Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients (Review)

BACKGROUND: Reducing weaning time is desirable in minimizing potential complications from mechanical ventilation. Standardized weaning protocols are purported to reduce time spent on mechanical ventilation. However, evidence supporting their use in clinical practice is inconsistent.

OBJECTIVES: To assess the effects of protocolized weaning from mechanical ventilation on the total duration of mechanical ventilation for critically ill adults; ascertain differences between protocolized and non-protocolized weaning in terms of mortality, adverse events, quality of life, weaning duration, intensive care unit (ICU) and hospital length of stay (LOS); and explore variation in outcomes by type of ICU, type of protocol and approach to delivering the protocol.

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2010), MEDLINE (1950 to 2010), EMBASE (1988 to 2010), CINAHL (1937 to 2010), LILACS (1982 to 2010), ISI Web of Science and ISI Conference Proceedings (1970 to 2010), Cambridge Scientific Abstracts (inception to 2010) and reference lists of articles. We did not apply language restrictions.

SELECTION CRITERIA: We included randomized and quasi-randomized controlled trials of protocolized weaning versus non-protocolized weaning from mechanical ventilation in critically ill adults.

DATA COLLECTION AND ANALYSIS: Three authors independently assessed trial quality and extracted data. A priori subgroup and sensitivity analyses were performed. We contacted study authors for additional information.

MAIN RESULTS: Eleven trials that included 1971 patients met the inclusion criteria. The total duration of mechanical ventilation geometric mean in the protocolized weaning group was on average reduced by 25% compared with the usual care group (N = 10 trials, 95% CI 9% to 39%, P = 0.006); weaning duration was reduced by 78% (N = 6 trials, 95% CI 31% to 93%, P = 0.009); and ICU LOS by 10% (N = 8 trials, 95% CI 2% to 19%, P = 0.02). There was significant heterogeneity among studies for total duration of mechanical ventilation (I(2) = 76%, P <0.01) and weaning duration (I(2) = 97%, P <0.01), which could not be explained by subgroup analyses based on type of unit or type of approach.

AUTHORS' CONCLUSIONS: There is some evidence of a reduction in the duration of mechanical ventilation, weaning duration and ICU LOS with use of standardized protocols, but there is significant heterogeneity among studies and an insufficient number of studies to investigate the source of this heterogeneity. Although some study authors suggest that organizational context may influence outcomes, these factors were not considered in all included studies and therefore could not be evaluated.

Eradication of marine biofilms by atmospheric pressure non-thermal plasma: A potential approach to control biofouling?

Although the antimicrobial activity of atmospheric pressure non-thermal plasmas, including its capacity to eradicate microbial biofilms, has been gaining an ever increasing interest for different medical applications, its potential utilisation in the control of biofouling and biodeterioration has, to date, received no attention. In this study, the ability of atmospheric pressure plasma to eradicate biofilms of four biofouling bacterial species, frequently encountered in marine environments, was investigated. Biofilms were grown on both polystyrene and stainless steel surfaces before being exposed to the plasma source. Viability and biomass of biofilms were evaluated using colony count method and differential Live/Dead fluorescence staining followed by confocal laser scanning microscopy. Rapid and complete eradication of all biofilms under study was achieved after plasma exposures ranging from 60 to 120 s. Confocal microscopy examination showed that plasma treatment has mediated not only cell killing but also varying degrees of physical removal of biofilms. Further investigation and tailored development of atmospheric pressure non-thermal plasma sources for this particular application could provide an additional powerful and effective weapon in the current anti-biofouling armamentarium.

Infrared non-detection of fomalhaut b: Implications for the planet interpretation

The nearby A4-type star Fomalhaut hosts a debris belt in the form of an eccentric ring, which is thought to be caused by dynamical influence from a giant planet companion. In 2008, a detection of a point source inside the inner edge of the ring was reported and was interpreted as a direct image of the planet, named Fomalhaut b. The detection was made at 600-800nm, but no corresponding signatures were found in the near-infrared range, where the bulk emission of such a planet should be expected. Here, we present deep observations of Fomalhaut with Spitzer/IRAC at 4.5 µm, using a novel point-spread function subtraction technique based on angular differential imaging and Locally Optimized Combination of Images, in order to substantially improve the Spitzer contrast at small separations. The results provide more than an order ofmagnitude improvement in the upper flux limit of Fomalhaut b and exclude the possibility that any flux from a giant planet surface contributes to the observed flux at visible wavelengths. This renders any direct connection between the observed light source and the dynamically inferred giant planet highly unlikely. We discuss several possible interpretations of the total body of observations of the Fomalhaut system and find that the interpretation that best matches the available data for the observed source is scattered light from a transient or semi-transient dust cloud. © 2012 The American Astronomical Society. All rights reserved.

A light microscopic and autoradiographic study of non-irradiated and irradiated ocular wounds

Focal gamma irradiation was used to limit the intraocular extension of scar tissue which typically occurs after posterior perforating injury to the eye. Standard posterior perforating injuries were created in the right eye of forty-eight rabbits, half of which had the site of perforation focally irradiated using a Cobalt 60 ophthalmic plaque. Non-irradiated wounds healed with profuse formation of highly cellular and vascularised granulation tissue which invaded the vitreous to form contractile vitreo-retinal membranes. In irradiated eyes vitreo-retinal membrane formation was infrequent; the wounds showing only sparse granulation tissue with little or no extension into the vitreous cavity. Autoradiographic studies carried out in a second group of 40 animals showed that the episclera was the main source of the proliferating fibroblasts, and cell counts confirmed that the inflammatory and repair responses in irradiated wounds were both delayed and attenuated.

Dose, dose-rate and field size effects on cell survival following exposure to non-uniform radiation fields

For the delivery of intensity-modulated radiation therapy (IMRT), highly modulated fields are used to achieve dose conformity across a target tumour volume. Recent in vitro evidence has demonstrated significant alterations in cell survival occurring out-of-field which cannot be accounted for on the basis of scattered dose. The radiobiological effect of area, dose and dose-rate on out-of-field cell survival responses following exposure to intensity-modulated radiation fields is presented in this study. Cell survival was determined by clonogenic assay in human prostate cancer (DU-145) and primary fibroblast (AG0-1522) cells following exposure to different modulated field configurations delivered using a X-Rad 225 kVp x-ray source. Uniform survival responses were compared to in- and out-of-field responses in which 25-99% of the cell population was shielded. Dose delivered to the out-of-field region was varied from 1.6-37.2% of that delivered to the in-field region using different levels of brass shielding. Dose rate effects were determined for 0.2-4 Gy min⁻¹ for uniform and modulated exposures with no effect seen in- or out-of-field. Survival responses showed little dependence on dose rate and area in- and out-of-field with a trend towards increased survival with decreased in-field area. Out-of-field survival responses were shown to scale in proportion to dose delivered to the in-field region and also local dose delivered out-of-field. Mathematical modelling of these findings has shown survival response to be highly dependent on dose delivered in- and out-of-field but not on area or dose rate. These data provide further insight into the radiobiological parameters impacting on cell survival following exposure to modulated irradiation fields highlighting the need for refinement of existing radiobiological models to incorporate non-targeted effects and modulated dose distributions.

A new look at dual-hop relaying: Performance limits with hardware impairments

Physical transceivers have hardware impairments that create distortions which degrade the performance of communication systems. The vast majority of technical contributions in the area of relaying neglect hardware impairments and, thus, assume ideal hardware. Such approximations make sense in low-rate systems, but can lead to very misleading results when analyzing future high-rate systems. This paper quantifies the impact of hardware impairments on dual-hop relaying, for both amplify-and-forward and decode-and-forward protocols. The outage probability (OP) in these practical scenarios is a function of the effective end-to-end signal-to-noise-and-distortion ratio (SNDR). This paper derives new closed-form expressions for the exact and asymptotic OPs, accounting for hardware impairments at the source, relay, and destination. A similar analysis for the ergodic capacity is also pursued, resulting in new upper bounds. We assume that both hops are subject to independent but non-identically distributed Nakagami-m fading. This paper validates that the performance loss is small at low rates, but otherwise can be very substantial. In particular, it is proved that for high signal-to-noise ratio (SNR), the end-to-end SNDR converges to a deterministic constant, coined the SNDR ceiling, which is inversely proportional to the level of impairments. This stands in contrast to the ideal hardware case in which the end-to-end SNDR grows without bound in the high-SNR regime. Finally, we provide fundamental design guidelines for selecting hardware that satisfies the requirements of a practical relaying system.

Source depletion and extent of melting in the Tongan sub-arc mantle

The fluid immobile High Field Strength Elements (HFSE) Nb and Ta can be used to distinguish between the effects of variable extents of melting and prior source depletion of the Tongan sub-arc mantle. Melting of spinel Iherzolite beneath the Lau Basin back-arc spreading centres has the ability to fractionate Nb from Ta due to the greater compatibility of the latter in clinopyroxene. The identified spatial variation in plate velocities and separation of melt extraction zones, combined with extremely depleted lavas make Tonga an ideal setting in which to test models for arc melt generation and the role of back-arc magmatism. We present new data acquired by laser ablation-ICPMS of fused sample glasses produced without the use of a melt fluxing agent. The results show an arc trend towards strongly sub-chondritic Nb/Ta (

Levels of Arsenic and Other Trace Elements in Southern Libyan Agricultural Irrigated Soil and Non-irrigated Soil Projects

The levels of As and various other trace elements found in the irrigated agricultural soil (Tsoil) of southern Libya were compared with non-irrigated soil (Csoil) from the same sampling campaign collected between April and May 2008. The soil samples represented agronomic practice in the southern Libyan regions of Maknwessa (MAK), Aril (ARL) and Taswaa (TAS), and were analyzed by Inductively coupled plasma mass spectrometry (ICP-MS) for Co, Ni, Cu, Se, Mo, Zn, As, Pb, Cd and P. Concentrations of P and As in TAS and MAK were found to be higher in Tsoil compared to Csoil, while the opposite was true for ARL. In general, As concentrations in these areas were 2-3 times lower than the global average. In ARL, the average P concentrations of the Csoil samples were significantly higher than those of Tsoil samples: this site is composed mainly of pasture for animal production, where phosphate fertilizers are used regularly. Distance from the source of irrigation was found to be of an important influence on the heavy metal concentration of the soil, with greater concentrations found closer to the irrigation source. It can be concluded from the results that irrigation water contains elevated levels of As, which finds its way into the soil profile and can lead to accumulation of As in the soil over time.

From ideal reactor concepts to reality:The novel drum reactor for photocatalytic wastewater treatment

This article reports the development of a novel drum photocatalytic reactor for treating dye effluent streams. The parameters for operation including drum rotation speed, light source distance, catalyst loading and H2O2 doping have been investigated using methylene blue as a model pollutant. Effluent can be generated by a number of domestic and industrial sources, including pharmaceutical, oil and gas, agricultural, food and chemical sectors. The work reported here proposes the application of semiconductor photocatalysis as a final polishing step for the removal of hydrocarbons from effluents sources, initial studies have proved effective in removing residual hydrocarbons from the effluent.

Freedom as non-domination: radicalisation or retreat?

Key challenges for contemporary neorepublicans are identified and explored. Firstly, the attempt to maintain a sharp line between neorepublicanism and the wider family of liberal–egalitarian political theories is questioned. Secondly, in response to challenges from democratic theorists, it is argued that republicanism needs to effect an appropriate rapprochement with the ideal of collective political autonomy, on which it appears to rely. Thirdly, it is argued that freedom as non-domination draws so heavily on the idea of equal respect that it is hard to maintain that freedom is the sole value grounding the theory. Finally, it is suggested that the consequentialist framework of Pettit’s theory imposes significant limitations on republican social justice. How republican political theorists respond to these challenges will determine whether the neorepublican revival will be seen as enriching contemporary debates about democracy and social justice or as a retreat from more ambitious accounts of freedom and justice.

Non-equilibrium modeling of the FE XVII 3C/3D Line Ratio in an Intense X-ray Free-electron Laser Excited Plasma

Recent measurements using an X-ray Free Electron Laser (XFEL) and an Electron Beam Ion Trap at the Linac Coherent Light Source facility highlighted large discrepancies between the observed and theoretical values for the Fe XVII 3C/3D line intensity ratio. This result raised the question of whether the theoretical oscillator strengths may be significantly in error, due to insufficiencies in the atomic structure calculations. We present time-dependent spectral modeling of this experiment and show that non-equilibrium effects can dramatically reduce the predicted 3C/3D line intensity ratio, compared with that obtained by simply taking the ratio of oscillator strengths. Once these non-equilibrium effects are accounted for, the measured line intensity ratio can be used to determine a revised value for the 3C/3D oscillator strength ratio, giving a range from 3.0 to 3.5. We also provide a framework to narrow this range further, if more precise information about the pulse parameters can be determined. We discuss the implications of the new results for the use of Fe XVII spectral features as astrophysical diagnostics and investigate the importance of time-dependent effects in interpreting XFEL-excited plasmas.

A high-energy, high-flux source of gamma-rays from all-optical nonlinear Thomson scattering

γ-Ray sources are among the most fundamental experimental tools currently available to modern physics. As well as the obvious benefits to fundamental research, an ultra-bright source of γ-rays could form the foundation of scanning of shipping containers for special nuclear materials and provide the bases for new types of cancer therapy.

However, for these applications to prove viable, γ-ray sources must become compact and relatively cheap to manufacture. In recent years, advances in laser technology have formed the cornerstone of optical sources of high energy electrons which already have been used to generate synchrotron radiation on a compact scale. Exploiting the scattering induced by a second laser, one can further enhance the energy and number of photons produced provided the problems of synchronisation and compact γ-ray detection are solved.

Here, we report on the work that has been done in developing an all-optical and hence, compact non-linear Thomson scattering source, including the new methods of synchronisation and compact γ-ray detection. We present evidence of the generation of multi-MeV (maximum 16–18 MeV) and ultra-high brilliance (exceeding 10²⁰ photons s⁻¹mm⁻²mrad⁻² 0.1% BW at 15 MeV) γ-ray beams. These characteristics are appealing for the paramount practical applications mentioned above.

Quantum criptography in optical fibers

As comunicações quânticas aplicam as leis fundamentais da física quântica para codificar, transmitir, guardar e processar informação. A mais importante e bem-sucedida aplicação é a distribuição de chaves quânticas (QKD). Os sistemas de QKD são suportados por tecnologias capazes de processar fotões únicos. Nesta tese analisamos a geração, transmissão e deteção de fotões únicos e entrelaçados em fibras óticas. É proposta uma fonte de fotões única baseada no processo clássico de mistura de quatro ondas (FWM) em fibras óticas num regime de baixas potências. Implementamos essa fonte no laboratório, e desenvolvemos um modelo teórico capaz de descrever corretamente o processo de geração de fotões únicos. O modelo teórico considera o papel das nãolinearidades da fibra e os efeitos da polarização na geração de fotões através do processo de FWM. Analisamos a estatística da fonte de fotões baseada no processo clássico de FWM em fibras óticas. Derivamos um modelo teórico capaz de descrever a estatística dessa fonte de fotões. Mostramos que a estatística da fonte de fotões evolui de térmica num regime de baixas potências óticas, para Poissoniana num regime de potências óticas moderadas. Validamos experimentalmente o modelo teórico, através do uso de fotodetetores de avalanche, do método estimativo da máxima verossimilhança e do algoritmo de maximização de expectativa. Estudamos o processo espontâneo de FWM como uma fonte condicional de fotões únicos. Analisamos a estatística dessa fonte em termos da função condicional de coerência de segunda ordem, considerando o espalhamento de Raman na geração de pares de fotões, e a perda durante a propagação de fotões numa fibra ótica padrão. Identificamos regimes apropriados onde a fonte é quase ideal. Fontes de pares de fotões implementadas em fibras óticas fornecem uma solução prática ao problema de acoplamento que surge quando os pares de fotões são gerados fora da fibra. Exploramos a geração de pares de fotões através do processo espontâneo de FWM no interior de guias de onda com suceptibilidade elétrica de terceira ordem. Descrevemos a geração de pares de fotões em meios com elevado coeficiente de absorção, e identificamos regimes ótimos para o rácio contagens coincidentes/acidentais (CAR) e para a desigualdade de Clauser, Horne, Shimony, and Holt (CHSH), para o qual o compromisso entre perda do guia de onda e não-linearidades maximiza esses parâmetros.

How hydrogen peroxide and CXCL8 modulate neutrophil recruitment "in vivo"

Tese de doutoramento, Ciências Biomédicas (Biologia Celular e Molecular), Universidade de Lisboa, Faculdade de Medicina, 2014

Using non-invasive techniques to examine black bear (Ursus americanus) abundance in the North Cascades Ecosystem, Washington State

Thesis (Master's)--University of Washington, 2013