Adjuvant use of nutritional and herbal medicines with antidepressants, mood stabilizers and benzodiazepines

Adjuvant use of nutritional and herbal medicines has potential to increase the efficacy of synthetic pharmaceuticals, and perhaps also decrease their side-effects by allowing lower doses to be prescribed. We evaluated current evidence for adjuvant use of nutritional and herbal medicines with antidepressants, mood stabilizers and benzodiazepines; and explored novel future areas of research. The paper also critiques current evidence for co-administration of St. John’s wort with synthetic antidepressants. We performed a systematic search of MEDLINE, CINAHL, PsycINFO, The Cochrane database, China National Knowledge Infrastructure and the Chinese Science Citation Database. Search results were supplemented by a review of reference lists and a forward search using the Web of Science. Where possible we calculated effect sizes. Encouraging evidence exists for the use of omega-3 fatty acids, SAMe, folic acid and l-tryptophan adjuvantly with antidepressants to enhance response and improve efficacy. Various nutrients also have emerging evidence as effective adjuncts with antipsychotics and mood stabilizers. While some evidence supports nutritional adjuvancy with various psychopharmacotherapies, adjuvant use of herbal therapies has not been sufficiently studied to warrant standard clinical application. This remains a promising area of research via robust, safety-conscious studies.

Queensland Emergency Medical System : a structural and organizational model for the emergency medical system in Australia

Objective: The emergency medical system (EMS) can be defined as a comprehensive, coordinated and integrated system of care for patients suffering acute illness and injury. The aim of the present paper is to describe the evolution of the Queensland Emergency Medical System (QEMS) and to recommend a strategic national approach to EMS development. Methods: Following the formation of the Queensland Ambulance Service in 1991, a state EMS committee was formed. This committee led the development and approval of the cross portfolio QEMS policy framework that has resulted in dynamic policy development, system monitoring and evaluation. This framework is led by the Queensland Emergency Medical Services Advisory Committee. Results: There has been considerable progress in the development of all aspects of the EMS in Queensland. These developments have derived from the improved coordination and leadership that QEMS provides and has resulted in widespread satisfaction by both patients and stakeholders. Conclusions: The strategic approach outlined in the present paper offers a model for EMS arrangements throughout Australia. We propose that the Council of Australian Governments should require each state and Territory to maintain an EMS committee. These state EMS committees should have a broad portfolio of responsibilities. They should provide leadership and direction to the development of the EMS and ensure coordination and quality of outcomes. A national EMS committee with broad representation and broad scope should be established to coordinate the national development of Australia's EMS.

How does ambulance service utilisation impact demand for Emergency Departments in Queensland, Australia?

Background: There are indications that pre-hospital emergency care and management of patients can help reduce the demand for hospital emergency departments (EDs). Ambulance services play a significant role at this stage of care. In 2003, the Queensland Government introduced a Community Ambulance Cover (CAC) levy in return for a free ambulance service at the point of access to all Queenslanders. This may have led to the impression in consumers of an entitlement to free ambulance services under any circumstances regardless of the urgency of the matter which may have in turn contributed to the crowding of EDs in Queensland. Objectives: This paper aims to answer the following questions: - How many patients arrive at hospital EDs by ambulance in Queensland, compared to other modes of arrival? - How has this changed over time, particularly after the CAC introduction in 2003? What percentage of ambulance arrivals are urgent ED patients? - Has the perceived free ambulance services created extra demand for EDs in Queensland, compared with other Australian jurisdictions that charge patients for ambulance services? Methods: We will secondary analyse the data from sources such as Queensland Ambulance Services, Department of Health and Australian Bureau of Statistics to answer the research questions. Findings and Conclusions Queensland has the highest utilization rate of ambulance services (about 18% in 2007-08) and the highest annual growth rate in demand for these services (7.7% on average since 2000-01), well above the population growth. On the other hand, the proportion of ED patients arriving by ambulance in Queensland has increased by about 4% annually. However, when compared with other states and territories with charge at the point of access, it seems that the growth in demand for EDs cannot be explained solely or mainly by CAC or ambulance utilisation in Queensland.

Emergency department triage revisited

Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.

Emergency department surge capacity : Recommendations of the Australasian surge strategy working group

Background For more than a decade emergency medicine organizations have produced guidelines, training and leadership for disaster management. However to date, there have been limited guidelines for emergency physicians needing to provide a rapid response to a surge in demand. The aim of this study is to identify strategies which may guide surge management in the Emergency Department. Method A working group of individuals experienced in disaster medicine from the Australasian College for Emergency Medicine Disaster Medicine Subcommittee (the Australasian Surge Strategy Working Group) was established to undertake this work. The Working Group used a modified Delphi technique to examine response actions in surge situations. The Working Group identified underlying assumptions from epidemiological and empirical understanding and then identified remedial strategies from literature and from personal experience and collated these within domains of space, staff, supplies, and system operation. Findings These recommendations detail 22 potential actions available to an emergency physician working in the context of surge. The Working Group also provides detailed guidance on surge recognition, triage, patient flow through the emergency department and clinical goals and practices. Discussion These strategies provide guidance to emergency physicians confronting the challenges of a surge in demand. The paper also identifies areas that merit future research including the measurement of surge capacity, constraints to strategy implementation, validation of surge strategies and measurement of strategy impacts on throughput, cost, and quality of care.

Control and protection of a microgrid with converter interfaced micro sources

This paper describes protection and control of a microgrid with converter interfaced micro sources. The proposed protection and control scheme consider both grid connected and autonomous operation of the microgrid. A protection scheme, capable of detecting faults effectively in both grid connected and islanded operations is proposed. The main challenge of the protection, due to current limiting state of the converters is overcome by using admittance relays. The relays operate according to the inverse time characteristic based on measured admittance of the line. The proposed scheme isolates the fault from both sides, while downstream side of the microgrid operates in islanding condition. Moreover faults can be detected in autonomous operation. In grid connected mode distributed generators (DG) supply the rated power while in absence of the grid, DGs share the entire power requirement proportional to rating based on output voltage angle droop control. The protection scheme ensures minimum load shedding with isolating the faulted network and DG control provides a smooth islanding and resynchronization operation. The efficacy of coordinated control and protection scheme has been validated through simulation for various operating conditions.

Reliability driven reconfiguration of rural power distribution systems

This paper presents a reliability-based reconfiguration methodology for power distribution systems. Probabilistic reliability models of the system components are considered and Monte Carlo method is used while evaluating the reliability of the distribution system. The reconfiguration is aimed at maximizing the reliability of the power supplied to the customers. A binary particle swarm optimization (BPSO) algorithm is used as a tool to determine the optimal configuration of the sectionalizing and tie switches in the system. The proposed methodology is applied on a modified IEEE 13-bus distribution system.

Power sharing and stability enhancement of an autonomous microgrid with inertial and non-inertial DGs with DSTATCOM

This paper proposes a method of enhancing system stability with a distribution static compensator (DSTATCOM) in an autonomous microgrid with multiple distributed generators (DG). It is assumed that there are both inertial and non-inertial DGs connected to the microgrid. The inertial DG can be a synchronous machine of smaller rating while inertia less DGs (solar) are assumed as DC sources. The inertia less DGs are connected through Voltage Source Converter (VSC) to the microgrid. The VSCs are controlled by either state feedback or current feedback mode to achieve desired voltage-current or power outputs respectively. The power sharing among the DGs is achieved by drooping voltage angle. Once the reference for the output voltage magnitude and angle is calculated from the droop, state feedback controllers are used to track the reference. The angle reference for the synchronous machine is compared with the output voltage angle of the machine and the error is fed to a PI controller. The controller output is used to set the power reference of the synchronous machine. The rate of change in the angle in a synchronous machine is restricted by the machine inertia and to mimic this nature, the rate of change in the VSCs angles are restricted by a derivative feedback in the droop control. The connected distribution static compensator (DSTATCOM) provides ride through capability during power imbalance in the microgrid, especially when the stored energy of the inertial DG is not sufficient to maintain stability. The inclusion of the DSATCOM in such cases ensures the system stability. The efficacies of the controllers are established through extensive simulation studies using PSCAD.

Sensitivity analysis of voltage imbalance in distribution networks with rooftop PVs

A comprehensive voltage imbalance sensitivity analysis and stochastic evaluation based on the rating and location of single-phase grid-connected rooftop photovoltaic cells (PVs) in a residential low voltage distribution network are presented. The voltage imbalance at different locations along a feeder is investigated. In addition, the sensitivity analysis is performed for voltage imbalance in one feeder when PVs are installed in other feeders of the network. A stochastic evaluation based on Monte Carlo method is carried out to investigate the risk index of the non-standard voltage imbalance in the network in the presence of PVs. The network voltage imbalance characteristic based on different criteria of PV rating and location and network conditions is generalized. Improvement methods are proposed for voltage imbalance reduction and their efficacy is verified by comparing their risk index using Monte Carlo simulations.

Optimal allocation and sizing of DGs in distribution networks

In this paper, the placement and sizing of Distributed Generators (DG) in distribution networks are determined optimally. The objective is to minimize the loss and to improve the reliability. The constraints are the bus voltage, feeder current and the reactive power flowing back to the source side. The placement and size of DGs are optimized using a combination of Discrete Particle Swarm Optimization (DPSO) and Genetic Algorithm (GA). This increases the diversity of the optimizing variables in DPSO not to be stuck in the local minima. To evaluate the proposed algorithm, the semi-urban 37-bus distribution system connected at bus 2 of the Roy Billinton Test System (RBTS), which is located at the secondary side of a 33/11 kV distribution substation, is used. The results finally illustrate the efficiency of the proposed method.

A bidirectional two-leg resonant converter for high voltage pulsed power application

A high voltage pulsed power supply is proposed in this paper based on oscillation between an inductor and a capacitor in an LC circuit. A two-leg resonant circuit, supplied through an inverter with an alternative voltage waveform, can generate output voltage up to four times an input voltage magnitude. Bipolar and unipolar modulations are used in a single phase inverter to analyse their effects on the proposed resonant converter. Simulations have been carried out to evaluate the proposed topology and control.

A novel high voltage pulsed power supply based on low voltage switch-capacitor units

This paper presents a high voltage pulsed power system based on low voltage switch-capacitor units connected to a current source for several applications such as plasma systems. A buck-boost converter topology is used to utilize the current source and a series of low voltage switch-capacitor units is connected to the current source in order to provide high voltage with high voltage stress (dv/dt) as demanded by loads. This pulsed power converter is flexible in terms of energy control, in that the stored energy in the current source can be adjusted by changing the current magnitude to significantly improve the efficiency of various systems with different requirements. Output voltage magnitude and stress (dv/dt) can be controlled by a proper selection of components and control algorithm to turn on and off switching devices.

Droop control of converter interfaced micro sources in rural distributed generation

This paper proposes new droop control methods for load sharing in a rural area with distributed generation. Highly resistive lines, typical of rural low voltage networks, always create a big challenge for conventional droop control. To overcome the conflict between higher feedback gain for better power sharing and system stability in angle droop, two control methods have been proposed. The first method considers no communication among the distributed generators (DGs) and regulates the converter output voltage and angle ensuring proper sharing of load in a system having strong coupling between real and reactive power due to high line resistance. The second method, based on a smattering of communication, modifies the reference output volt-age angle of the DGs depending on the active and reactive power flow in the lines connected to point of common coupling (PCC). It is shown that with the second proposed control method, an economical and minimum communication system can achieve significant improvement in load sharing. The difference in error margin between proposed control schemes and a more costly high bandwidth communication system is small and the later may not be justified considering the increase in cost. The proposed control shows stable operation of the system for a range of operating conditions while ensuring satisfactory load sharing.

Operation and control of a hybrid microgrid containing unbalanced and nonlinear loads

This paper shows how the power quality can be improved in a microgrid that is supplying a nonlinear and unbalanced load. The microgrid contains a hybrid combination of inertial and converter interfaced distributed generation units where a decentralized power sharing algorithm is used to control its power management. One of the distributed generators in the microgrid is used as a power quality compensator for the unbalanced and harmonic load. The current reference generation for power quality improvement takes into account the active and reactive power to be supplied by the micro source which is connected to the compensator. Depending on the power requirement of the nonlinear load, the proposed control scheme can change modes of operation without any external communication interfaces. The compensator can operate in two modes depending on the entire power demand of the unbalanced nonlinear load. The proposed control scheme can even compensate system unbalance caused by the single-phase micro sources and load changes. The efficacy of the proposed power quality improvement control and method in such a microgrid is validated through extensive simulation studies using PSCAD/EMTDC software with detailed dynamic models of the micro sources and power electronic converters