Pulse oximetry as a screening test for congenital heart defects in newborn infants: a test accuracy study with evaluation of acceptability and cost-effectiveness

Background: Screening for congenital heart defects (CHDs) relies on antenatal ultrasound and postnatal clinical examination; however, life-threatening defects often go undetected. Objective: To determine the accuracy, acceptability and cost-effectiveness of pulse oximetry as a screening test for CHDs in newborn infants. Design: A test accuracy study determined the accuracy of pulse oximetry. Acceptability of testing to parents was evaluated through a questionnaire, and to staff through focus groups. A decision-analytic model was constructed to assess cost-effectiveness. Setting: Six UK maternity units. Participants: These were 20,055 asymptomatic newborns at = 35 weeks’ gestation, their mothers and health-care staff. Interventions: Pulse oximetry was performed prior to discharge from hospital and the results of this index test were compared with a composite reference standard (echocardiography, clinical follow-up and follow-up through interrogation of clinical databases). Main outcome measures: Detection of major CHDs – defined as causing death or requiring invasive intervention up to 12 months of age (subdivided into critical CHDs causing death or intervention before 28 days, and serious CHDs causing death or intervention between 1 and 12 months of age); acceptability of testing to parents and staff; and the cost-effectiveness in terms of cost per timely diagnosis. Results: Fifty-three of the 20,055 babies screened had a major CHD (24 critical and 29 serious), a prevalence of 2.6 per 1000 live births. Pulse oximetry had a sensitivity of 75.0% [95% confidence interval (CI) 53.3% to 90.2%] for critical cases and 49.1% (95% CI 35.1% to 63.2%) for all major CHDs. When 23 cases were excluded, in which a CHD was already suspected following antenatal ultrasound, pulse oximetry had a sensitivity of 58.3% (95% CI 27.7% to 84.8%) for critical cases (12 babies) and 28.6% (95% CI 14.6% to 46.3%) for all major CHDs (35 babies). False-positive (FP) results occurred in 1 in 119 babies (0.84%) without major CHDs (specificity 99.2%, 95% CI 99.0% to 99.3%). However, of the 169 FPs, there were six cases of significant but not major CHDs and 40 cases of respiratory or infective illness requiring medical intervention. The prevalence of major CHDs in babies with normal pulse oximetry was 1.4 (95% CI 0.9 to 2.0) per 1000 live births, as 27 babies with major CHDs (6 critical and 21 serious) were missed. Parent and staff participants were predominantly satisfied with screening, perceiving it as an important test to detect ill babies. There was no evidence that mothers given FP results were more anxious after participating than those given true-negative results, although they were less satisfied with the test. White British/Irish mothers were more likely to participate in the study, and were less anxious and more satisfied than those of other ethnicities. The incremental cost-effectiveness ratio of pulse oximetry plus clinical examination compared with examination alone is approximately £24,900 per timely diagnosis in a population in which antenatal screening for CHDs already exists. Conclusions: Pulse oximetry is a simple, safe, feasible test that is acceptable to parents and staff and adds value to existing screening. It is likely to identify cases of critical CHDs that would otherwise go undetected. It is also likely to be cost-effective given current acceptable thresholds. The detection of other pathologies, such as significant CHDs and respiratory and infective illnesses, is an additional advantage. Other pulse oximetry techniques, such as perfusion index, may enhance detection of aortic obstructive lesions.

How well do the theory of reasoned action and theory of planned behaviour predict intentions and attendance at screening programmes? A meta-analysis

Meta-analysis was used to quantify how well the Theories of Reasoned Action and Planned Behaviour have predicted intentions to attend screening programmes and actual attendance behaviour. Systematic literature searches identified 33 studies that were included in the review. Across the studies as a whole, attitudes had a large-sized relationship with intention, while subjective norms and perceived behavioural control (PBC) possessed medium-sized relationships with intention. Intention had a medium-sized relationship with attendance, whereas the PBC-attendance relationship was small sized. Due to heterogeneity in results between studies, moderator analyses were conducted. The moderator variables were (a) type of screening test, (b) location of recruitment, (c) screening cost and (d) invitation to screen. All moderators affected theory of planned behaviour relationships. Suggestions for future research emerging from these results include targeting attitudes to promote intention to screen, a greater use of implementation intentions in screening information and examining the credibility of different screening providers.

Reliability, normative data, and the effect of age-related macular disease on the Eger Macular Stressometer photostress recovery time

Purpose: To assess repeatability and reproducibility, to determine normative data, and to investigate the effect of age-related macular disease, compared with normals, on photostress recovery time measured using the Eger Macular Stressometer (EMS). Method: The study population comprised 49 healthy eyes of 49 participants. Four EMS measurements were taken in two sessions separated by 1 h by two practitioners, with reversal of order in the second session. EMS readings were also taken from 17 age-related maculopathy (ARM), and 12 age-related macular degeneration (AMD), affected eyes. Results: EMS readings are repeatable to within ± 7 s. There is a statistically significant difference between controls and ARM affected eyes (t = 2.169, p = 0.045), and AMD affected eyes (t = 2.817, p = 0.016). The EMS is highly specific, and demonstrates sensitivity of 29% for ARM, and 50% for AMD. Conclusions: The EMS may be a useful screening test for ARM, however, direct illumination of the macula of greater intensity and longer duration may yield less variable results. © 2004 The College of Optometrists.

The effect of elevated temperature on the wear of stainless steel in contact with tungsten carbide

The bearings in the air motors of modern jet aircraft engines must operate dry in hostile conditions at temperatures up to 500° C, where the thrust races in the actuators operate at temperatures up to 300° C. One of the few metallurgical combinations which can function efficiently under these conditions is martensitic stainless steel on tungsten carbide. The work described was initiated to isolate the wear mechanisms of two such steels in contact with tungsten carbide at temperatures up to 500° C. Experiments were carried out on angular contact bearings similar to these used in service, where both rolling and sliding is present and also for pure sliding conditions using a pin-on-disc apparatus. Wear measurements of the bearings were obtained with wear rates, friction and surface temperatures from the pin-on-disc machine for a series of loads and speeds. Extensive X-ray diffraction analysis was carried out on the wear debris, with also S.E.M. analysis and hardness tests on the worn surfaces along with profilometry measurements of the disc. The oxidational parameters of the steel were obtained from measurements of oxide growth rates by ellipsometry. Three distinct mechanisms of wear were established and the latter two were found to be present in both configurations. These involve an oxidational-abrasive mechanism at loads below 40 N with pin surface temperatures up to about 300 °C, with the mechanism changing to severe wear for higher loads. As the temperature increases a third wear mechanism appears due to transfer of relatively soft oxide films to the steel surface reducing the wear rate. Theoretical K factors were derived and compared with experimental values which were found to be in good agreement for the severe wear mechanism. The pin-on-disc experiments may be useful as a screening test for material selection, without the considerable cost of producing the angular contact bearings.

An investigation to determine the influence of illumination sources on colour discrimination in normal subjects and smokers

Accurate colour vision testing requires using the correct illumination. With the plethora of 'daylight' lamps available, is there a cost-effective alternative to the discontinued MacBeth Easel lamp? Smoking is a known risk factor for macula degeneration. As the macula is responsible for colour discrimination, any toxin that affects it has the potential to influence colour discrimination. Aims: To find a costeffective light source for colour vision testing. To investigate the effect of smoking on colour discrimination. To explore how deuteranomalous trichromats compare with normal trichromats. Methods: Using the Ishihara colour vision test subjects were classified into the groups: 'Normal/Control', 'Smoker/Test', and 'Case Study' (subjects who failed the screening test and did not smoke). They completed the Farnsworth Munsell 100 Hue test under each of the three light sources: Phillips EcoHalo Twist (tungsten halogen - THL), Kosnic KCF07ALU/GU10-865 (compact fluorescent- CFL), and Deal Guardian Ltd. GU103X2WA4B-60 (light-emitting diode - LED) Results: 42 subjects took part in the study: 18 in the Normal/Control group, 18 in the Smoker/Test group, and 6 in the Case Study group. For the Normal/Control group the total error scores (TESs) were significantly lower with the CFL than with the THL (p = 0.017) as it was for the Case Study group (p = 0.009). No significant differences were found between the Normal/Control group and the Smoker/Test group for each light source. Decision tree analysis found pack years to be a significant variable for TES. Discussion: All three light sources were comparable with previous studies. The CFL provided better colour discrimination than the LED despite them both being 6500 K. Deuteranomalous trichromats showed a greatest deviation than normal trichromats using the LED. Conclusions: The Kosnic KCF07ALU/GU10-865 is a cost-effective alternative for colour vision testing. Smoking appears to have an effect on colour vision, but requires further investigation.

Women outperform men in remembering to remember

The study of gender differences in prospective memory (i.e., remembering to remember) has received modest attention in the literature. The few reported studies investigating either subjective or objective evaluations of prospective memory have shown inconsistent data. In this study, we aimed to verify the presence of gender differences during the performance of an objective prospective memory test by considering the weight of specific variables such as length of delay, type of response, and type of cue. We submitted a sample of 100 healthy Italian participants (50 men and 50 women) to a test expressly developed to assess prospective memory: The Memory for Intentions Screening Test. Women performed better than men in remembering to do an event-based task (i.e., prompted by an external event) and when the task required a physical response modality. We discuss the behavioural differences that emerged by considering the possible role of sociological, biological, neuroanatomical, and methodological variables.

New product screening in fast moving consumer goods

Theory suggests that the dimensions that are incorporated in the new product screening decision will differ according to the stage of the development process. The outcome of the application of different screening dimensions would be quicker, realistic and more reliable screening decisions. This research project builds on existing new product development and screening literature by investigating new product screening in international fast moving consumer goods companies. It further builds on the existing literature by measuring decision-making relating to projects in 'real time', as managers' responses refer to projects they are currently working on. The introduction of branded consumer products allows us to evolve scales used in new product research by further developing variables relating to branding, promotion and retailer power. The project uncovers multiple dimensions of new product screening and evaluation within this branded product sector. These dimensions are found to differ in their ability to discriminate between two groups of accepted and rejected projects at each of four stages of the new product development process. This investigation provides the intelligence with which managers can determine the likelihood of project acceptance and rejection at different stages of the development process. It highlights the need for managers to apply stage-specific dimensions in the new product screening decision and advocates the redefinition of new product screening from both an academic and managerial perspective. The screening decision should not be viewed as a single, early decision in a product development process, but as a series of stage specific decisions regarding future project potential.

Upgrading fast pyrolysis liquids:blends of biodiesel and pyrolysis oil

Fast pyrolysis liquid or bio-oil has been used in engines with limited success. It requires a pilot fuel and/or an additive for successful combustion and there are problems with materials and liquid properties. It is immiscible with all conventional hydrocarbon fuels. Biodiesel, a product of esterification of vegetable oil with an alcohol, is widely used as a renewable liquid fuel as an additive to diesel at up to 20%. There are however limits to its use in conventional engines due to poor low temperature performance and variability in quality from a variety of vegetable oil qualities and variety of esterification processes. Within the European Project Bioliquids-CHP - a joint project between the European Commission and Russia - a study was undertaken to develop small scale CHP units based on engines and microturbines fuelled with bioliquids from fast pyrolysis and methyl esters of vegetable oil. Blends of bio-oil and biodiesel were evaluated and tested to overcome some of the disadvantages of using either fuel by itself. An alcohol was used as the co-solvent in the form of ethanol, 1-butanol or 2-propanol. Visual inspection of the blend homogeneity after 48 h was used as an indicator of the product stability and the results were plotted in a three phase chart for each alcohol used. An accelerated stability test was performed on selected samples in order to predict its long term stability. We concluded that the type and quantity of alcohol is critical for the blend formation and stability. Using 1-butanol gave the widest selection of stable blends, followed by blends with 2-propanol and finally ethanol, thus 1-butanol blends accepted the largest proportion of bio-oil in the mixture. © 2013 Elsevier Ltd. All rights reserved.

Biomass fast pyrolysis energy balance of a 1kg/h test rig

The present paper offers a methodological approach towards the estimation and definition of enthalpies constituting an energy balance around a fast pyrolysis experiment conducted in a laboratory scale fluid bed with a capacity of 1 kg/ h. Pure N2 was used as fluidization medium at atmospheric pressure and the operating temperature (∼500°C) was adjusted with electrical resistors. The biomass feedstock type that was used was beech wood. An effort was made to achieve a satisfying 92.5% retrieval of products (dry basis mass balance) with the differences mainly attributed to loss of some bio-oil constituents into the quenching medium, ISOPAR™. The chemical enthalpy recovery for bio-oil, char and permanent gases is calculated 64.6%, 14.5% and 7.1%, respectively. All the energy losses from the experimental unit into the environment, namely the pyrolyser, cooling unit etc. are discussed and compared to the heat of fast pyrolysis that was calculated at 1123.5 kJ per kg of beech wood. This only represents 2.4% of the biomass total enthalpy or 6.5% its HHV basis. For the estimation of some important thermo-physical properties such as heat capacity and density, it was found that using data based on the identified compounds from the GC/MS analysis is very close to the reference values despite the small fraction of the bio-oil components detected. The methodology and results can help as a starting point for the proper design of fast pyrolysis experiments, pilot and/or industrial scale plants.

Comparison of the effect of pre-treatment and catalysts on liquid quality from fast pyrolysis of biomass

The overall objective of this work was to compare the effect of pre-treatment and catalysts on the quality of liquid products from fast pyrolysis of biomass. This study investigated the upgrading of bio-oil in terms of its quality as a bio-fuel and/or source of chemicals. Bio-oil used directly as a biofuel for heat or power needs to be improved particularly in terms of temperature sensitivity, oxygen content, chemical instability, solid content, and heating values. Chemicals produced from bio-oil need to be able to meet product specifications for market acceptability. There were two main objectives in this research. The first was to examine the influence of pre-treatment of biomass on the fast pyrolysis process and liquid quality. The relationship between the method of pre-treatment of biomass feedstock to fast pyrolysis oil quality was studied. The thermal decomposition behaviour of untreated and pretreated feedstocks was studied by using a TGA (thermogravimetric analysis) and a Py-GC/MS (pyroprobe-gas chromatography/mass spectrometry). Laboratory scale reactors (100g/h, 300g/h, 1kg/h) were used to process untreated and pretreated feedstocks by fast pyrolysis. The second objective was to study the influence of numerous catalysts on fast pyrolysis liquids from wheat straw. The first step applied analytical pyrolysis (Py-GC/MS) to determine which catalysts had an effect on fast pyrolysis liquid, in order to select catalysts for further laboratory fast pyrolysis. The effect of activation, temperature, and biomass pre-treatment on catalysts were also investigated. Laboratory experiments were also conducted using the existing 300g/h fluidised bed reactor system with a secondary catalytic fixed bed reactor. The screening of catalysts showed that CoMo was a highly active catalyst, which particularly reduced the higher molecular weight products of fast pyrolysis. From these screening tests, CoMo catalyst was selected for larger scale laboratory experiments. With reference to the effect of pre-treatment work on fast pyrolysis process, a significant effect occurred on the thermal decomposition of biomass, as well as the pyrolysis products composition, and the proportion of key components in bio-oil. Torrefaction proved to have a mild influence on pyrolysis products, when compared to aquathermolysis and steam pre-treatment.

The macular mapping test:a reliability study

Background: Age-related macular degeneration (ARMD) is the leading cause of visual disability in people over 60 years of age in the developed world. The success of treatment deteriorates with increased latency of diagnosis. The purpose of this study was to determine the reliability of the macular mapping test (MMT), and to investigate its potential as a screening tool. Methods: The study population comprised of 31 healthy eyes of 31 participants. To assess reliability, four macular mapping test (MMT) measurements were taken in two sessions separated by one hour by two practitioners, with reversal of order in the second session. MMT readings were also taken from 17 age-related maculopathy (ARM), and 12 AMD affected eyes. Results: For the normal cohort, average MMT scores ranged from 85.5 to 100.0 MMT points. Scores ranged from 79.0 to 99.0 for the ARM group and from 9.0 to 92.0 for the AMD group. MMT scores were reliable to within ± 7.0 points. The difference between AMD affected eyes and controls (z = 3.761, p = < 0.001) was significant. The difference between ARM affected eyes and controls was not significant (z = -0.216, p = 0.829). Conclusion: The reliability data shows that a change of 14 points or more is required to indicate a clinically significant change. This value is required for use of the MMT as an outcome measure in clinical trials. Although there was no difference between MMT scores from ARM affected eyes and controls, the MMT has the advantage over the Amsler grid in that it uses a letter target, has a peripheral fixation aid, and it provides a numerical score. This score could be beneficial in office and home monitoring of AMD progression, as well as an outcome measure in clinical research. © 2005 Bartlett et al; licensee BioMed Central Ltd.

Evaluation of a 2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant

The efficacy of a new skin disinfectant, 2% (w/v) chlorhexidine gluconate (CHG) in 70% (v/v) isopropyl alcohol (IPA) (ChloraPrep®), was compared with five commonly used skin disinfectants against Staphylococcus epidermidis RP62A in the presence or absence of protein, utilizing quantitative time-kill suspension and carrier tests. All six disinfectants [70% (v/v) IPA, 0.5% (w/v) aqueous CHG, 2% (w/v) aqueous CHG, 0.5% (w/v) CHG in 70% (v/v) IPA and 10% (w/v) aqueous povidone iodine (PI)] achieved a log10 reduction factor of 5, in colony-forming units/mL, in a suspension test (exposure time 30 s) in the presence and absence of 10% human serum. Subsequent challenges of S. epidermidis RP62A in a biofilm (with and without human serum) demonstrated reduced bactericidal activity. Overall, the most effective skin disinfectants tested against S. epidermidis RP62A were 2% (w/v) CHG in 70% IPA and 10% (w/v) PI. These results suggest that enhanced skin antisepsis may be achieved with 2% (w/v) CHG in 70% (v/v) IPA compared with the three commonly used CHG preparations [0.5% (w/v) aqueous CHG, 2% (w/v) aqueous CHG and 0.5% (w/v) CHG in 70% (v/v) IPA]. © 2005 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Fast pyrolysis of biomass in a circulating fluidised bed reactor

The objective of this work was to design, construct, test and operate a novel circulating fluid bed fast pyrolysis reactor system for production of liquids from biomass. The novelty lies in incorporating an integral char combustor to provide autothermal operation. A reactor design methodology was devised which correlated input parameters to process variables, namely temperature, heat transfer and gas/vapour residence time, for both the char combustor and biomass pyrolyser. From this methodology a CFB reactor was designed with integral char combustion for 10 kg/h biomass throughput. A full-scale cold model of the CFB unit was constructed and tested to derive suitable hydrodynamic relationships and performance constraints. Early difficulties encountered with poor solids circulation and inefficient product recovery were overcome by a series of modifications. A total of 11 runs in a pyrolysis mode were carried out with a maximum total liquids yield of 61.50% wt on a maf biomass basis, obtained at 500°C and with 0.46 s gas/vapour residence time. This could be improved by improved vapour recovery by direct quenching up to an anticipated 75 % wt on a moisture-and-ash-free biomass basis. The reactor provides a very high specific throughput of 1.12 - 1.48 kg/hm2 and the lowest gas-to-feed ratio of 1.3 - 1.9 kg gas/kg feed compared to other fast pyrolysis processes based on pneumatic reactors and has a good scale-up potential. These features should provide significant capital cost reduction. Results to date suggest that the process is limited by the extent of char combustion. Future work will address resizing of the char combustor to increase overall system capacity, improvement in solid separation and substantially better liquid recovery. Extended testing will provide better evaluation of steady state operation and provide data for process simulation and reactor modeling.

The acceptability of alcohol fuels for automobile engines

The aim of this project was to carry out an investigastion into suitable alternatives to gasoline for use in modern automobiles. The fuel would provide the western world with a means of extending the natural gasoline resources and the third world a way of cutting down their dependence on the oil producing countries for their energy supply. Alcohols, namely methanol and ethanol, provide this solution. They can be used as gasoline extenders or as fuels on their own.In order to fulfil the aims of the project a literature study was carried out to investigate methods and costs of producing these fuels. An experimental programme was then set up in which the performance of the alcohols was studied on a conventional engine. The engine used for this purpose was the Fiat 127 930cc four cylinder engine. This engine was used because of its popularity in the European countries. The Weber fixed jet carburettor, since it was designed to be used with gasoline, was adapted so that the alcohol fuels and the blends could be used in the most efficient way. This was mainly to take account of the lower heat content of the alcohols. The adaptation of the carburettor was in the form of enlarging the main metering jet. Allowances for the alcohol's lower specfic gravity were made during fuel metering.Owing to the low front end volatility of methanol and ethanol, it was expected that `start up' problems would occur. An experimental programme was set up to determine the temperature range for a minimum required percentage `take off' that would ease start-up since it was determined that a `take off' of about 5% v/v liquid in the vapour phase would be sufficient for starting. Additions such as iso-pentane and n-pentane were used to improve the front end volatility. This proved to be successful.The lower heat content of the alcohol fuels also meant that a greater charge of fuel would be required. This was seen to pose further problems with fuel distribution from the carburettor to the individual cylinders on a multicylinder engine. Since it was not possible to modify the existing manifold on the Fiat 127 engine, experimental tests on manifold geometry were carried out using the Ricardo E6 single cylinder variable compression engine. Results from these tests showed that the length, shape and cross-sectional area of the manifold play an important part in the distribution of the fuel entering the cylinder, ie. vapour phase, vapour/small liquid droplet/liquid film phase, vapour/large liquid droplet/liquid film phase etc.The solvent properties of the alcohols and their greater electrical conductivity suggested that the materials used on the engine would be prone to chemical attack. In order to determine the type and rate of chemical attack, an experimental programme was set up whereby carburettor and other components were immersed in the alcohols and in blends of alcohol with gasoline. The test fuels were aerated and in some instances kept at temperatures ranging from 50oC to 90oC. Results from these tests suggest that not all materials used in the conventional engine are equally suitable for use with alcohols and alcohol/gasoline blends. Aluminium for instance was severely attacked by methanol causing pitting and pin-holing in the surface.In general this whole experimental programme gave valuable information on the acceptability of substitute fuels. While the long term effects of alcohol use merit further study, it is clear that methanol and ethanol will be increasingly used in place of gasoline.

Fast algorithms for automatic mapping with space-limited covariance functions

In this paper we discuss a fast Bayesian extension to kriging algorithms which has been used successfully for fast, automatic mapping in emergency conditions in the Spatial Interpolation Comparison 2004 (SIC2004) exercise. The application of kriging to automatic mapping raises several issues such as robustness, scalability, speed and parameter estimation. Various ad-hoc solutions have been proposed and used extensively but they lack a sound theoretical basis. In this paper we show how observations can be projected onto a representative subset of the data, without losing significant information. This allows the complexity of the algorithm to grow as O(n m 2), where n is the total number of observations and m is the size of the subset of the observations retained for prediction. The main contribution of this paper is to further extend this projective method through the application of space-limited covariance functions, which can be used as an alternative to the commonly used covariance models. In many real world applications the correlation between observations essentially vanishes beyond a certain separation distance. Thus it makes sense to use a covariance model that encompasses this belief since this leads to sparse covariance matrices for which optimised sparse matrix techniques can be used. In the presence of extreme values we show that space-limited covariance functions offer an additional benefit, they maintain the smoothness locally but at the same time lead to a more robust, and compact, global model. We show the performance of this technique coupled with the sparse extension to the kriging algorithm on synthetic data and outline a number of computational benefits such an approach brings. To test the relevance to automatic mapping we apply the method to the data used in a recent comparison of interpolation techniques (SIC2004) to map the levels of background ambient gamma radiation. © Springer-Verlag 2007.