Temperature Prediction Model for Bone Drilling Based on Density Distribution and In Vivo Experiments for Minimally Invasive Robotic Cochlear Implantation

Surgical robots have been proposed ex vivo to drill precise holes in the temporal bone for minimally invasive cochlear implantation. The main risk of the procedure is damage of the facial nerve due to mechanical interaction or due to temperature elevation during the drilling process. To evaluate the thermal risk of the drilling process, a simplified model is proposed which aims to enable an assessment of risk posed to the facial nerve for a given set of constant process parameters for different mastoid bone densities. The model uses the bone density distribution along the drilling trajectory in the mastoid bone to calculate a time dependent heat production function at the tip of the drill bit. Using a time dependent moving point source Green's function, the heat equation can be solved at a certain point in space so that the resulting temperatures can be calculated over time. The model was calibrated and initially verified with in vivo temperature data. The data was collected in minimally invasive robotic drilling of 12 holes in four different sheep. The sheep were anesthetized and the temperature elevations were measured with a thermocouple which was inserted in a previously drilled hole next to the planned drilling trajectory. Bone density distributions were extracted from pre-operative CT data by averaging Hounsfield values over the drill bit diameter. Post-operative [Formula: see text]CT data was used to verify the drilling accuracy of the trajectories. The comparison of measured and calculated temperatures shows a very good match for both heating and cooling phases. The average prediction error of the maximum temperature was less than 0.7 °C and the average root mean square error was approximately 0.5 °C. To analyze potential thermal damage, the model was used to calculate temperature profiles and cumulative equivalent minutes at 43 °C at a minimal distance to the facial nerve. For the selected drilling parameters, temperature elevation profiles and cumulative equivalent minutes suggest that thermal elevation of this minimally invasive cochlear implantation surgery may pose a risk to the facial nerve, especially in sclerotic or high density mastoid bones. Optimized drilling parameters need to be evaluated and the model could be used for future risk evaluation.

[Pilot Project: Improved Lung Deposition via a New Nasal Inhalation Procedure].

INTRODUCTION Inhaled drugs can only be effective if they reach the middle and small airways. This study introduces a system that combines a trans-nasal application of aerosols with noninvasive pressure support ventilation. METHODS In a pilot study, 7 COPD patients with GOLD stages II and III inhaled a radiolabeled marker dissolved in water via a trans-nasal route. The mean aerosol particle size was 5.5 µm. Each patient took part in two inhalation sessions that included two application methods and were at least 70 hours apart. During the first session ("passive method"), the patient inhaled the aerosol through an open tube system. The second session ("active method") included pressure support ventilation during the inhalation process. A gamma camera and planar scintigraphy was used to determine the distribution of aerosol particles in the patient's body and lung. RESULTS The pressure supported inhalation ("active method") results in an increased aerosol lung deposition compared to the passive method. Above all, we could demonstrate deposition in the lung periphery with relatively large aerosol particles (5.5 µm). DISCUSSION The results prove that the combination of trans-nasal inhalation with noninvasive pressure support ventilation leads to significantly increased particle deposition in the lung.

A Bootstrap-Regression Procedure to Capture Unit Specific Effects in Data Envelopment Analysis

The Data Envelopment Analysis (DEA) efficiency score obtained for an individual firm is a point estimate without any confidence interval around it. In recent years, researchers have resorted to bootstrapping in order to generate empirical distributions of efficiency scores. This procedure assumes that all firms have the same probability of getting an efficiency score from any specified interval within the [0,1] range. We propose a bootstrap procedure that empirically generates the conditional distribution of efficiency for each individual firm given systematic factors that influence its efficiency. Instead of resampling directly from the pooled DEA scores, we first regress these scores on a set of explanatory variables not included at the DEA stage and bootstrap the residuals from this regression. These pseudo-efficiency scores incorporate the systematic effects of unit-specific factors along with the contribution of the randomly drawn residual. Data from the U.S. airline industry are utilized in an empirical application.

A simplified protocol for the treatment of acute radiation overexposures from sources external to the body

When compared to other types of occupational injuries, radiation overexposure events are somewhat rare, so health care providers may not be familiar with the actual clinical care to be provided when such an event occurs. Radiation overexposure treatment decisions are predicated on the amount of radiation dose received, which is a value many health care providers may not have the knowledge or expertise to either calculate or even estimate. Even the different units of measure for radiation exposure and dose received can be a source of confusion. The prompt treatment of radiation overexposure victims could be enhanced and facilitated through the creation of a single, simple protocol that consists of the various means of dose measurement and estimation, correlated to the corresponding appropriate clinical care measures. This culminating experience will assemble essential information currently maintained in disparate references to create a single, simplified protocol to facilitate the treatment of victims of acute external radiation overexposure. ^

A standard operation procedure and a pilot water testing for herbicides in northwest Harris County, Texas

Herbicides are used to control the growth of weeds along highways, power lines, and many other urban locations. Exposure to herbicides has been linked to adverse health outcomes. This study was initiated to pretest for the presence of herbicides in multiple water sources near intersections in a corridor in the Northwest Harris County (specifically in the Highway 6/FM 1960, North Freeway 45, US 290 and S 99 corridor). Roadside water and tap water samples were collected and analyzed for herbicides using the established Environmental Protection Agency (EPA) Method 515.4: "Determination of Chlorinated Acids in Drinking Water by Liquid-Liquid Micro-extraction, Derivatization, and Fast Gas Chromatography with Electron Capture Detection." A standard operating procedure (adapted from the US EPA Method 515.4) was developed for subsequent, larger studies of environmental fate of herbicides and non-occupational exposure risks. Preliminary testing of 16 water samples was performed to pretest the existence of trace herbicides; all concentrations that were greater than the minimum reporting limits of each analyte are reported with a 99 percent confidence. This study failed to find concentrations above the limits of detection of the method in any of the samples collected on June 15, 2008. However, this does not indicate that the waters around the NW Harris County are free of herbicides and metabolites. A larger and repeated sampling in the region would be necessary to make that claim. ^

Procedure for the identification of population characteristics for targeting intervention services on the basis of outcome-goal priorities: Case management services for the chronic mentally ill

Although the processes involved in rational patient targeting may be obvious for certain services, for others, both the appropriate sub-populations to receive services and the procedures to be used for their identification may be unclear. This project was designed to address several research questions which arise in the attempt to deliver appropriate services to specific populations. The related difficulties are particularly evident for those interventions about which findings regarding effectiveness are conflicting. When an intervention clearly is not beneficial (or is dangerous) to a large, diverse population, consensus regarding withholding the intervention from dissemination can easily be reached. When findings are ambiguous, however, conclusions may be impossible.^ When characteristics of patients likely to benefit from an intervention are not obvious, and when the intervention is not significantly invasive or dangerous, the strategy proposed herein may be used to identify specific characteristics of sub-populations which may benefit from the intervention. The identification of these populations may be used both in further informing decisions regarding distribution of the intervention and for purposes of planning implementation of the intervention by identifying specific target populations for service delivery.^ This project explores a method for identifying such sub-populations through the use of related datasets generated from clinical trials conducted to test the effectiveness of an intervention. The method is specified in detail and tested using the example intervention of case management for outpatient treatment of populations with chronic mental illness. These analyses were applied in order to identify any characteristics which distinguish specific sub-populations who are more likely to benefit from case management service, despite conflicting findings regarding its effectiveness for the aggregate population, as reported in the body of related research. However, in addition to a limited set of characteristics associated with benefit, the findings generated, a larger set of characteristics of patients likely to experience greater improvement without intervention. ^

THE USE OF ARM CIRCUMFERENCE FOR SIMPLIFIED SCREENING FOR MALNUTRITION BY MINIMALLY TRAINED HEALTH WORKERS

Because of its simplicity and low cost, arm circumference (AC) is being used increasingly in screening for protein energy malnutrition among pre-school children in many parts of the developing world, especially where minimally trained health workers are employed. The objectives of this study were as follows: (1) To determine the relationship of the AC measure with weight for age and weight for height in the detection of malnutrition among pre-school children in a Guatemalan Indian village. (2) To determine the performance of minimally trained promoters under field conditions in measuring AC, weight and height. (3) To describe the practical aspects of taking AC measures versus weight, age and height.^ The study was conducted in San Pablo La Laguna, one of four villages situated on the shores of Lake Atitlan, Guatemala, in which a program of simplified medical care was implemented by the Institute for Nutrition for Central America and Panama (INCAP). Weight, height, AC and age data were collected for 144 chronically malnourished children. The measurements obtained by the trained investigator under the controlled conditions of the health post were correlated against one another and AC was found to have a correlation with weight for age of 0.7127 and with weight for height of 0.7911, both well within the 0.65 to 0.80 range reported in the literature. False positive and false negative analysis showed that AC was more sensitive when compared with weight for height than with weight for age. This was fortunate since, especially in areas with widespread chronic malnutrition, weight for height detects those acute cases in immediate danger of complicating illness or death. Moreover, most of the cases identified as malnourished by AC, but not by weight for height (false positives), were either young or very stunted which made their selection by AC better than weight for height. The large number of cases detected by weight for age, but not by AC (false negative rate--40%) were, however, mostly beyond the critical age period and had normal weight for heights.^ The performance of AC, weight for height and weight for age under field conditions in the hands of minimally trained health workers was also analyzed by correlating these measurements against the same criterion measurements taken under ideally controlled conditions of the health post. AC had the highest correlation with itself indicating that it deteriorated the least in the move to the field. Moreover, there was a high correlation between AC in the field and criterion weight for height (0.7509); this correlation was almost as high as that for field weight for height versus the same measure in the health post (0.7588). The implication is that field errors are so great for the compounded weight for height variable that, in the field, AC is about as good a predictor of the ideal weight for height measure.^ Minimally trained health workers made more errors than the investigator as exemplified by their lower intra-observer correlation coefficients. They consistently measured larger than the investigator for all measures. Also there was a great deal of variability between these minimally trained workers indicating that careful training and followup is necessary for the success of the AC measure.^ AC has many practical advantages compared to the other anthropometric tools. It does not require age data, which are often unreliable in these settings, and does not require sophisticated subtraction and two dimensional table-handling skills that weight for age and weight for height require. The measure is also more easily applied with less disturbance to the child and the community. The AC tape is cheap and not easily damaged or jarred out of calibration while being transported in rugged settings, as is often the case with weight scales. Moreover, it can be kept in a health worker's pocket at all times for continual use in a widespread range of settings. ^

INTAKE VARIABLES AS PREDICTORS OF ASSESSMENT AND REFERRAL PROCEDURE OUTCOMES IN EMPLOYEE ASSISTANCE PROGRAMS

While reported prevalence rates of troubled employees vary considerably, even conservative estimates indicate a major public health problem. For example, alcohol and drug related problems alone cost U.S. industry more than 45 billion dollars annually.^ Of the alternatives available to deal with these problems, e.g., dismissal or disciplinary actions, the most viable and cost effective are employee assistance programs (EAP), designed to provide professional assistance to employees experiencing alcohol, drug, emotional or personal crisis.^ The principal component of an EAP is that of assessment and referral, and this study was developed to determine which EAP client intake variables are the most efficacious predictors of assessment and referral procedures.^ Although, specific client intake variables were statistically significant the discriminant classification analysis was demonstrably inadequate. Nevertheless, the identification of A/R procedure phases which were not efficacious, as well as EAP client populations for whom services were not effective, were extremely valuable discernments. Identifying the less efficacious components of the A/R process provided an opportunity to recommend alternatives to current program procedures and practices, which may ameliorate program effectiveness. ^

Development of a standard sign-out procedure for clinicians in a pediatric intensive care unit

Background: Poor communication among health care providers is cited as the most common cause of sentinel events involving patients. Sign-out of patient data at the change of clinician shifts is a component of communication that is especially vulnerable to errors. Sign-outs are particularly extensive and complex in intensive care units (ICUs). There is a paucity of validated tools to assess ICU sign-outs. ^ Objective: To design a valid and reliable survey tool to assess the perceptions of Pediatric ICU (PICU) clinicians about sign-out. ^ Design: Cross-sectional, web-based survey ^ Setting: Academic hospital, 31-bed PICU ^ Subjects: Attending faculty, fellows, nurse practitioners and physician assistants. ^ Interventions: A survey was designed with input from a focus group and administered to PICU clinicians. Test-retest reliability, internal consistency and validity of the survey tool were assessed. ^ Measurements and Main Results: Forty-eight PICU clinicians agreed to participate. We had 42(88%) and 40(83%) responses in the test and retest phases. The mean scores for the ten survey items ranged from 2.79 to 3.67 on a five point Likert scale with no significant test-retest difference and a Pearson correlation between pre and post answers of 0.65. The survey item scores showed internal consistency with a Cronbach's Alpha of 0.85. Exploratory factor analysis revealed three constructs: efficacy of sign-out process, recipient satisfaction and content applicability. Seventy eight % clinicians affirmed the need for improvement of the sign-out process and 83% confirmed the need for face- to-face verbal sign-out. A system-based sign-out format was favored by fellows and advanced level practitioners while attendings preferred a problem-based format (p=0.003). ^ Conclusions: We developed a valid and reliable survey to assess clinician perceptions about the ICU sign-out process. These results can be used to design a verbal template to improve and standardize the sign-out process.^

The dynamic evaluation of the learning potential: a procedure

Fil: Malbrán, María del Carmen. Universidad Nacional de La Plata. Facultad de Humanidades y Ciencias de la Educación; Argentina.

The dynamic evaluation of the learning potential: a procedure

Fil: Malbrán, María del Carmen. Universidad Nacional de La Plata. Facultad de Humanidades y Ciencias de la Educación; Argentina.

Evaluación de la profundidad de la fisuración superficial descendente en pavimentos asfálticos mediante técnicas de ultrasonidos. Validación teórico-práctica y modelos

La fisuración iniciada en la superficie de los pavimentos asfálticos constituye uno de los más frecuentes e importantes modos de deterioro que tienen lugar en los firmes bituminosos, como han demostrado los estudios teóricos y experimentales llevados a cabo en la última década. Sin embargo, este mecanismo de fallo no ha sido considerado por los métodos tradicionales de diseño de estos firmes. El concepto de firmes de larga duración se fundamenta en un adecuado seguimiento del proceso de avance en profundidad de estos deterioros y la intervención en el momento más apropiado para conseguir mantenerlos confinados como fisuras de profundidad parcial en la capa superficial más fácilmente accesible y reparable, de manera que pueda prolongarse la durabilidad y funcionalidad del firme y reducir los costes generalizados de su ciclo de vida. Por lo tanto, para la selección de la estrategia óptima de conservación de los firmes resulta esencial disponer de metodologías que posibiliten la identificación precisa in situ de la fisuración descendente, su seguimiento y control, y que además permitan una determinación fiable y con alto rendimiento de su profundidad y extensión. En esta Tesis Doctoral se presentan los resultados obtenidos mediante la investigación sistemática de laboratorio e in situ llevada a cabo para la obtención de datos sobre fisuración descendente en firmes asfálticos y para el estudio de procedimientos de evaluación de la profundidad de este tipo de fisuras empleando técnicas de ultrasonidos. Dichos resultados han permitido comprobar que la metodología no destructiva propuesta, de rápida ejecución, bajo coste y sencilla implementación (principalmente empleada hasta el momento en estructuras metálicas y de hormigón, debido a las dificultades que introduce la naturaleza viscoelástica de los materiales bituminosos) puede ser aplicada con suficiente fiabilidad y repetibilidad sobre firmes asfálticos. Las medidas resultan asimismo independientes del espesor total del firme. Además, permite resolver algunos de los inconvenientes frecuentes que presentan otros métodos de diagnóstico de las fisuras de pavimentos, tales como la extracción de testigos (sistema destructivo, de alto coste y prolongados tiempos de interrupción del tráfico) o algunas otras técnicas no destructivas como las basadas en medidas de deflexiones o el georradar, las cuales no resultan suficientemente precisas para la investigación de fisuras superficiales. Para ello se han realizado varias campañas de ensayos sobre probetas de laboratorio en las que se han estudiado diferentes condiciones empíricas como, por ejemplo, distintos tipos de mezclas bituminosas en caliente (AC, SMA y PA), espesores de firme y adherencias entre capas, temperaturas, texturas superficiales, materiales de relleno y agua en el interior de las grietas, posición de los sensores y un amplio rango de posibles profundidades de fisura. Los métodos empleados se basan en la realización de varias medidas de velocidad o de tiempo de transmisión del pulso ultrasónico sobre una única cara o superficie accesible del material, de manera que resulte posible obtener un coeficiente de transmisión de la señal (mediciones relativas o autocompensadas). Las mediciones se han realizado a bajas frecuencias de excitación mediante dos equipos de ultrasonidos diferentes dotados, en un caso, de transductores de contacto puntual seco (DPC) y siendo en el otro instrumento de contacto plano a través de un material especialmente seleccionado para el acoplamiento (CPC). Ello ha permitido superar algunos de los tradicionales inconvenientes que presenta el uso de los transductores convencionales y no precisar preparación previa de las superficies. La técnica de autocalibración empleada elimina los errores sistemáticos y la necesidad de una calibración local previa, demostrando el potencial de esta tecnología. Los resultados experimentales han sido comparados con modelos teóricos simplificados que simulan la propagación de las ondas ultrasónicas en estos materiales bituminosos fisurados, los cuales han sido deducidos previamente mediante un planteamiento analítico y han permitido la correcta interpretación de dichos datos empíricos. Posteriormente, estos modelos se han calibrado mediante los resultados de laboratorio, proporcionándose sus expresiones matemáticas generalizadas y gráficas para su uso rutinario en las aplicaciones prácticas. Mediante los ensayos con ultrasonidos efectuados en campañas llevadas a cabo in situ, acompañados de la extracción de testigos del firme, se han podido evaluar los modelos propuestos. El máximo error relativo promedio en la estimación de la profundidad de las fisuras al aplicar dichos modelos no ha superado el 13%, con un nivel de confianza del 95%, en el conjunto de todos los ensayos realizados. La comprobación in situ de los modelos ha permitido establecer los criterios y las necesarias recomendaciones para su utilización sobre firmes en servicio. La experiencia obtenida posibilita la integración de esta metodología entre las técnicas de auscultación para la gestión de su conservación. Abstract Surface-initiated cracking of asphalt pavements constitutes one of the most frequent and important types of distress that occur in flexible bituminous pavements, as clearly has been demonstrated in the technical and experimental studies done over the past decade. However, this failure mechanism has not been taken into consideration for traditional methods of flexible pavement design. The concept of long-lasting pavements is based on adequate monitoring of the depth and extent of these deteriorations and on intervention at the most appropriate moment so as to contain them in the surface layer in the form of easily-accessible and repairable partial-depth topdown cracks, thereby prolonging the durability and serviceability of the pavement and reducing the overall cost of its life cycle. Therefore, to select the optimal maintenance strategy for perpetual pavements, it becomes essential to have access to methodologies that enable precise on-site identification, monitoring and control of top-down propagated cracks and that also permit a reliable, high-performance determination of the extent and depth of cracking. This PhD Thesis presents the results of systematic laboratory and in situ research carried out to obtain information about top-down cracking in asphalt pavements and to study methods of depth evaluation of this type of cracking using ultrasonic techniques. These results have demonstrated that the proposed non-destructive methodology –cost-effective, fast and easy-to-implement– (mainly used to date for concrete and metal structures, due to the difficulties caused by the viscoelastic nature of bituminous materials) can be applied with sufficient reliability and repeatability to asphalt pavements. Measurements are also independent of the asphalt thickness. Furthermore, it resolves some of the common inconveniences presented by other methods used to evaluate pavement cracking, such as core extraction (a destructive and expensive procedure that requires prolonged traffic interruptions) and other non-destructive techniques, such as those based on deflection measurements or ground-penetrating radar, which are not sufficiently precise to measure surface cracks. To obtain these results, extensive tests were performed on laboratory specimens. Different empirical conditions were studied, such as various types of hot bituminous mixtures (AC, SMA and PA), differing thicknesses of asphalt and adhesions between layers, varied temperatures, surface textures, filling materials and water within the crack, different sensor positions, as well as an ample range of possible crack depths. The methods employed in the study are based on a series of measurements of ultrasonic pulse velocities or transmission times over a single accessible side or surface of the material that make it possible to obtain a signal transmission coefficient (relative or auto-calibrated readings). Measurements were taken at low frequencies by two short-pulse ultrasonic devices: one equipped with dry point contact transducers (DPC) and the other with flat contact transducers that require a specially-selected coupling material (CPC). In this way, some of the traditional inconveniences presented by the use of conventional transducers were overcome and a prior preparation of the surfaces was not required. The auto-compensating technique eliminated systematic errors and the need for previous local calibration, demonstrating the potential for this technology. The experimental results have been compared with simplified theoretical models that simulate ultrasonic wave propagation in cracked bituminous materials, which had been previously deduced using an analytical approach and have permitted the correct interpretation of the aforementioned empirical results. These models were subsequently calibrated using the laboratory results, providing generalized mathematical expressions and graphics for routine use in practical applications. Through a series of on-site ultrasound test campaigns, accompanied by asphalt core extraction, it was possible to evaluate the proposed models, with differences between predicted crack depths and those measured in situ lower than 13% (with a confidence level of 95%). Thereby, the criteria and the necessary recommendations for their implementation on in-service asphalt pavements have been established. The experience obtained through this study makes it possible to integrate this methodology into the evaluation techniques for pavement management systems.