The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK).

Background
The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention.

Methods
Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff.

Results
Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision.

Conclusions
We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes.

Multiple edges of a quantum Hall system in a strong electric

In this paper we show that if the electrons in a quantum Hall sample are subjected to a constant electric field in the plane of the material, comparable in magnitude to the background magnetic field on the system of electrons, a multiplicity of edge states localized at different regions of space is produced in the sample. The actions governing the dynamics of these edge states are obtained starting from the well-known Schrödinger field theory for a system of nonrelativistic electrons, where on top of the constant background electric and magnetic fields, the electrons are further subject to slowly varying weak electromagnetic fields. In the regions between the edges, dubbed as the "bulk," the fermions can be integrated out entirely and the dynamics expressed in terms of a local effective action involving the slowly varying electromagnetic potentials. It is further shown how the bulk action is gauge noninvariant in a particular way, and how the edge states conspire to restore the U(1) electromagnetic gauge invariance of the system. In the edge action we obtain a heretofore unnoticed gauge-invariant term that depends on the particular edge. We argue that this term may be detected experimentally as different edges respond differently to a monochromatic probe due to this term

Microgranitic Enclaves as Products of Self-mixing Events: a Study of Open-system Processes in the Maua Granite, Sao Paulo, Brazil, Based on in situ Isotopic and Trace Elements in Plagioclase

Felsic microgranular enclaves with structures indicating that they interacted in a plastic state with their chemically similar host granite are abundant in the Maua Pluton, SE Brazil. Larger plagioclase xenocrysts are in textural disequilibrium with the enclave groundmass and show complex zoning patterns with partially resorbed An-rich cores (locally with patchy textures) surrounded by more sodic rims. In situ laser ablation-(multi-collector) inductively coupled plasma mass spectrometry trace element and Sr isotopic analyses performed on the plagioclase xenocrysts indicate open-system crystallization; however, no evidence of derivation from more primitive basic melts is observed. The An-rich cores have more radiogenic initial Sr isotopic ratios that decrease towards the outermost part of the rims, which are in isotopic equilibrium with the matrix plagioclase. These profiles may have been produced by either (1) diffusional re-equilibration after rim crystallization from the enclave-forming magma, as indicated by relatively short calculated residence times, or (2) episodic contamination with a decrease of the contaminant ratio proportional to the extent to which the country rocks were isolated by the crystallization front. Profiles of trace elements with high diffusion coefficients would require unrealistically long residence times, and can be modeled in terms of fractional crystallization. A combination of trace element and Sr isotope data suggests that the felsic microgranular enclaves from the Maua Pluton are the products of interaction between end-member magmas that had similar compositions, thus recording `self-mixing` events.

Finite-momentum condensate of magnetic excitons in a bilayer quantum Hall system

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Possible open-system (hydraulic) pingos in and around the Argyre impact region of Mars

We report the observation of possible (hydraulic) open-system pingos (OSPs ) at the mid latitudes (∼37°S) in and around the Argyre impact-basin. OSPs are perennial (water)–ice cored mounds; they originate and evolve in periglacial and pro-glacial landscapes on Earth where intra- or sub-permafrost water under hydraulic/artesian pressure uplifts localised sections of surface or near-surface permafrost that then freezes in-situ. We invoke three lines of evidence in support of our analogue-based interpretation: (1) similarities of shape, size and summit traits between terrestrial OSPs and the Martian mounds; (2) clustered distribution and the slope-side location of the mounds, consistent with terrestrial permafrost-environments where OSPs are found; and, (3) spatially-associated landforms putatively indicative of periglacial and glacial processes on Mars that characterise OSP landscapes on Earth. This article presents five OSP candidate-locations and nests these mound locations within a new geological map of the Argyre impact-basin and margins. It also presents three periglacial hypotheses about the possible origin of the water required to develop the mounds. Alternative (non-periglacial) formation-hypotheses also are considered; however, we show that their robustness is not equal to that of the periglacial ones.

Charge transport in a quantum electromechanical system

We describe a quantum electromechanical system comprising a single quantum dot harmonically bound between two electrodes and facilitating a tunneling current between them. An example of such a system is a fullerene molecule between two metal electrodes [Park et al., Nature 407, 57 (2000)]. The description is based on a quantum master equation for the density operator of the electronic and vibrational degrees of freedom and thus incorporates the dynamics of both diagonal (population) and off diagonal (coherence) terms. We derive coupled equations of motion for the electron occupation number of the dot and the vibrational degrees of freedom, including damping of the vibration and thermo-mechanical noise. This dynamical description is related to observable features of the system including the stationary current as a function of bias voltage

Multi-types of Skyrmions in SU(N) Quantum Hall System

The skyrmions in SU(N) quantum Hall (QH) system are discussed. By analyzing the gauge field structure and the topological properties of this QH system it is pointed out that in the SU(N) QH system there can exist (N-1) types of skyrmion structures, instead of only one type of skyrmions. In this paper, by means of the Abelian projections according to the (N-1) Cartan subalgebra local bases, we obtain the (N-1) U(1) electromagnetic field tensors in the SU(N) gauge field of the QH system, and then derive (N-1) types of skyrmion structures from these U(1) sub-field tensors. Furthermore, in light of the phi-mapping topological current method, the topological charges and the motion of these skyrmions are also discussed.

Phase control of gain and dispersion in an open lambda-type inversionless lasing system

The control role of the relative phase between the probe and driving fields on the gain and dispersion in an open Lambda-type inversionless lasing system with spontaneously generated coherence (SGC) is investigated. It is shown that the inversionless gain and dispersion are quite sensitive to variation in the relative phase; by adjusting the value of the relative phase, electromagnetically induced transparency (EIT), a high refractive index with zero absorption and a larger inversionless gain can be realized. It is also shown that, in the contributions to the inversionless gain ( absorption) and dispersion, the contribution from SGC is always much larger than that from the dynamically induced coherence for any value of the relative phase. Our analysis shows that variation in the SGC effect will cause the spectrum regions and values of the inversionless gain and dispersion to vary evidently. We also found that, under the same conditions, the values of the inversionless gain and dispersion in the open system are evidently larger than those in the corresponding closed system; EIT occurs in the open system but cannot occur in the closed system.

Lasing without or with inversion in an open four-level system with a phase-fluctuation driving field

The effect of exit rate and the ratio of atomic injection rate on gain behaviour has been investigated, and the effects of phase fluctuation on absorption, dispersion and population difference in an open four-level system have been analysed by using numerical simulation from the steady linear, analytical solution. The variation of the linewidth, Rabi frequency of the driving field, the exit rate or the ratio of atomic injection rate can change the lasing properties in the open system. The presence of finite linewidth due to driving-field phase fluctuation prevents the open four-level atomic system from obtaining a high refractive index along with zero absorption.

Phase control of gain and dispersion in an open V-type system

The control role of the relative phase between the probe and driving fields on gain, dispersion and populations in an open V-type three-level system with spontaneously generated coherence is studied. The result shows that by adjusting the value of the relative phase, the transformation between lasing with inversion and lasing without inversion (LWI) can be realized and high dispersion (refractive index) without absorption can be obtained. The shape and value range of the dispersion curve are similar to those of the gain curve, and this similarity is closely related to the relative phase. The effects of the atomic exit and injection rates and the incoherent pump rate on the control role of the relative phase are also analysed. It is found easier to get LWI by adjusting the value of the relative phase using the open system rather than the closed system, and using an incoherent pump rather than without using the incoherent pump. Moreover the open system can give a larger LWI gain than the closed system.

Group velocity of the light pulse in an open V-type system

We investigate the group velocity of the probe light pulse in an open V-type system with spontaneously generated coherence. We find that, not only varying the relative phase between the probe and driving pulses can but varying the atomic exit rate or incoherent pumping rate also can manipulate dramatically the group velocity, even make the pulse propagation switching from subluminal to superluminal; the subliminal propagation can be companied with gain or absorption, but the superluminal propagation is always companied with absorption. (c) 2006 Elsevier GmbH. All rights reserved.