ECG interpretation during the acute phase of coronary syndromes: in need of improvement?

QUESTION UNDER STUDY: Emergency room (ER) interpretation of the ECG is critical to assessment of patients with acute coronary syndromes (ACS). Our aim was to assess its reliability in our institution, a tertiary teaching hospital. METHODS: Over a 6-month period all consecutive patients admitted for ACS were included in the study. ECG interpretation by emergency physicians (EPs) was recorded on a preformatted sheet and compared with the interpretation of two specialist physicians (SPs). Discrepancies between the 2 specialists were resolved by an ECG specialist. RESULTS: Over the 6-month period, 692 consecutive patients were admitted with suspected ACS. ECG interpretation was available in 641 cases (93%). Concordance between SPs was 87%. Interpretation of normality or abnormality of the ECG was concordant between EPs and SPs in 475 cases (74%, kappa = 0.51). Interpretation of ischaemic modifications was concordant in 69% of cases, and as many ST segment elevations were unrecognised as overdiagnosed (5% each). The same findings occurred for ST segment depressions and negative T waves (12% each). CONCLUSIONS: Interpretation of the ECG recorded during ACS by 2 SPs was discrepant in 13% of cases. Similarly, EP interpretation was discrepant from SP interpretation in 25% of cases, equally distributed between over- and underdiagnosing of ischaemic changes. The clinical implications and impact of medical education on ECG interpretation require further study.

Proposed Improvement of the Iowa State Capitol Grounds, An Address before the Iowa Chapter American Institute of Architects at the State Historical Buiding, Des Moines, Iowa, October 22, 1913.

Concerning improvements to the State Capitol Grounds including placement of the Allison memorial and Soldiers and Sailor's momuments; removal of heating plant and relieving the state of coal, ashes, gas and smoke; provision of office space to the Adjutant General; an eventual executive mansion; provision of office buildings; and for a Supreme Court building where together with its library auxiliaries will have perpetual growth and constant accessbility; and propose restoration of natural scenic value of the capitol site.

Facilitating coordination improvement efforts in cross-functional process development programs

Business process improvement is a common approach in increasing the effectiveness of an organization. It can be seen as an effort to increase coordination between units. Process improvement has proved to be challenging, and most management consultation firms facilitate organizations in this kind of initiatives. Cross-functional improvement is one of the main areas for internal consultants as well. However, the needs, challenges and means of cross-functional help have been rarely discussed in the literature. The objective of this thesis is on one hand to present a conceptual and descriptive framework to help understand the challenges of facilitating coordination improvement efforts in cross-functional improvement programs, and on the other hand to develop and test feasible solutions for some facilitation situations. The research questions are: 1. Why and in what kind of situations do organizations need help in developing coordination in cross-functional processes? 2. How can a facilitator help organizations in improving coordination to develop cross-functional processes? The study consists of two parts. The first part is an overview of the dissertation, and the second part comprises six research publications. The theoretical background for the study are the differentiation causing challenges in cross-functional settings, the coordination needed to improve processes, change management principles, methods and tools, and consultation practises. Three of the publications introduce tools for helping in developing prerequisites, planning responsibilities and supporting learning during the cross-functional program. The three other papers present frameworks to help understand and analyse the improvement situation. The main methodological approaches used in this study are design science research, action research and case research. The research data has been collected from ten cases representing different kinds of organizations, processes and developing situations. The data has been collected mainly by observation, semi-structured interviews and questionnaires. The research contributes to the rare literature combining coordination theories and process improvement practises. It also provides additional understanding of a holistic point of view in process improvement situations. The most important contribution is the addition to the theories of facilitating change in process improvement situations. From the managerial point of view, this study gives advice to managers and consultants in planning and executing cross-functional programs. The main factors increasing the need for facilitation are the challenges for differentiation, challenges of organizational change in general, and the novelty of initiatives and improvement practices concerning process development. Organizations need help in creating the prerequisites to change, in planning initiatives, easing conflict management and collaboration between groups, as well as supporting the learning of cross-functional improvement. The main challenges of facilitation are combining the different roles as a consultant, maintaining the ownership for the improvement project with the client, and supporting learning in the client organization.

The improvement of enclosure protection class of power electronics device

Tässä diplomityössä tutkittiin vaihtoehtoja tehoelektroniikkalaitteiden kotelointiluokan kehittämiseksi. Haasteena paremman suojauksen suunnittelussa on laitteiden tuottama suuri määrä lämpöä, joka vaatii tehokkaan jäähdytyksen. Työn tuloksena saatu prototyyppi IP33 luokkaa varten täyttää standardissa SFS-EN 60529+A1 asetetut vaatimukset kyseiselle kotelointiluokalle. Rakenteessa ja valmistettavuudessa havaittiin muutama ongelma, jotka ovat korjattavissa pienillä muutoksilla. Korkeampia suojausluokkia varten testattiin IP54-luokiteltujen filtterituulettimien vaikutusta laitteen jäähdytykseen. Testien perusteella jäähdytysteho on riittävä ja filtterituulettimet todettiin toimivaksi ratkaisuksi korkeammille suojausluokille. Työn perusteella voidaan todeta, että nykyiset laitteet voidaan muokata vastaamaan IP33 luokan vaatimuksia kohtuullisen pienillä muutoksilla. Tätä korkeammat suojausluokat vaatisivat niin suuria muutoksia designiin, että todennäköisesti täysin uuden laitteen suunnittelu olis kannattavin vaihtoehto.

Evaluating the Norfolk physical education program with respect to fitness-level improvement

The grades seven and eight physical education program of the Norfolk Board of Education was evaluated with respect to fitnesslevel improvement, an objective of the Ministry of Education for the province of Ontario. The Canada Fitness Award battery of fitness tests was used to measure fitness levels. It was established that in September the students were unfit, and in May they were fit. This indicated that the Norfolk physical education program was effective, with respect to the criterion used for this research. In addition, it was discovered that fitness-level improvement was significantly related to certain variables: teacher qualifications, teaching experience, school, and participation in extracurricular physical activity. Considering the results of the research, it was recommended that the Norfolk Board of Education hire young, qualified physical education teachers; create the position of Physical Education Consultant; and strive to create equitable resources for physical education instruction, in order that the school to which a student belongs no longer will be a determinant of fitness improvement.

Imagery or video feedback : which is the "route" to strategic improvement?

The implementation of imagery and video feedback programs has become an important tool for aiding athletes in achieving peak performance (Halliwell, 1990). The purpose of the study was to determine the effect of strategic imagery training and video feedback on immediate performance. Participants were two university goaltenders. An alternating treatment design (ATD; Barlow & Hayes, 1979; Tawney & Gast, 1984) was employed. The strategies were investigated using three plays originating from the right side by a right-handed shooting defenceman from the blueline. The baseline condition consisted of six practices and was used to establish a stable and "ideal" measure of performance. The intervention conditions included alternating the use of strategic imagery (Cognitive general; Paivio, 1985) and video feedback. Both participants demonstrated an increase in the frequency of Cognitive general use. Specific and global performance measures were assessed to determine the relative effectiveness of the interventions. Poor inter-rater reliability resulted in the elimination of specific performance measures. Consequently, only the global measure (i.e., save percentage) was used in subsequent analyses. Visual inspection of participant save percentage was conducted to determine the benefits of the intervention. Strategic imagery training resulted in performance improvements for both participants. Video feedback facilitated performance for Participant 2, but not Participant 1. Results are discussed with respect to imagery and video interventions and the challenges associated with applied research. KEYWORDS: imagery, video, goaltenders, alternating treatment design.

Benefits of Using Target Activities to Assist in Improvement of Striking in Striking and Fielding Games for Individuals with Autism: A Comparative Case Study

The purpose of the research study was to increase understanding about the potential benefits of combining target activities with striking-fielding games for individuals with high functioning autism spectrum disorder. A comparative case study was conducted to understand if target activities can assist in improving the skills of striking and throwing, aid the learning of tactics and add to current understanding of how certain teaching skills might be linked to the transfer between target and striking-fielding games. Data was collected through observations, student journals and interviews and were analyzed using both inductive and deductive methods. Results show an appearance of improvement in throwing, striking, bowling and badminton for overall skill levels. In regards to teaching skills, appropriate and effective teaching techniques, appropriate and effective equipment, dynamic of participants and student-instructors and consistency of attendance are vital. Future research should further look at the transferability to outdoor settings and interview the participants.

Process Improvement in Phlebotomy

This study has two main objectives. First, the phlebotomy process at the St. Catharines Site of the Niagara Health System is investigated, which starts when an order for a blood test is placed, and ends when the specimen arrives at the lab. The performance measurement is the flow time of the process, which reflects concerns and interests of both the hospital and the patients. Three popular operational methodologies are applied to reduce the flow time and improve the process: DMAIC from Six Sigma, lean principles and simulation modeling. Potential suggestions are provided for the St. Catharines Site, which could result in an average of seven minutes reduction in the flow time. The second objective addresses the fact that these three methodologies have not been combined before in a process improvement effort. A structured framework combining them is developed to benefit future study of phlebotomy and other hospital processes.

Livestock Handling Needs Improvement

The article discusses problems with the handling of livestock and the conclusion of the article states "rough handling of livestock is not only inhumane, but can cause excessive losses due to sickness and slower growth...careful handling of livestock in all phases of production is prerequisite to a profitable business".

Morphophysiological traits in crop improvement case study-sorghum [by] Ratikanta Maiti; ed. [by] Pedro A. Wesche-Ebeling, Manuel Rojas Garcidueñas [and] Paul R. Earl

UANL

The elementary spelling book being an improvement on the American Spelling-book

UANL

Limited sampling strategies for estimation of cyclosporine exposure in pediatric hematopoietic stem cell transplant recipients : methodological improvement and introduction of sampling time deviation analysis.

Le suivi thérapeutique est recommandé pour l’ajustement de la dose des agents immunosuppresseurs. La pertinence de l’utilisation de la surface sous la courbe (SSC) comme biomarqueur dans l’exercice du suivi thérapeutique de la cyclosporine (CsA) dans la transplantation des cellules souches hématopoïétiques est soutenue par un nombre croissant d’études. Cependant, pour des raisons intrinsèques à la méthode de calcul de la SSC, son utilisation en milieu clinique n’est pas pratique. Les stratégies d’échantillonnage limitées, basées sur des approches de régression (R-LSS) ou des approches Bayésiennes (B-LSS), représentent des alternatives pratiques pour une estimation satisfaisante de la SSC. Cependant, pour une application efficace de ces méthodologies, leur conception doit accommoder la réalité clinique, notamment en requérant un nombre minimal de concentrations échelonnées sur une courte durée d’échantillonnage. De plus, une attention particulière devrait être accordée à assurer leur développement et validation adéquates. Il est aussi important de mentionner que l’irrégularité dans le temps de la collecte des échantillons sanguins peut avoir un impact non-négligeable sur la performance prédictive des R-LSS. Or, à ce jour, cet impact n’a fait l’objet d’aucune étude. Cette thèse de doctorat se penche sur ces problématiques afin de permettre une estimation précise et pratique de la SSC. Ces études ont été effectuées dans le cadre de l’utilisation de la CsA chez des patients pédiatriques ayant subi une greffe de cellules souches hématopoïétiques. D’abord, des approches de régression multiple ainsi que d’analyse pharmacocinétique de population (Pop-PK) ont été utilisées de façon constructive afin de développer et de valider adéquatement des LSS. Ensuite, plusieurs modèles Pop-PK ont été évalués, tout en gardant à l’esprit leur utilisation prévue dans le contexte de l’estimation de la SSC. Aussi, la performance des B-LSS ciblant différentes versions de SSC a également été étudiée. Enfin, l’impact des écarts entre les temps d’échantillonnage sanguins réels et les temps nominaux planifiés, sur la performance de prédiction des R-LSS a été quantifié en utilisant une approche de simulation qui considère des scénarios diversifiés et réalistes représentant des erreurs potentielles dans la cédule des échantillons sanguins. Ainsi, cette étude a d’abord conduit au développement de R-LSS et B-LSS ayant une performance clinique satisfaisante, et qui sont pratiques puisqu’elles impliquent 4 points d’échantillonnage ou moins obtenus dans les 4 heures post-dose. Une fois l’analyse Pop-PK effectuée, un modèle structural à deux compartiments avec un temps de délai a été retenu. Cependant, le modèle final - notamment avec covariables - n’a pas amélioré la performance des B-LSS comparativement aux modèles structuraux (sans covariables). En outre, nous avons démontré que les B-LSS exhibent une meilleure performance pour la SSC dérivée des concentrations simulées qui excluent les erreurs résiduelles, que nous avons nommée « underlying AUC », comparée à la SSC observée qui est directement calculée à partir des concentrations mesurées. Enfin, nos résultats ont prouvé que l’irrégularité des temps de la collecte des échantillons sanguins a un impact important sur la performance prédictive des R-LSS; cet impact est en fonction du nombre des échantillons requis, mais encore davantage en fonction de la durée du processus d’échantillonnage impliqué. Nous avons aussi mis en évidence que les erreurs d’échantillonnage commises aux moments où la concentration change rapidement sont celles qui affectent le plus le pouvoir prédictif des R-LSS. Plus intéressant, nous avons mis en exergue que même si différentes R-LSS peuvent avoir des performances similaires lorsque basées sur des temps nominaux, leurs tolérances aux erreurs des temps d’échantillonnage peuvent largement différer. En fait, une considération adéquate de l'impact de ces erreurs peut conduire à une sélection et une utilisation plus fiables des R-LSS. Par une investigation approfondie de différents aspects sous-jacents aux stratégies d’échantillonnages limités, cette thèse a pu fournir des améliorations méthodologiques notables, et proposer de nouvelles voies pour assurer leur utilisation de façon fiable et informée, tout en favorisant leur adéquation à la pratique clinique.

Low Temperature Curing of NBR for Property Improvement

Zinc salts of ethyl, isopropyl, and butyl xanthates are prepared in the laboratory, and the effect of these xanthates with zinc diethyl dithiocarbamate (ZDC) on the vulcanization of HAF-filled nitrile butadiene rubber (NBR) compounds has been studied at different temperatures. The cure times of these compounds have been compared with that of NBR compounds containing TMTD/MBTS. The rubber compounds with the three xanthate accelerators and ZDC are cured at various temperatures from 60 to 150°C. The sheets are molded and properties such as tensile strength, tear strength, cross-link density, elongation at break, compression set, abrasion resistance, flex resistance, etc. have been evaluated. The properties show that zinc salt of the xanthate/ZDC accelerator system has a positive synergistic effect on the cure rate and mechanical properties of NBR compounds.

Starved Extrusion for the Improvement of Mechanical Properties of Rubber Vulcanizates

Filled compounds of natural rubber, isobutylene-isoprene rubber and styrene-butadiene rubber compounds were extruded through a laboratory extruder by varying the feeding rate at different temperatures and revolutions per minute. The extruded compounds were vulcanized up to their optimum cure times and the mechanical properties of the vulcanizates were determined. The properties suggest that there is a particular feeding rate in the starved fed region which results in maximum mechanical properties. The study shows that running the extruder at a slightly starved condition is an attractive means of improving the physical properties.

Performance improvement of multiple Connections in AODV with the concern of Node bandwidth

Mobile Ad-hoc Networks (MANETS) consists of a collection of mobile nodes without having a central coordination. In MANET, node mobility and dynamic topology play an important role in the performance. MANET provide a solution for network connection at anywhere and at any time. The major features of MANET are quick set up, self organization and self maintenance. Routing is a major challenge in MANET due to it’s dynamic topology and high mobility. Several routing algorithms have been developed for routing. This paper studies the AODV protocol and how AODV is performed under multiple connections in the network. Several issues have been identified. The bandwidth is recognized as the prominent factor reducing the performance of the network. This paper gives an improvement of normal AODV for simultaneous multiple connections under the consideration of bandwidth of node.