A longitudinal qualitative exploration of healthcare and informal support needs among survivors of critical illness: the RELINQUISH protocol.

Introduction and background: Survival following critical illness is associated with a significant burden of physical, emotional and psychosocial morbidity. Recovery can be protracted and incomplete, with important and sustained effects upon everyday life, including family life, social participation and return to work. In stark contrast with other critically ill patient groups (eg, those following cardiothoracic surgery), there are comparatively few interventional studies of rehabilitation among the general intensive care unit patient population. This paper outlines the protocol for a sub study of the RECOVER study: a randomised controlled trial evaluating a complex intervention of enhanced ward-based rehabilitation for patients following discharge from intensive care. Methods and analysis: The RELINQUISH study is a nested longitudinal, qualitative study of family support and perceived healthcare needs among RECOVER participants at key stages of the recovery process and at up to 1 year following hospital discharge. Its central premise is that recovery is a dynamic process wherein patients’ needs evolve over time. RELINQUISH is novel in that we will incorporate two parallel strategies into our data analysis: (1) a pragmatic health services-oriented approach, using an a priori analytical construct, the ‘Timing it Right’ framework and (2) a constructivist grounded theory approach which allows the emergence of new themes and theoretical understandings from the data. We will subsequently use Qualitative Health Needs Assessment methodology to inform the development of timely and responsive healthcare interventions throughout the recovery process. Ethics and dissemination: The protocol has been approved by the Lothian Research Ethics Committee (protocol number HSRU011). The study has been added to the UK Clinical Research Network Database (study ID. 9986). The authors will disseminate the findings in peer reviewed publications and to relevant critical care stakeholder groups.

Do simple ventilation and gas exchange measurements predict early successful weaning from respiratory support in unselected general intensive care patients?

Background. The value of respiratory variables as weaning predictors in the intensive care unit (ICU) is controversial. We evaluated the ability of tidal volume (Vtexp), respiratory rate ( f ), minute volume (MVexp), rapid shallow breathing index ( f/Vt), inspired–expired oxygen concentration difference [(I–E)O2], and end-tidal carbon dioxide concentration (PE′CO2) at the end of a weaning trial to predict early weaning outcomes. Methods. Seventy-three patients who required .24 h of mechanical ventilation were studied. A controlled pressure support weaning trial was undertaken until 5 cm H2O continuous positive airway pressure or predefined criteria were reached. The ability of data from the last 5 min of the trial to predict whether a predefined endpoint indicating discontinuation of ventilator support within the next 24 h was evaluated. Results. Pre-test probability for achieving the outcome was 44% in the cohort (n¼32). Non-achievers were older, had higher APACHE II and organ failure scores before the trial, and higher baseline arterial H+ concentrations. The Vt, MV, f, and f/Vt had no predictive power using a range of cut-off values or from receiver operating characteristic (ROC) analysis. The [I–E]O2 and PE′CO2 had weak discriminatory power [areaunder the ROC curve: [I–E]O2 0.64 (P¼0.03); PE′CO2 0.63 (P¼0.05)]. Using best cut-off values for [I–E]O2 of 5.6% and PE′CO2 of 5.1 kPa, positive and negative likelihood ratios were 2 and 0.5, respectively, which only changed the pre- to post-test probability by about 20%. Conclusions. In unselected ICU patients, respiratory variables predict early weaning from mechanical ventilation poorly.

D3M: multicast listener mobility support mechanisms over distributed mobility anchoring architectures

The explosion in mobile data traffic is a driver for future network operator technologies, given its large potential to affect both network performance and generated revenue. The concept of distributed mobility management (DMM) has emerged in order to overcome efficiency-wise limitations in centralized mobility approaches, proposing not only the distribution of anchoring functions but also dynamic mobility activation sensitive to the applications needs. Nevertheless, there is not an acceptable solution for IP multicast in DMM environments, as the first proposals based on MLD Proxy are prone to tunnel replication problem or service disruption. We propose the application of PIM-SM in mobility entities as an alternative solution for multicast support in DMM, and introduce an architecture enabling mobile multicast listeners support over distributed anchoring frameworks in a network-efficient way. The architecture aims at providing operators with flexible options to provide multicast mobility, supporting three modes: the first one introduces basic IP multicast support in DMM; the second improves subscription time through extensions to the mobility protocol, obliterating the dependence on MLD protocol; and the third enables fast listener mobility by avoiding potentially slow multicast tree convergence latency in larger infrastructures, by benefiting from mobility tunnels. The different modes were evaluated by mathematical analysis regarding disruption time and packet loss during handoff against several parameters, total and tunneling packet delivery cost, and regarding packet and signaling overhead.

Government management of tourism in fostering residents support for sustainable tourism development: Evidence from a Portuguese historic town

This study proposes a conceptual framework that explores the correlations between economic dependence (ED), local government management of tourism (GMT), perceived tourism benefits and costs, and support for sustainable tourism development (STD). A quantitative research design was adopted. Data collection was carried out by personal survey applied to 300 residents of the small historic town of Lamego, located within the Douro Valley World Heritage Site. Structural equation modelling methods were employed to analyse the proposed model. Results suggest that GMT has a significant effect on the perceived impacts of tourism, both in the positive and in the negative. The effect of GMT in fostering residents’ support to STD was also empirically supported. Additionally, it was also determined that positive perceptions of the impacts of tourism directly influence support to STD. Nevertheless, ED does not have a significant effect either on perceivedbenefits, nor on perceived costs or on residents’ support to STD. Likewise, perceptions of the negative impacts do not predict residents’ support to STD.

Characterization of patients undergoing noninvasive ventilation admitted in unit intermediate care

Non-invasive ventilation (NIV) is the application of a ventilatory support without resorting to invasive methods. Today it’s considered a credible therapeutic option, with enough scientiic evidence to support its application in various situations and clinical settings related to the treatment of acute respiratory disease, as well as chronic respiratory disease. Objectives: Characterize patients undergoing NIV admitted in Unit Intermediate Care (ICU) in the period from October 1st 2015 to June 30th 2016. Methods: Prospective study conducted in ICU between October 2015 and June 2016. In this study were included all patients hospitalized in this unit (ICU) and in that time period a sample of 57 participants was obtained. As data collection instruments we used a questionnaire for sociodemographic and clinical data and the Braden scale. Results: Participants were mostly male 38 (66.7%), the average age 69.5 ± 11.3 years, ranging between 43 and 92 years. They weighed on average 76.6 kg (52 and 150), with an average body mass index of 28.5 kg/m2 (20 to 58.5). With skin intact 28 (49.1%) with abnormal perfusion 12 (21.1%), with altered sensitivity 11 (19.3%) and a high risk of ulcer on the scale of Braden 37 (65%). The admission diagnosis was respiratory failure 33 (57.3%) and had different backgrounds. We used reused mask 53 (93.0%), the average time of NIV was 7.1 days (1-28), 4.8 days of hospitalization (1-18) and an average of 7.8 IPAP pressure. 11 (19.3%) of the participants developed face ulcer pressure.Conclusions: The NIV is used in patients with advanced age, obesity, respiratory failure and high risk of face ulcer development.

A Risk Analysis Method to Support Virtual Organization Partners’ Selection

Part 17: Risk Analysis

OUTSOURCING SALARIAL: opción generadora de empleo en la crisis económica actual

Resumen En este artículo se presenta un modelo de reducción de costos para una unidad productiva mediante la opción de outsourcing salarial dentro de la misma organización y que permite simultáneamente disminuir los costos salariales y mantener los derechos de los trabajadores estipulados en la legislación laboral del país. Una opción alternativa en situaciones de crisis económica mundial. Abstract In this article there presents himself a model of reduction of costs for a productive unit by means of the option of wage outsourcing inside the same organization and that allows to diminish simultaneously the wage costs and to support the rights of the workpeople stipulated in the labor legislation of the country. An alternative option in situations of economic world crisis.

Preparation and characterization of grafted nonwoven membranes for bioseparations

Protein purification plays a crucial role in biotechnology and biomanufacturing, where downstream unit operations account for 40%-80% of the overall costs. To overcome this issue, companies strive to simplify the separation process by reducing the number of steps and replacing expensive separation devices. In this context, commercially available polybutylene terephthalate (PBT) melt-blown nonwoven membranes have been developed as a novel disposable membrane chromatography support. The PBT nonwoven membrane is able to capture products and reduce contaminants by ion exchange chromatography. The PBT nonwoven membrane was modified by grafting a poly(glycidyl methacrylate) (GMA) layer by either photo-induced graft polymerization or heat induced graft polymerization. The epoxy groups of GMA monomer were subsequently converted into cation and anion exchangers by reaction with either sulfonic acid groups or diethylamine (DEA), respectively. Several parameters of the procedure were studied, especially the effect of (i) % weight gain and (ii) ligand density on the static protein binding capacity. Bovine Serum Albumin (BSA) and human Immunoglobulin G (hIgG) were utilized as model proteins in the anion and cation exchange studies. The performance of ion exchange PBT nonwovens by HIG was evaluated under flow conditions. The anion- and cation- exchange HIG PBT nonwovens were evaluated for their ability to selectively adsorb and elute BSA or hIgG from a mixture of proteins. Cation exchange nonwovens were not able to reach a good protein separation, whereas anion exchange HIG nonwovens were able to absorb and elute BSA with very high value of purity and yield, in only one step of purification.

Motor Unit Spike Trains Recontruction from sEMG Signals for Gesture Classification on a Low-Power Processing Platform

Hand gesture recognition based on surface electromyography (sEMG) signals is a promising approach for the development of intuitive human-machine interfaces (HMIs) in domains such as robotics and prosthetics. The sEMG signal arises from the muscles' electrical activity, and can thus be used to recognize hand gestures. The decoding from sEMG signals to actual control signals is non-trivial; typically, control systems map sEMG patterns into a set of gestures using machine learning, failing to incorporate any physiological insight. This master thesis aims at developing a bio-inspired hand gesture recognition system based on neuromuscular spike extraction rather than on simple pattern recognition. The system relies on a decomposition algorithm based on independent component analysis (ICA) that decomposes the sEMG signal into its constituent motor unit spike trains, which are then forwarded to a machine learning classifier. Since ICA does not guarantee a consistent motor unit ordering across different sessions, 3 approaches are proposed: 2 ordering criteria based on firing rate and negative entropy, and a re-calibration approach that allows the decomposition model to retain information about previous sessions. Using a multilayer perceptron (MLP), the latter approach results in an accuracy up to 99.4% in a 1-subject, 1-degree of freedom scenario. Afterwards, the decomposition and classification pipeline for inference is parallelized and profiled on the PULP platform, achieving a latency < 50 ms and an energy consumption < 1 mJ. Both the classification models tested (a support vector machine and a lightweight MLP) yielded an accuracy > 92% in a 1-subject, 5-classes (4 gestures and rest) scenario. These results prove that the proposed system is suitable for real-time execution on embedded platforms and also capable of matching the accuracy of state-of-the-art approaches, while also giving some physiological insight on the neuromuscular spikes underlying the sEMG.

Can We Predict The Clinical Outcomes Of Genitourinary Trauma Patients And Offer Them An Evidence-based Support? The Case For Telemedicine Network.

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Hypothermia And Early Neonatal Mortality In Preterm Infants.

To evaluate intervention practices associated with hypothermia at both 5 minutes after birth and at neonatal intensive care unit (NICU) admission and to determine whether hypothermia at NICU admission is associated with early neonatal death in preterm infants. This prospective cohort included 1764 inborn neonates of 22-33 weeks without malformations admitted to 9 university NICUs from August 2010 through April 2012. All centers followed neonatal International Liaison Committee on Resuscitation recommendations for the stabilization and resuscitation in the delivery room (DR). Variables associated with hypothermia (axillary temperature <36.0 °C) 5 minutes after birth and at NICU admission, as well as those associated with early death, were analyzed by logistic regression. Hypothermia 5 minutes after birth and at NICU admission was noted in 44% and 51%, respectively, with 6% of early neonatal deaths. Adjusted for confounding variables, practices associated with hypothermia at 5 minutes after birth were DR temperature <25 °C (OR 2.13, 95% CI 1.67-2.28), maternal temperature at delivery <36.0 °C (OR 1.93, 95% CI 1.49-2.51), and use of plastic bag/wrap (OR 0.53, 95% CI 0.40-0.70). The variables associated with hypothermia at NICU admission were DR temperature <25 °C (OR 1.44, 95% CI 1.10-1.88), respiratory support with cold air in the DR (OR 1.40, 95% CI 1.03-1.88) and during transport to NICU (OR 1.51, 95% CI 1.08-2.13), and cap use (OR 0.55, 95% CI 0.39-0.78). Hypothermia at NICU admission increased the chance of early neonatal death by 1.64-fold (95% CI 1.03-2.61). Simple interventions, such as maintaining DR temperature >25 °C, reducing maternal hypothermia prior to delivery, providing plastic bags/wraps and caps for the newly born infants, and using warm resuscitation gases, may decrease hypothermia at NICU admission and improve early neonatal survival.

Factors Associated With Reporting Of Abuse Against Children And Adolescents By Nurses Within Primary Health Care.

to analyze the factors associated with the underreporting on the part of nurses within Primary Health Care of abuse against children and adolescents. cross-sectional study with 616 nurses. A questionnaire addressed socio-demographic data, profession, instrumentation and knowledge on the topic, identification and reporting of abuse cases. Bivariate and multivariate logistic regression was used. female nurses, aged between 21 and 32 years old, not married, with five or more years since graduation, with graduate studies, and working for five or more years in PHC predominated. The final regression model showed that factors such as working for five or more years, having a reporting form within the PHC unit, and believing that reporting within Primary Health Care is an advantage, facilitate reporting. the study's results may, in addition to sensitizing nurses, support management professionals in establishing strategies intended to produce compliance with reporting as a legal device that ensures the rights of children and adolescents.

Matrix Support And Institutional Support: Analyzing Their Construction.

This is an analysis of the theoretical and practical construction of the methodology of Matrix Support by means of studies on Paideia Support (Institutional and Matrix Support), which is an inter-professional work of joint care in recent literature and official documents of the Unified Health System (SUS). An attempt was made to describe methodological concepts and strategies. A comparative analysis of Institutional Support and Matrix Support was also conducted using the epistemological framework of Field and Core Knowledge and Practices.

Modelos de transferência de metal pesado na cana-de-açúcar adubada com composto de lixo urbano

The research approaches recycling of urban waste compost (UWC) as an alternative fertilizer for sugarcane crop and as a social and environmental solution to the solids residuals growth in urban centers. A mathematical model was used in order to know the metal dynamics as decision support tool, aiming to establish of criteria and procedures for UWC's safe use, limited by the amount of heavy metal. A compartmental model was developed from experimental data in controlled conditions and partially checked with field data. This model described the heavy metal transference in the system soil-root-aerial portion of sugarcane plants and concluded that nickel was metal to be concern, since it takes approximately three years to be attenuated in the soil, reaching the aerial portions of the plant at high concentrations. Regarding factors such as clay content, oxide level and soil pH, it was observed that for soil with higher buffering capacity, the transfer of the majority of the metals was slower. This model may become an important tool for the attainment of laws regarding the UWC use, aiming to reduce environment contamination the waste accumulation and production costs.

Fatores associados à maior mortalidade e tempo de internação prolongado em uma unidade de terapia intensiva de adultos

OBJECTIVE: The intensive care unit is synonymous of high severity, and its mortality rates are between 5.4 and 33%. With the development of new technologies, a patient can be maintained for long time in the unit, causing high costs, psychological and moral for all involved. This study aimed to evaluate the risk factors for mortality and prolonged length of stay in an adult intensive care unit. METHODS: The study included all patients consecutively admitted to the adult medical/surgical intensive care unit of Hospital das Clínicas da Universidade Estadual de Campinas, for six months. We collected data such as sex, age, diagnosis, personal history, APACHE II score, days of invasive mechanical ventilation orotracheal reintubation, tracheostomy, days of hospitalization in the intensive care unit and discharge or death in the intensive care unit. RESULTS: Were included in the study 401 patients; 59.6% men and 40.4% women, age 53.8±18.0. The mean intensive care unit stay was 8.2±10.8 days, with a mortality rate of 13.5%. Significant data for mortality and prolonged length of stay in intensive care unit (p <0.0001), were: APACHE II>11, OT-Re and tracheostomy. CONCLUSION: The mortality and prolonged length of stay in intensive care unit intensive care unit as risk factors were: APACHE>11, orotracheal reintubation and tracheostomy.