Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 - 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 - 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence). MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).

Single vehicle roadway departure crashes: problem size assessment and statistical description.

Mode of access: Internet.

Backing crashes: problem size assessment and statistical description.

Mode of access: Internet.

Lane change/merge crashes: problem size assessment and statistical description.

Mode of access: Internet.

Rear-end crashes: problem size assessment and statistical description.

Mode of access: Internet.

Assessment and classification of Illinois lakes /

"Staff report."

Lake Killarney Partnership: Ecological Planning with Roots in Science and Policy

Thesis (Master's)--University of Washington, 2016-06

Mapping and characterising subtropical estuarine landscapes using aerial photography and GIS for potential application in wildlife conservation and management

Coarse-resolution thematic maps derived from remotely sensed data and implemented in GIS play an important role in coastal and marine conservation, research and management. Here, we describe an approach for fine-resolution mapping of land-cover types using aerial photography and ancillary GIs and ground data in a large (100 x 35 km) subtropical estuarine system (Moreton Bay, Queensland, Australia). We have developed and implemented a classification scheme representing 24 coastal (subtidal, intertidal. mangrove, supratidal and terrestrial) cover types relevant to the ecology of estuarine animals, nekton and shorebirds. The accuracy of classifications of the intertidal and subtidal cover types, as indicated by the agreement between the mapped (predicted) and reference (ground) data, was 77-88%, depending on the zone and level of generalization required. The variability and spatial distribution of habitat mosaics (landscape types) across the mapped environment were assessed using K-means clustering and validated with Classification and Regression Tree models. Seven broad landscape types could be distinguished and ways of incorporating the information on landscape composition into site-specific conservation and field research are discussed. This research illustrates the importance and potential applications of fine-resolution mapping for conservation and management of estuarine habitats and their terrestrial and aquatic wildlife. (c) 2005 Elsevier Ltd. All rights reserved.

Integrated project evaluation and selection using multiple-attribute decision-making technique

The evaluation and selection of industrial projects before investment decision is customarily done using marketing, technical and financial information. Subsequently, environmental impact assessment and social impact assessment are carried out mainly to satisfy the statutory agencies. Because of stricter environment regulations in developed and developing countries, quite often impact assessment suggests alternate sites, technologies, designs, and implementation methods as mitigating measures. This causes considerable delay to complete project feasibility analysis and selection as complete analysis requires to be taken up again and again till the statutory regulatory authority approves the project. Moreover, project analysis through above process often results sub-optimal project as financial analysis may eliminate better options, as more environment friendly alternative will always be cost intensive. In this circumstance, this study proposes a decision support system, which analyses projects with respect to market, technicalities, and social and environmental impact in an integrated framework using analytic hierarchy process, a multiple-attribute decision-making technique. This not only reduces duration of project evaluation and selection, but also helps select optimal project for the organization for sustainable development. The entire methodology has been applied to a cross-country oil pipeline project in India and its effectiveness has been demonstrated. © 2005 Elsevier B.V. All rights reserved.

Integrated manufacturing, empowerment, and company performance

There is controversy over whether integrated manufacturing (IM), comprising advanced manufacturing technology, just-in-time inventory control and total quality management, empowers or deskills shop floor work. Moreover, both IM and empowerment are promoted on the assumption that they enhance competitiveness. We examine these issues in a study of 80 manufacturing companies. The extent of use of IM was positively associated with empowerment (i.e., job enrichment and employee skill enhancement), but, with the minor exception of AMT, bore little relationship with subsequent company performance. In contrast, the extent of empowerment within companies predicted the subsequent level of company performance controlling for prior performance, with the effect on productivity mediating that on profit. Copyright © 2004 John Wiley & Sons, Ltd.

e-CAF: flexible marking schemes for electronic coursework assessment and feedback

Recent surveys reveal that many university students in the U.K. are not satisfied with the timeliness and usefulness of the feedback given by their tutors. Ensuring timeliness in marking can result in a reduction in the quality of feedback. Though suitable use of Information and Communication Technology should alleviate this problem, existing Virtual Learning Environments are inadequate to support detailed marking scheme creation and they provide little support for giving detailed feedback. This paper describes a unique new web-based tool called e-CAF for facilitating coursework assessment and feedback management directed by marking schemes. Using e-CAF, tutors can create or reuse detailed marking schemes efficiently without sacrificing the accuracy or thoroughness in marking. The flexibility in marking scheme design also makes it possible for tutors to modify a marking scheme during the marking process without having to reassess the students’ submissions. The resulting marking process will become more transparent to students.

Computer integrated manufacturing (CIM) and the principle of business control

In response to the increasing international competitiveness, many manufacturing businesses are rethinking their management strategies and philosophies towards achieving a computer integrated environment. The explosive growth in Advanced Manufacturing Technology (AMI) has resulted in the formation of functional "Islands of Automation" such as Computer Aided Design (CAD), Computer Aided Manufacturing (CAM), Computer Aided Process Planning (CAPP) and Manufacturing Resources Planning (MRPII). This has resulted in an environment which has focussed areas of excellence and poor overall efficiency, co-ordination and control. The main role of Computer Integrated Manufacturing (CIM) is to integrate these islands of automation and develop a totally integrated and controlled environment. However, the various perceptions of CIM, although developing, remain focussed on a very narrow integration scope and have consequently resulted in mere linked islands of automation with little improvement in overall co-ordination and control. This thesis, that is the research described within, develops and examines a more holistic view of CIM, which is based on the integration of various business elements. One particular business element, namely control, has been shown to have a multi-facetted and underpinning relationship with the CIM philosophy. This relationship impacts various CIM system design aspects including the CIM business analysis and modelling technique, the specification of systems integration requirements, the CIM system architectural form and the degree of business redesign. The research findings show that fundamental changes to CIM system design are required; these are incorporated in a generic CIM design methodology. The affect and influence of this holistic view of CIM on a manufacturing business has been evaluated through various industrial case study applications. Based on the evidence obtained, it has been concluded that this holistic, control based approach to CIM can provide a greatly improved means of achieving a totally integrated and controlled business environment. This generic CIM methodology will therefore make a significant contribution to the planning, modelling, design and development of future CIM systems.