Is PaCO2 management optimal under controlled mechanical ventilation (CMV) during neuro-resuscitation?

INTRODUCTION. Both hypocapnia and hypercapnia can be deleterious to brain injured patients. Strict PaCO2 control is difficult to achieve because of patient's instability and unpredictable effects of ventilator settings changes. OBJECTIVE. The aim of this study was to evaluate our ability to comply with a protocol of controlled mechanical ventilation (CMV) aiming at a PaCO2 between 35 and 40 mmHg in patients requiring neuro-resuscitation. METHODS. Retrospective analysis of consecutive patients (2005-2011) requiring intracranial pressure (ICP) monitoring for traumatic brain injury (TBI), subarachnoid haemorrhage (SAH), intracranial haemorrhage (ICH) or ischemic stroke (IS). Demographic data, GCS, SAPS II, hospital mortality, PaCO2 and ICP values were recorded. During CMV in the first 48 h after admission, we analyzed the time spent within the PaCO2 target in relation to the presence or absence of intracranial hypertension (ICP[20 mmHg, by periods of 30 min) (Table 1). We also compared the fraction of time (determined by linear interpolation) spent with normal, low or high PaCO2 in hospital survivors and non-survivors (Wilcoxon, Bonferroni correction, p\0.05) (Table 2). PaCO2 samples collected during and after apnoea tests were excluded. Results given as median [IQR]. RESULTS. 436 patients were included (TBI: 51.2 %, SAH: 20.6 %, ICH: 23.2 %, IS: 5.0 %), age: 54 [39-64], SAPS II score: 52 [41-62], GCS: 5 [3-8]. 8744 PaCO2 samples were collected during 150611 h of CMV. CONCLUSIONS. Despite a high number of PaCO2 samples collected (in average one sample every 107 min), our results show that patients undergoing CMV for neuro- resuscitation spent less than half of the time within the pre-defined PaCO2 range. During documented intracranial hypertension, hypercapnia was observed in 17.4 % of the time. Since non-survivors spent more time with hypocapnia, further analysis is required to determine whether hypocapnia was detrimental per se, or merely reflects increased severity of brain insult.

Lite4Life (Tier 2 adult weight management service)

This service Aims: To provide a multi-component weight management service that supports sustainable behaviour change and weight loss in adults 16 years and over with a BMI 28. To enable patients to develop the necessary personal attributes for their own long term weight management and to understand the impact of their weight on their health and co-morbidities. Objectives: To provide an evidence based, multi-component tier 2 weight management service that improves patients knowledge and skills for effective and sustainable weight loss helps patients identify their own facilitators for positive behaviour change and to address underlying barriers to long-term behaviour changeincreases patients self-efficacy and confidence in their ability to address their weight To be an integral part of the tiered approach to weight management services for the population of Stockton. To ensure equitable service provision across Stockton-on-Tees. To provide intensive group based service, one-to-one support and maintenance support. To support the service user to develop and review a personalised goal setting plan phase 2 and at discharge after phase 2. To ensure a smooth transition from the service (tier2) to tier 1 services to ensure continuity of care for service users.Recruit referrals using a variety of and appropriate methods. To establish a single point of contact for referrals into the service.Continually promote the service across a range of mediums and liaise and work in partnership with key interdependencies (refer to 2.4) To establish a robust database and data collection system in line with information governance. To ensure the access criteria, care pathway and referral process is clearly understood by all health care professionals and those who may refer into the service. To establish close links with, and signpost and/or enable service users to access suitable services where patient needs indicate this. This may include access to Tees Time to Talk (IAPT) for psychological therapies; Specialist Weight Management Service; physical activity programmes; Tier 1 services; and primary care. To provide the necessary venues, equipment and assets needed to deliver the programme, ensuring due regard is given to the quality and safety of all materials used. To collect and provide data in quarterly reports to the Commissioner to allow for continued monitoring and evaluation of the service in line with the Standard Evaluation Framework (available at www.noo.org.uk/core/SEF) and as specified by the Commissioner.

Lightweight monitoring of label switched paths for bandwidth management

The purpose of resource management is the efficient and effective use of network resources, for instance bandwidth. In this article, a connection oriented network scenario is considered, where a certain amount of bandwidth is reserved for each label switch path (LSP), which is a logical path, in a MPLS or GMPLS environment. Assuming there is also some kind of admission control (explicit or implicit), these environments typically provide quality of service (QoS) guarantees. It could happen that some LSPs become busy, thus rejecting connections, while other LSPs may be under-utilised. We propose a distributed lightweight monitoring technique, based on threshold values, the objective of which is to detect congestion when it occurs in an LSP and activate the corresponding alarm which will trigger a dynamic bandwidth reallocation mechanism

Iron deficiency and anaemia in bariatric surgical patients: causes, diagnosis and proper management

Obesity-induced chronic inflammation leads to activation of the immune system that causes alterations of iron homeostasis including hypoferraemia, iron-restricted erythropoiesis, and finally mild-to-moderate anaemia. Thus, preoperative anaemia and iron deficiency are common among obese patients scheduled for bariatric surgery (BS). Assessment of patients should include a complete haematological and biochemical laboratory work-up, including measurement of iron stores, vitamin B12 and folate. In addition, gastrointestinal evaluation is recommended for most patients with iron-deficiency anaemia. On the other hand, BS is a long-lasting inflammatory stimulus in itself and entails a reduction of the gastric capacity and/or exclusion from the gastrointestinal tract which impair nutrients absorption, including dietary iron. Chronic gastrointestinal blood loss and iron-losingenteropathy may also contribute to iron deficiency after BS. Perioperative anaemia has been linked to increased postoperative morbidity and mortality and decreased quality of life after major surgery, whereas treatment of perioperative anaemia, and even haematinic deficiency without anaemia, has been shown to improve patient outcomes and quality of life. However, long-term follow-up data in regard to prevalence, severity, and causes of anaemia after BS are mostly absent. Iron supplements should be administered to patients after BS, but compliance with oral iron is no good. In addition, once iron deficiency has developed, it may prove refractory to oral treatment. In these situations, IV iron (which can circumvent the iron blockade at enterocytes and macrophages) has emerged as a safe and effective alternative for perioperative anaemia management. Monitoring should continue indefinitely even after the initial iron repletion and anaemia resolution, and maintenance IV iron treatment should be provided as required. New IV preparations, such ferric carboxymaltose, are safe, easy to use and up to 1000 mg can be given in a single session, thus providing an excellent tool to avoid or treat iron deficiency in this patient population.

Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care.

BACKGROUND In the last decades the presence of social inequalities in diabetes care has been observed in multiple countries, including Spain. These inequalities have been at least partially attributed to differences in diabetes self-management behaviours. Communication problems during medical consultations occur more frequently to patients with a lower educational level. The purpose of this cluster randomized trial is to determine whether an intervention implemented in a General Surgery, based in improving patient-provider communication, results in a better diabetes self-management in patients with lower educational level. A secondary objective is to assess whether telephone reinforcement enhances the effect of such intervention. We report the design and implementation of this on-going study. METHODS/DESIGN The study is being conducted in a General Practice located in a deprived neighbourhood of Granada, Spain. Diabetic patients 18 years old or older with a low educational level and inadequate glycaemic control (HbA1c > 7%) were recruited. General Practitioners (GPs) were randomised to three groups: intervention A, intervention B and control group. GPs allocated to intervention groups A and B received training in communication skills and are providing graphic feedback about glycosylated haemoglobin levels. Patients whose GPs were allocated to group B are additionally receiving telephone reinforcement whereas patients from the control group are receiving usual care. The described interventions are being conducted during 7 consecutive medical visits which are scheduled every three months. The main outcome measure will be HbA1c; blood pressure, lipidemia, body mass index and waist circumference will be considered as secondary outcome measures. Statistical analysis to evaluate the effectiveness of the interventions will include multilevel regression analysis with three hierarchical levels: medical visit level, patient level and GP level. DISCUSSION The results of this study will provide new knowledge about possible strategies to promote a better diabetes self-management in a particularly vulnerable group. If effective, this low cost intervention will have the potential to be easily incorporated into routine clinical practice, contributing to decrease health inequalities in diabetic patients. TRIAL REGISTRATION Clinical Trials U.S. National Institutes of Health, NCT01849731.

Resource management research in Passive Optical Networks (PON)

Next Generation Access Networks (NGAN) are the new step forward to deliver broadband services and to facilitate the integration of different technologies. It is plausible to assume that, from a technological standpoint, the Future Internet will be composed of long-range high-speed optical networks; a number of wireless networks at the edge; and, in between, several access technologies, among which, the Passive Optical Networks (xPON) are very likely to succeed, due to their simplicity, low-cost, and increased bandwidth. Among the different PON technologies, the Ethernet-PON (EPON) is the most promising alternative to satisfy operator and user needs, due to its cost, flexibility and interoperability with other technologies. One of the most interesting challenges in such technologies relates to the scheduling and allocation of resources in the upstream (shared) channel. The aim of this research project is to study and evaluate current contributions and propose new efficient solutions to address the resource allocation issues in Next Generation EPON (NG-EPON). Key issues in this context are future end-user needs, integrated quality of service (QoS) support and optimized service provisioning for real time and elastic flows. This project will unveil research opportunities, issue recommendations and propose novel mechanisms associated with the convergence within heterogeneous access networks and will thus serve as a basis for long-term research projects in this direction. The project has served as a platform for the generation of new concepts and solutions that were published in national and international conferences, scientific journals and also in book chapter. We expect some more research publications in addition to the ones mentioned to be generated in a few months.

Monitoring compliance in resistant hypertension: an important step in patient management.

Poor compliance with antihypertensive drug regimens is one recognized cause of inadequate blood pressure control. Compliance is difficult to measure, so poor adherence to treatment remains largely undiagnosed in clinical practice. When the therapeutic response to a drug is not the one expected, it is a major challenge for many physicians to decide whether the patient is a non-responder or a non-complier. Poor compliance is therefore often incorrectly interpreted as a lack of response to treatment. Not detecting non-compliance can lead to the wrong measures being taken. Electronic monitoring of compliance provides important longitudinal information about drug-intake behaviour that cannot be obtained in the clinic. Such monitoring can improve both compliance and blood pressure control, and help physicians to make more rational therapeutic decisions. A reliable assessment of compliance could have a great impact on medical costs by preventing unnecessary investigations or dose adaptations in patients who are not taking their drugs adequately, or potentially reducing the number of hospitalizations. Side-effects and lack of effectiveness are two frequent causes of poor compliance. The right choice of antihypertensive drug can therefore contribute to compliance. In this respect, it is important to find a drug regimen that is effective, long-acting and well tolerated. Long-acting antihypertensive drugs that provide good blood pressure control beyond the 24-h dosing period should perhaps be considered as drugs of choice in non-compliant patients with hypertension because they help to prevent the consequences of occasional drug omissions.

Postoperative management of adult central neurosurgical patients: systemic and neuro-monitoring.

Postoperative neurosurgical patients are at risk of developing complications. Systemic and neuro-monitoring are used to identify patients who deteriorate in order to treat the underlying cause and minimize the impact on outcome. Hypotension and hypoxia are likely to be the most frequent insults and can be detected easily with blood pressure monitoring and pulse oximetry. Repeated clinical examination, however, is probably the most important monitor in the postoperative setting. Clinical scores such as the Glasgow Coma Score and the more recently introduced FOUR Score are important tools to standardize the clinical assessment. Intracranial pressure monitoring, cerebral blood flow monitoring, electroencephalography, and brain imaging are often used postoperatively. Despite the numerous publications on this topic only few studies address the impact of postoperative monitoring on outcome. Accordingly, in most patients the decision on which monitors are to be used must be based on the patient's presentation and clinical judgment.

Phenotypes influencing low physical activity in maintenance dialysis.

OBJECTIVE: The "Pas à Pas" initiative aimed at evaluating the weekly physical activity (PA) and its determinants in a large cohort of dialysis patients. SETTING: Physical inactivity is a risk factor for mortality in maintenance dialysis patients and is still poorly documented in this population. DESIGN: A prospective national epidemiological study was performed. SUBJECTS: A total of 1,163 patients on maintenance dialysis (hemodialysis and peritoneal dialysis) were included. INTERVENTION AND MAIN OUTCOME MEASURE: PA was recorded during seven consecutive days using a pedometer to measure daily step numbers. RESULTS: Median age was 63 years (Q1 51-Q3 75). Sixty-three percent were sedentary (<5000 steps/day) with a median of 3,688 steps/day (1,866-6,271)]. PA level was similar between hemodialysis patients and those on peritoneal dialysis (3,693 steps [1,896-6,307] vs. 3,320 [1,478-5,926], P = .33). In hemodialysis patients, PA was lower on dialysis days compared with nondialysis days (2,912 [1,439-5,232] vs. 4,054 [2,136-7,108], respectively, P < .01). PA gradually decreased with age, 57% being sedentary between 50 and 65 years and 83% of patients after 80 years. Beyond this age effect, we identified, for the first time, specific phenotypes of patients with lower PA, such as inflammation, cardiovascular disease, protein energy wasting, obesity, and diabetes. By contrast, previous kidney transplantation and a higher muscle mass were associated with higher PA. CONCLUSIONS: Dialysis patients present a very low level of PA with high sedentary. Acting on patient's modifiable phenotypes may help to increase PA to improve morbidity, mortality, and quality of life.

Hidrossedimentologia e disponibilidade hídrica da bacia hidrográfica da Barragem de Poilão

TEIXEIRA, José João Lopes. Departamento de Engenharia Agrícola, Centro de Ciências Agrárias da Universidade Federal do Ceará, Agosto de 2011. Hidrossedimentologia e disponibilidade hídrica da bacia hidrográfica da Barragem de Poilão, Cabo Verde. Orientador: José Carlos de Araújo. Examinadores: George Leite Mamede, Pedro Henrique Augusto Medeiros. O Arquipélago de Cabo Verde, situado na costa ocidental africana, sofre influência do deserto de Saara tornando o clima caraterizado por pluviometria muito baixa e distribuída irregularmente no espaço e no tempo. As chuvas são muito concentradas, gerando grandes escoamentos para o mar. O aumento da disponibilidade hídrica requer além da construção e manutenção de infraestrutura de captação e conservação de águas pluviais, uma gestão eficiente destes recursos. Atualmente, constitui um dos eixos estratégicos da política do estado de Cabo Verde, a captação, armazenamento e mobilização de águas superficiais através de construção de barragens. Estudos do comportamento hidrológico e sedimentológico do reservatório e da sua bacia de contribuição constituem premissas básicas para um ótimo dimensionamento, gestão e monitoramento da referida infraestrutura. É neste sentido que o presente estudo objetivou sistematizar informações hidrológicas e sedimentológicas da bacia hidrográfica da Barragem de Poilão (BP) e apresentar proposta operacional de longo prazo. A área de estudo ocupa 28 km² a montante da Bacia Hidrográfica da Ribeira Seca (BHRS) na Ilha de Santiago. A altitude da bacia varia de 99 m, situada na cota da barragem, até 1394 m. Para o estudo, foram utilizados e sistematizados, série pluviométrica de 1973 a 2010, registos de vazão instantânea do período 1984 a 2000 e registos agroclimáticos da área de estudo (1981 a 2004). Para o preenchimento das falhas tanto dos escoamentos como da descarga sólida em suspensão, foi utilizado o método de curva chave. Para estimativa de produção de sedimentos na bacia, aplicou-se a Equação Universal de Perda de Solo (USLE) e a razão de aporte de sedimentos (SDR). O índice de retenção de sedimentos no reservatório foi estimado pelo método de Brune e a distribuição de sedimento pelo método empírico de redução de área descrito por Borland e Miller e, revisado por Lara. Para gerar e simular curvas de vazão versus garantia foi utilizado código computacional VYELAS, desenvolvido por Araújo e baseado na abordagem de Campos. Também foi avaliada a redução da vazão de retirada do período 2006 a 2026, provocado pelo assoreamento do reservatório. Concluiu-se que em média a precipitação anual é de 323 mm, concentrando-se 73% nos meses de agosto e setembro; a bacia de contribuição apresenta como valor um número de curva (CN) de 76, com abstração inicial (Ia) de 26 mm, coeficiente de escoamento de 19% e uma vazão anual afluente de 1,7 hm³(cv= 0,73); a disponibilidade hídrica para uma garantia de 85% é avaliada em 0,548 hm³/ano e não 0,671 hm³/ano como indica o projeto original. Com uma descarga sólida estimada em 22.185 m³/ano conclui-se que até o ano de 2026, a capacidade do reservatório reduz a uma taxa de 1,8 % ao ano, devido ao assoreamento, provocando uma redução de 41% da disponibilidade hídrica inicial. Nessa altura, as perdas por evaporação e sangria serão da ordem de 81% da vazão afluente de entrada no reservatório. Na base desses resultados se apresentou proposta de operação da BP.

Eosinophilic esophagitis: overview of clinical management.

A validated disease-specific symptom-assessment tool for eosinophilic esophagitis (EoE) has yet to be approved by regulatory authorities for use in clinical trials. Relevant end points for daily practice include EoE-related symptoms and esophageal eosinophilic inflammation. Endoscopic features should also be taken into account when establishing a therapy plan. A reasonable clinical goal is to achieve a reduction in EoE-related symptoms and esophageal eosinophilic inflammation. Evidence is increasing to support an anti-inflammatory maintenance therapy, as this can reduce esophageal remodeling. In EoE patients in clinical remission, annual disease monitoring with symptom, endoscopic, and histologic assessments of sustained treatment response is recommended.

Why Objective Monitoring of Compliance is Important in the Management of Hypertension.

Hypertensive patients often experience poor adherence to treatment, a frequent cause of uncontrolled blood pressure. In this study, we have evaluated whether or not the use of electronic monitoring for drug adherence is a useful approach to identify and correct compliance problems in hypertensive patients, which may ultimately enhance the effect of antihypertensive therapy. Sixty-nine treated patients with an office blood pressure greater than 140/90 mm Hg were enrolled in this study. With patient consent, current antihypertensive therapy was dispensed in electronic pillboxes that record the time and date of each opening without changing the drug regimen. The intention was to provide physicians with objective measurements of drug compliance. The monitoring of compliance per se without any other intervention induced a marked decrease of blood pressure in the whole group (from 159/104Â+/-23/12 mm Hg to 143/92Â+/-20/15, meansÂ+/-standard deviation, p less than 0.001). A complete normalization of blood pressure (less than 140/90 mm Hg) was obtained in one third of the patients (group 1, n=23) during the monitoring period. A significant improvement of blood pressure control was found in another third (group 2, n=23), whereas in the remaining patients (group 3, n=23) no change in blood pressure was observed. The distribution of individual compliance values, as well as the mean compliances was comparable in the three subgroups. Conversely, the compliance reports have identified several potentially overtreated patients in group 1, a large number of patients with a poor adherence to the prescribed therapy in all groups, and patients who clearly needed a change in pharmacotherapy mainly in group 3. Thus, our results suggest that electronic monitoring of compliance can considerably enhance the efficacy of antihypertensive therapy in patients with uncontrolled hypertension. This procedure should be used more extensively in clinical practice whenever the blood pressure response to therapy appears insufficient. (c)2000 by Le Jacq Communications, Inc.

Clinical Experience with Immune Monitoring for Cytomegalovirus in Solid-Organ Transplant Recipients.

Novel strategies are needed to further reduce the burden of cytomegalovirus (CMV) disease in solid-organ transplant (SOT) recipients. Measurement of the specific cell-mediated immunity against CMV can identify the actual risk for the development of CMV disease in a given patient. Thus, immune monitoring is an attractive strategy for individualizing the management of CMV after transplantation. A growing number of observational studies on immune monitoring for CMV have been published over recent years, although there is a lack of data coming from interventional trials. In high-risk patients, measurement of CMV-specific T-cell responses appropriately stratifies the risk of CMV disease after discontinuation of antiviral prophylaxis. Immune monitoring may also help to identify patients followed by the preemptive approach at low risk for progression to CMV disease. Pretransplant assessment of cell-mediated immunity in seropositive patients may predict the development of posttransplant CMV infection. Overall, these studies indicate that the use of cell-mediated immunity assays has the potential to improve the management of CMV disease in SOT recipients.

When "enough" is not enough: new perspectives on optimal methadone maintenance dose.

Some methadone maintenance treatment (MMT) programs prescribe inadequate daily methadone doses. Patients complain of withdrawal symptoms and continue illicit opioid use, yet practitioners are reluctant to increase doses above certain arbitrary thresholds. Serum methadone levels (SMLs) may guide practitioners dosing decisions, especially for those patients who have low SMLs despite higher methadone doses. Such variation is due in part to the complexities of methadone metabolism. The medication itself is a racemic (50:50) mixture of 2 enantiomers: an active "R" form and an essentially inactive "S" form. Methadone is metabolized primarily in the liver, by up to five cytochrome P450 isoforms, and individual differences in enzyme activity help explain wide ranges of active R-enantiomer concentrations in patients given identical doses of racemic methadone. Most clinical research studies have used methadone doses of less than 100 mg/day [d] and have not reported corresponding SMLs. New research suggests that doses ranging from 120 mg/d to more than 700 mg/d, with correspondingly higher SMLs, may be optimal for many patients. Each patient presents a unique clinical challenge, and there is no way of prescribing a single best methadone dose to achieve a specific blood level as a "gold standard" for all patients. Clinical signs and patient-reported symptoms of abstinence syndrome, and continuing illicit opioid use, are effective indicators of dose inadequacy. There does not appear to be a maximum daily dose limit when determining what is adequately "enough" methadone in MMT.

Environmental and agricultural benefits of a management system designed for sandy loam soils of the humid tropics

A sustainable management of soils with low natural fertility on family farms in the humid tropics is a great challenge and overcoming it would be an enormous benefit for the environment and the farmers. The objective of this study was to assess the environmental and agronomic benefits of alley cropping, based on the evaluation of C sequestration, soil quality indicators, and corn yields. Combinations of four legumes were used in alley cropping systems in the following treatments: Clitoria fairchildiana + Cajanus cajan; Acacia mangium + Cajanus cajan; Leucaena leucocephala + Cajanus cajan; Clitoria fairchildiana + Leucaena leucocephala; Leucaena leucocephala + Acacia mangium and a control. Corn was used as a cash crop. The C content was determined in the different compartments of soil organic matter, CEC, available P, base saturation, percentage of water saturation, the period of the root hospitality factor below the critical level and corn yield. It was concluded that alley cropping could substitute the slash and burn system in the humid tropics. The main environmental benefit of alley cropping is the maintenance of a dynamic equilibrium between C input and output that could sustain up to 10 Mg ha-1 of C in the litter layer, decreasing atmospheric CO2 levels. Alley cropping is also beneficial from the agricultural point of view, because it increases base saturation and decreases physical resistance to root penetration in the soil layer 0 - 10 cm, which ensures the increase and sustainability of corn yield.