Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children (Review)

Abstract
Background: Automated closed loop systems may improve adaptation of the mechanical support to a patient's ventilatory needs and
facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of
ventilation.

Objectives: To compare the duration of weaning from mechanical ventilation for critically ill ventilated adults and children when managed
with automated closed loop systems versus non-automated strategies. Secondary objectives were to determine differences
in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); MEDLINE (OvidSP) (1948 to August 2011); EMBASE (OvidSP) (1980 to August 2011); CINAHL (EBSCOhost) (1982 to August 2011); and the Latin American and Caribbean Health Sciences Literature (LILACS). In addition we received and reviewed auto-alerts for our search strategy in MEDLINE, EMBASE, and CINAHL up to August 2012. Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles.

Selection criteria: We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning
strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an intensive care unit (ICU).

Data collection and analysis: Two authors independently extracted study data and assessed risk of bias. We combined data into forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria.

Main results: Pooled data from 15 eligible trials (14 adult, one paediatric) totalling 1173 participants (1143 adults, 30 children) indicated that automated closed loop systems reduced the geometric mean duration of weaning by 32% (95% CI 19% to 46%, P =0.002), however heterogeneity was substantial (I2 = 89%, P < 0.00001). Reduced weaning duration was found with mixed or
medical ICU populations (43%, 95% CI 8% to 65%, P = 0.02) and Smartcare/PS™ (31%, 95% CI 7% to 49%, P = 0.02) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (17%, 95% CI 8% to 26%) and ICU length of stay (LOS) (11%, 95% CI 0% to 21%). There was no difference in mortality rates or hospital LOS. Overall the quality of evidence was high with the majority of trials rated as low risk.

Authors' conclusions: Automated closed loop systems may result in reduced duration of weaning, ventilation, and ICU stay. Reductions are more
likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized
controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.

Retinal vascular geometry predicts incident renal dysfunction in young people with type 1 diabetes

OBJECTIVE - To examine the relationship between retinal vascular geometry parameters and development of incident renal dysfunction in young people with type 1 diabetes. RESEARCH DESIGN AND METHODS - This was a prospective cohort study of 511 adolescents with type 1 diabetes of at least 2 years duration, with normal albumin excretion rate (AER) and no retinopathy at baseline while attending an Australian tertiary-care hospital. AER was quantified using three overnight, timed urine specimen collections and early renal dysfunction was defined as AER >7.5 µg/min. Retinal vascular geometry (including length-to-diameter ratio [LDR] and simple tortuosity [ST]) was quantified from baseline retinal photographs. Generalized estimating equations were used to examine the relationship between incident renal dysfunction and baseline venular LDR and ST, adjusting for age, diabetes duration, glycated hemoglobin (A1C), blood pressure (BP), BMI, and cholesterol. RESULTS - Diabetes duration at baseline was 4.8 (IQR 3.3-7.5) years. After amedian 3.7 (2.3-5.7) years follow-up, 34% of participants developed incident renal dysfunction. In multivariate analysis, higher retinal venular LDR (odds ratio 1.7, 95% CI 1.2-2.4; quartile 4 vs. 1-3) and lower venular ST (1.6, 1.1-2.2; quartile 1 vs. 2-4) predicted incident renal dysfunction. CONCLUSIONS - Retinal venular geometry independently predicted incident renal dysfunction in young people with type 1 diabetes. These noninvasive retinal measures may help to elucidate early mechanistic pathways for microvascular complications. Retinal venular geometry may be a useful tool to identify individuals at high risk of renal disease early in the course of diabetes. © 2012 by the American Diabetes Association.

Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: a cochrane systematic review and meta-analysis

IntroductionAutomated weaning systems may improve adaptation of mechanical support for a patient’s ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. Our objective was to compare mechanical ventilator weaning duration for critically ill adults and children when managed with automated systems versus non-automated strategies. Secondary objectives were to determine differences in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events.MethodsElectronic databases were searched to 30 September 2013 without language restrictions. We also searched conference proceedings; trial registration websites; and article reference lists. Two authors independently extracted data and assessed risk of bias. We combined data using random-effects modelling.ResultsWe identified 21 eligible trials totalling 1,676 participants. Pooled data from 16 trials indicated that automated systems reduced the geometric mean weaning duration by 30% (95% confidence interval (CI) 13% to 45%), with substantial heterogeneity (I2 = 87%, P <0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not with surgical populations or using other systems. Automated systems reduced ventilation duration with no heterogeneity (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of effect on mortality, hospital LOS, reintubation, self-extubation and non-invasive ventilation following extubation. Automated systems reduced prolonged mechanical ventilation and tracheostomy. Overall quality of evidence was high.ConclusionsAutomated systems may reduce weaning and ventilation duration and ICU stay. Due to substantial trial heterogeneity an adequately powered, high quality, multi-centre randomized controlled trial is needed.

Automated versus non-automated weaning for reducing the duration of mechanical ventilation in critically ill adults & children (Review)

Background Automated closed loop systems may improve adaptation of mechanical support for a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. This review was originally published in 2013 with an update published in 2014. Objectives The primary objective for this review was to compare the total duration of weaning from mechanical ventilation, defined as the time from study randomization to successful extubation (as defined by study authors), for critically ill ventilated patients managed with an automated weaning system versus no automated weaning system (usual care). Secondary objectives for this review were to determine differences in the duration of ventilation, intensive care unit (ICU) and hospital lengths of stay (LOS), mortality, and adverse events related to early or delayed extubation with the use of automated weaning systems compared to weaning in the absence of an automated weaning system. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8); MEDLINE (OvidSP) (1948 to September 2013); EMBASE (OvidSP) (1980 to September 2013); CINAHL (EBSCOhost) (1982 to September 2013); and the Latin American and Caribbean Health Sciences Literature (LILACS). Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles. The original search was run in August 2011, with database auto-alerts up to August 2012. Selection criteria We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an ICU. Data collection and analysis Two authors independently extracted study data and assessed risk of bias. We combined data in forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria. Main results We included 21 trials (19 adult, two paediatric) totaling 1676 participants (1628 adults, 48 children) in this updated review. Pooled data from 16 eligible trials reporting weaning duration indicated that automated closed loop systems reduced the geometric mean duration of weaning by 30% (95% confidence interval (CI) 13% to 45%), however heterogeneity was substantial (I2 = 87%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of an effect on mortality rates, hospital LOS, reintubation rates, self-extubation and use of non-invasive ventilation following extubation. Prolonged mechanical ventilation > 21 days and tracheostomy were reduced in favour of automated systems (relative risk (RR) 0.51, 95% CI 0.27 to 0.95 and RR 0.67, 95% CI 0.50 to 0.90 respectively). Overall the quality of the evidence was high with the majority of trials rated as low risk. Authors' conclusions Automated closed loop systems may result in reduced duration of weaning, ventilation and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.

Propagation modelling and measurements in a populated indoor environment at 5.2 GHz

Human occupants within indoor environments are not always stationary and their movement will lead to temporal channel variations that strongly affect the quality of indoor wireless communication systems. This paper describes a statistical channel characterization, based on experimental measurements, of human body effects on line-of-sight indoor narrowband propagation at 5.2 GHz. The analysis shows that, as the number of pedestrians within the measurement location increases, the Ricean K-factor that best fits the empirical data tends to decrease proportionally, ranging from K=7 with 1 pedestrian to K=0 with 4 pedestrians. Level crossing rate results were Rice distributed, while average fade duration results were significantly higher than theoretically computed Rice and Rayleigh, due to the fades caused by pedestrians. A novel CDF that accurately characterizes the 5.2 GHz channel in the considered indoor environment is proposed. For the first time, the received envelope CDF is explicitly described in terms of a quantitative measurement of pedestrian traffic within the indoor environment.

Comprehensive numerical modelling of the performance of a second harmonic generation stage coupled with a low-gain optical parametric amplifier

We present a comprehensive model for predicting the full performance of a second harmonic generation-optical parametric amplification system that aims at enhancing the temporal contrast of laser pulses. The model simultaneously takes into account all the main parameters at play in the system such as the group velocity mismatch, the beam divergence, the spectral content, the pump depletion, and the length of the nonlinear crystals. We monitor the influence of the initial parameters of the input pulse and the interdependence of the two related non-linear processes on the performance of the system and show its optimum configuration. The influence of the initial beam divergence on the spectral and the temporal characteristics of the generated pulse is discussed. In addition, we show that using a crystal slightly longer than the optimum length and introducing small delay between the seed and the pump ensures maximum efficiency and compensates for the spectral shift in the optical parametric amplification stage in case of chirped input pulse. As an example, calculations for bandwidth transform limited and chirped pulses of sub-picosecond duration in beta barium borate crystal are presented.

Modelling the airline costs of delay propagation

Reactionary delays constitute nearly half of all delay minutes in Europe. A capped, multi-component model is presented for estimating reactionary delay costs, as a non-linear function of primary delay duration. Maximum Take-Off Weights, historically established as a charging mechanism, may be used to model delay costs. Current industry reporting on delay is flight-centric. Passenger-centric metrics are needed to better understand delay propagation. In ATM, it is important to take account of contrasting flight- and passenger-centric effects, caused by cancellations, for example. Costs to airlines and passenger disutility will both continue to be driven by delay relative to the original schedule.

Analytical modelling of bacterial migration and accumulation with rate-limited sorption in discrete fractures

An analytical model for bacterial accumulation in a discrete fractllre has been developed. The transport and accumlllation processes incorporate into the model include advection, dispersion, rate-limited adsorption, rate-limited desorption, irreversible adsorption, attachment, detachment, growth and first order decay botl1 in sorbed and aqueous phases. An analytical solution in Laplace space is derived and nlln1erically inverted. The model is implemented in the code BIOFRAC vvhich is written in Fortran 99. The model is derived for two phases, Phase I, where adsorption-desorption are dominant, and Phase II, where attachment-detachment are dominant. Phase I ends yvhen enollgh bacteria to fully cover the substratllm have accllillulated. The model for Phase I vvas verified by comparing to the Ogata-Banks solution and the model for Phase II was verified by comparing to a nonHomogenous version of the Ogata-Banks solution. After verification, a sensitiv"ity analysis on the inpllt parameters was performed. The sensitivity analysis was condllcted by varying one inpllt parameter vvhile all others were fixed and observing the impact on the shape of the clirve describing bacterial concentration verSllS time. Increasing fracture apertllre allovvs more transport and thus more accllffilliation, "Vvhich diminishes the dllration of Phase I. The larger the bacteria size, the faster the sllbstratum will be covered. Increasing adsorption rate, was observed to increase the dllration of Phase I. Contrary to the aSSllmption ofllniform biofilm thickness, the accllffilliation starts frOll1 the inlet, and the bacterial concentration in aqlleous phase moving towards the olitiet declines, sloyving the accumulation at the outlet. Increasing the desorption rate, redllces the dliration of Phase I, speeding IIp the accllmlilation. It was also observed that Phase II is of longer duration than Phase I. Increasing the attachment rate lengthens the accliffililation period. High rates of detachment speeds up the transport. The grovvth and decay rates have no significant effect on transport, althollgh increases the concentrations in both aqueous and sorbed phases are observed. Irreversible adsorption can stop accllillulation completely if the vallIes are high.

Consequence modelling,vulnerability assessment and fuzzy fault tree analysis of hazardous storages in an industrial area

The hazards associated with major accident hazard (MAH) industries are fire, explosion and toxic gas releases. Of these, toxic gas release is the worst as it has the potential to cause extensive fatalities. Qualitative and quantitative hazard analyses are essential for the identitication and quantification of the hazards associated with chemical industries. This research work presents the results of a consequence analysis carried out to assess the damage potential of the hazardous material storages in an industrial area of central Kerala, India. A survey carried out in the major accident hazard (MAH) units in the industrial belt revealed that the major hazardous chemicals stored by the various industrial units are ammonia, chlorine, benzene, naphtha, cyclohexane, cyclohexanone and LPG. The damage potential of the above chemicals is assessed using consequence modelling. Modelling of pool fires for naphtha, cyclohexane, cyclohexanone, benzene and ammonia are carried out using TNO model. Vapor cloud explosion (VCE) modelling of LPG, cyclohexane and benzene are carried out using TNT equivalent model. Boiling liquid expanding vapor explosion (BLEVE) modelling of LPG is also carried out. Dispersion modelling of toxic chemicals like chlorine, ammonia and benzene is carried out using the ALOHA air quality model. Threat zones for different hazardous storages are estimated based on the consequence modelling. The distance covered by the threat zone was found to be maximum for chlorine release from a chlor-alkali industry located in the area. The results of consequence modelling are useful for the estimation of individual risk and societal risk in the above industrial area.Vulnerability assessment is carried out using probit functions for toxic, thermal and pressure loads. Individual and societal risks are also estimated at different locations. Mapping of threat zones due to different incident outcome cases from different MAH industries is done with the help of Are GIS.Fault Tree Analysis (FTA) is an established technique for hazard evaluation. This technique has the advantage of being both qualitative and quantitative, if the probabilities and frequencies of the basic events are known. However it is often difficult to estimate precisely the failure probability of the components due to insufficient data or vague characteristics of the basic event. It has been reported that availability of the failure probability data pertaining to local conditions is surprisingly limited in India. This thesis outlines the generation of failure probability values of the basic events that lead to the release of chlorine from the storage and filling facility of a major chlor-alkali industry located in the area using expert elicitation and proven fuzzy logic. Sensitivity analysis has been done to evaluate the percentage contribution of each basic event that could lead to chlorine release. Two dimensional fuzzy fault tree analysis (TDFFTA) has been proposed for balancing the hesitation factor invo1ved in expert elicitation .

PRISM and ENES: a European approach to Earth system modelling

Europe's widely distributed climate modelling expertise, now organized in the European Network for Earth System Modelling (ENES), is both a strength and a challenge. Recognizing this, the European Union's Program for Integrated Earth System Modelling (PRISM) infrastructure project aims at designing a flexible and friendly user environment to assemble, run and post-process Earth System models. PRISM was started in December 2001 with a duration of three years. This paper presents the major stages of PRISM, including: (1) the definition and promotion of scientific and technical standards to increase component modularity; (2) the development of an end-to-end software environment (graphical user interface, coupling and I/O system, diagnostics, visualization) to launch, monitor and analyse complex Earth system models built around state-of-art community component models (atmosphere, ocean, atmospheric chemistry, ocean bio-chemistry, sea-ice, land-surface); and (3) testing and quality standards to ensure high-performance computing performance on a variety of platforms. PRISM is emerging as a core strategic software infrastructure for building the European research area in Earth system sciences. Copyright (c) 2005 John Wiley & Sons, Ltd.

Modelling simultaneously water content and dry matter dynamics of wheat grains

A model was devised to describe simultaneously the grain masses of water and dry matter against thermal time during grain filling and maturation of winter wheat. The model accounted for a linear increase in water mass of duration anthesis-m(1) (end of rapid water assimilation phase) and rate a, followed by a more stable water mass until in,, after which water mass declined rapidly at rate e. Grain dry matter was described as a linear increase of rate bgf until a maximum size (maxgf) was attained at m(2).The model was fitted to plot data from weekly samples of grains taken from replicated field experiments investigating effects of grain position (apical or medial), fungicide (five contrasting treatments), sowing date (early or late), cultivar (Malacca or Shamrock) and season (2001/2002 and 2002/2003) on grain filling. The model accounted for between 83 and 99% of the variation ( 2) when fitted to data from individual plots, and between 97 and 99% when fitted to treatment means. Endosperm cell number of grains from early-sown plots in the first season were also counted. Differences in maxgf between grain positions and also between cultivars were mostly the result of effects on bgf and were empirically associated with water mass at nil. Fungicide application controlled S. tritici and powdery mildew infection, delayed flag leaf senescence, increased water mass at m(1) (wm(1)), and also increased m(2), bgf and maxgf. Fungicide effects on water mass were detected before fungicide effects on dry matter, but comparison of the effects of individual fungicide treatments showed no evidence that effects on wm(1), nor on endosperm cell numbers at about m(1), were required for fungicide effects on maxgf, (c) 2005 Elsevier B.V. All rights reserved.

Modelling economic returns to plant variety protection in the UK

This paper attempts an empirical assessment of the incentive effects of plant variety protection regimes in the generation of crop variety innovations. A duration model of plant variety protection certificates is used to infer the private appropriability of returns from agricultural crop variety innovations in the UK over the period 1965-2000. The results suggest that plant variety protection provides only modest appropriability of returns to innovators of agricultural crop varieties. The value distribution of plant variety protection certificates is highly skewed with a large proportion of innovations providing virtually no returns to innovators. Increasing competition from newer varieties appears to have accelerated the turnover of varieties reducing appropriability further. Plant variety protection emerges as a relatively weak instrument of protection.

Long duration stimuli and nonlinearities in the neural–haemodynamic coupling

Recent studies have shown that the haemodynamic responses to brief (<2 secs) stimuli can be well characterised as a linear convolution of neural activity with a suitable haemodynamic impulse response. In this paper, we show that the linear convolution model cannot predict measurements of blood flow responses to stimuli of longer duration (>2 secs), regardless of the impulse response function chosen. Modifying the linear convolution scheme to a nonlinear convolution scheme was found to provide a good prediction of the observed data. Whereas several studies have found a nonlinear coupling between stimulus input and blood flow responses, the current modelling scheme uses neural activity as an input, and thus implies nonlinearity in the coupling between neural activity and blood flow responses. Neural activity was assessed by current source density analysis of depth-resolved evoked field potentials, while blood flow responses were measured using laser Doppler flowmetry. All measurements were made in rat whisker barrel cortex after electrical stimulation of the whisker pad for 1 to 16 secs at 5 Hz and 1.2 mA (individual pulse width 0.3 ms).

Modelling signatures of pulsed magnetopause reconnection in cusp ion dispersion signatures seen at middle altitudes

It is shown that the open magnetosphere model can reproduce both the down-going and the up-going magnetosheath ions seen in the cusp and mantle regions by the Polar satellite at middle altitudes. ?he pass studied shows a series of discontinuities in the ion dispersion, most of which are shown to arise from pulses of magnetopause reconnection rate. A total of 9 pulses are detected in an interval estimated to be about 30 min long, giving a mean repetition period of about 3 min: they vary in length between 0.5 min and 3.5 min and are separated by periods of much slower reconnection of duration 1-3 min. One step is not as predicted for reconnection rate pulses but is explained in terms of compressive motions caused by a pulse of solar wind dynamic pressure. The reconnection site is found to be 16 +/- 3 R-E from the ionosphere along the separatrix field line, placing it at low latitudes on the dayside magnetopause.

A Spatial-Temporal Downscaling Approach To Construction Of Rainfall Intensity-Duration-Frequency Relations In The Context Of Climate Change

This paper proposes a spatial-temporal downscaling approach to construction of the intensity-duration-frequency (IDF) relations at a local site in the context of climate change and variability. More specifically, the proposed approach is based on a combination of a spatial downscaling method to link large-scale climate variables given by General Circulation Model (GCM) simulations with daily extreme precipitations at a site and a temporal downscaling procedure to describe the relationships between daily and sub-daily extreme precipitations based on the scaling General Extreme Value (GEV) distribution. The feasibility and accuracy of the suggested method were assessed using rainfall data available at eight stations in Quebec (Canada) for the 1961-2000 period and climate simulations under four different climate change scenarios provided by the Canadian (CGCM3) and UK (HadCM3) GCM models. Results of this application have indicated that it is feasible to link sub-daily extreme rainfalls at a local site with large-scale GCM-based daily climate predictors for the construction of the IDF relations for present (1961-1990) and future (2020s, 2050s, and 2080s) periods at a given site under different climate change scenarios. In addition, it was found that annual maximum rainfalls downscaled from the HadCM3 displayed a smaller change in the future, while those values estimated from the CGCM3 indicated a large increasing trend for future periods. This result has demonstrated the presence of high uncertainty in climate simulations provided by different GCMs. In summary, the proposed spatial-temporal downscaling method provided an essential tool for the estimation of extreme rainfalls that are required for various climate-related impact assessment studies for a given region.