from three common types of sirens (two-tone, wail and yelp) from actual test vehicles. It was found that the APA with a projection order of 2 gives comparably improved cancellation over the LMS and NLMS with only a moderate increase in algorithm complexity and code size. Therefore, this siren noise cancellation system using the APA offers an improvement in cancellation achieved by previous systems. The removal of the siren noise improves the response time for the emergency vehicle and thus the system can contribute to saving lives. The system also allows voice communication to take place even when the siren is on and as such the vehicle offers less risk of danger when moving at high speeds in heavy traffic.

Results of a DSP based adaptive cancellation filter system for the chirp, pulsar and localiser sirens

Sirens’ used by police, fire and paramedic vehicles generate noise that propagates inside the vehicle cab that subsequently corrupts intelligibility of voice communications from the emergency vehicle to the control room. It is even common for the siren to be turned off to enable the control room to hear what is being said. Both fixed filter and adaptive filter systems have previously been developed to help cancel the transmission of the siren noise over the radio. Previous cancellation systems have only concentrated on the traditional 2-tone, wail and yelp sirens. This paper discusses an improvement to a previous adaptive filter system and presents the cancellation results to three new types of sirens; being chirp pulsar and localiser. A siren noise filter system has the capability to improve the response time for an emergency vehicle and thus help save lives. To date, this system has been tested using live recordings taken from a nonemergency situation with good results.

Formal theory building for the avalanche game: explaining counter-intuitive behaviour of a complex system using geometrical and human behavioural/physiological effects

In 'Avalanche', an object is lowered, players staying in contact throughout. Normally the task is easily accomplished. However, with larger groups counter-intuitive behaviours appear. The paper proposes a formal theory for the underlying causal mechanisms. The aim is to not only provide an explicit, testable hypothesis for the source of the observed modes of behaviour-but also to exemplify the contribution that formal theory building can make to understanding complex social phenomena. Mapping reveals the importance of geometry to the Avalanche game; each player has a pair of balancing loops, one involved in lowering the object, the other ensuring contact. For more players, sets of balancing loops interact and these can allow dominance by reinforcing loops, causing the system to chase upwards towards an ever-increasing goal. However, a series of other effects concerning human physiology and behaviour (HPB) is posited as playing a role. The hypothesis is therefore rigorously tested using simulation. For simplicity a 'One Degree of Freedom' case is examined, allowing all of the effects to be included whilst rendering the analysis more transparent. Formulation and experimentation with the model gives insight into the behaviours. Multi-dimensional rate/level analysis indicates that there is only a narrow region in which the system is able to move downwards. Model runs reproduce the single 'desired' mode of behaviour and all three of the observed 'problematic' ones. Sensitivity analysis gives further insight into the system's modes and their causes. Behaviour is seen to arise only when the geometric effects apply (number of players greater than degrees of freedom of object) in combination with a range of HPB effects. An analogy exists between the co-operative behaviour required here and various examples: conflicting strategic objectives in organizations; Prisoners' Dilemma and integrated bargaining situations. Additionally, the game may be relatable in more direct algebraic terms to situations involving companies in which the resulting behaviours are mediated by market regulations. Finally, comment is offered on the inadequacy of some forms of theory building and the case is made for formal theory building involving the use of models, analysis and plausible explanations to create deep understanding of social phenomena.

A feasible study of EEG-driven assistive robotic system for stroke rehabilitation

Stroke is a medical emergency and can cause a neurological damage, affecting the motor and sensory systems. Harnessing brain plasticity should make it possible to reconstruct the closed loop between the brain and the body, i.e., association of the generation of the motor command with the somatic sensory feedback might enhance motor recovery. In order to aid reconstruction of this loop with a robotic device it is necessary to assist the paretic side of the body at the right moment to achieve simultaneity between motor command and feedback signal to somatic sensory area in brain. To this end, we propose an integrated EEG-driven assistive robotic system for stroke rehabilitation. Depending on the level of motor recovery, it is important to provide adequate stimulation for upper limb motion. Thus, we propose an assist arm incorporating a Magnetic Levitation Joint that can generate a compliant motion due to its levitation and mechanical redundancy. This paper reports on a feasibility study carried out to verify the validity of the robot sensing and on EEG measurements conducted with healthy volunteers while performing a spontaneous arm flexion/extension movement. A characteristic feature was found in the temporal evolution of EEG signal in the single motion prior to executed motion which can aid in coordinating timing of the robotic arm assistance onset.

A police state? The Nyasaland emergency and colonial intelligence.

The Nyasaland Emergency in 1959 proved a decisive turning point in the history of the Federation of Rhodesia and Nyasaland, which from 1953 to 1963 brought together the territories of Northern Rhodesia (Zambia), Southern Rhodesia (Zambia) and Nyasaland (Malawi) under a settler-dominated federal government. The British and Nyasaland governments defended the emergency by claiming to have gathered intelligence which showed that the Nyasaland African Congress was preparing a campaign of sabotage and murder. The Devlin Commission, appointed to investigate the emergency, dismissed the evidence of a ‘murder plot’, criticised the Nyasaland government's handling of the Emergency and, notoriously, described Nyasaland as a ‘police state’. This article has two principal aims. First, using the recently declassified papers of the Intelligence and Security Department (ISD) of the Colonial Office, it seeks to provide the first detailed account of what the British government knew of the intelligence relating to the ‘murder plot’ and how they assessed it, prior to the outbreak of the emergency. It demonstrates that officials in the ISD and members of the Security Service adopted a far more cautious attitude towards the intelligence than did Conservative ministers, and had greater qualms about allowing it into the public domain to justify government policy. Second, the article examines the implications of Devlin's use of the phrase ‘police state’ for Nyasaland and for the late colonial state in general. It contrasts Devlin's use of the term with that of security experts in the ISD, who routinely applied it to policing systems that diverged from their own preferred model. Hence, whereas Devlin compared policing in Nyasaland unfavourably with that in Southern Rhodesia, implying, ironically, that Nyasaland was ‘under-policed’ (because there were fewer police per head of population in Nyasaland than in Southern Rhodesia), the ISD regarded the intensive system of policing operated by the British South Africa Police in Southern Rhodesia as characteristic of a ‘police state’. The article suggests that the frequent use of the term ‘police state’ was indicative of broader anxieties about what Britain's legacy would be for the post-independence African state.

The European Flood Alert System and the communication, perception, and use of ensemble predictions for operational flood risk management

Although ensemble prediction systems (EPS) are increasingly promoted as the scientific state-of-the-art for operational flood forecasting, the communication, perception, and use of the resulting alerts have received much less attention. Using a variety of qualitative research methods, including direct user feedback at training workshops, participant observation during site visits to 25 forecasting centres across Europe, and in-depth interviews with 69 forecasters, civil protection officials, and policy makers involved in operational flood risk management in 17 European countries, this article discusses the perception, communication, and use of European Flood Alert System (EFAS) alerts in operational flood management. In particular, this article describes how the design of EFAS alerts has evolved in response to user feedback and desires for a hydrographic-like way of visualizing EFAS outputs. It also documents a variety of forecaster perceptions about the value and skill of EFAS forecasts and the best way of using them to inform operational decision making. EFAS flood alerts were generally welcomed by flood forecasters as a sort of ‘pre-alert’ to spur greater internal vigilance. In most cases, however, they did not lead, by themselves, to further preparatory action or to earlier warnings to the public or emergency services. Their hesitancy to act in response to medium-term, probabilistic alerts highlights some wider institutional obstacles to the hopes in the research community that EPS will be readily embraced by operational forecasters and lead to immediate improvements in flood incident management. The EFAS experience offers lessons for other hydrological services seeking to implement EPS operationally for flood forecasting and warning. Copyright © 2012 John Wiley & Sons, Ltd.

A conceptual valuation framework (VF) for home telecare system devices

Purpose – The aim of this paper is to present a conceptual valuation framework to allow telecare service stakeholders to assess telecare devices in the home in terms of their social, psychological and practical effects. The framework enables telecare service operators to more effectively engage with the social and psychological issues resulting from telecare technology deployment in the home and to design and develop appropriate responses as a result. Design/methodology/approach – The paper provides a contextual background for the need for sociologically pitched tools that engage with the social and cultural feelings of telecare service users before presenting the valuation framework and how it could be used. Findings – A conceptual valuation framework is presented for potential development/use. Research limitations/implications – The valuation framework has yet to be extensively tested or verified. Practical implications – The valuation framework needs to be tested and deployed by a telecare service operator but the core messages of the paper are valid and interesting for readership. Social implications – In addressing the social and cultural perspectives of telecare service stakeholders, the paper makes a link between the technologies in the home, the feelings and orientations of service users (e.g. residents, emergency services, wardens, etc.) and the telecare service operator. Originality/value – The paper is an original contribution to the field as it details how the sociological orientations of telecare technology service users should be valued and addressed by service operators. It has a value through the conceptual arguments made and through valuation framework presented.

An easily implemented agro-hydrological procedure with dynamic root simulation for water transfer in the crop-soil system: validation and application

Models for water transfer in the crop-soil system are key components of agro-hydrological models for irrigation, fertilizer and pesticide practices. Many of the hydrological models for water transfer in the crop-soil system are either too approximate due to oversimplified algorithms or employ complex numerical schemes. In this paper we developed a simple and sufficiently accurate algorithm which can be easily adopted in agro-hydrological models for the simulation of water dynamics. We used a dual crop coefficient approach proposed by the FAO for estimating potential evaporation and transpiration, and a dynamic model for calculating relative root length distribution on a daily basis. In a small time step of 0.001 d, we implemented algorithms separately for actual evaporation, root water uptake and soil water content redistribution by decoupling these processes. The Richards equation describing soil water movement was solved using an integration strategy over the soil layers instead of complex numerical schemes. This drastically simplified the procedures of modeling soil water and led to much shorter computer codes. The validity of the proposed model was tested against data from field experiments on two contrasting soils cropped with wheat. Good agreement was achieved between measurement and simulation of soil water content in various depths collected at intervals during crop growth. This indicates that the model is satisfactory in simulating water transfer in the crop-soil system, and therefore can reliably be adopted in agro-hydrological models. Finally we demonstrated how the developed model could be used to study the effect of changes in the environment such as lowering the groundwater table caused by the construction of a motorway on crop transpiration. (c) 2009 Elsevier B.V. All rights reserved.