Applications of transcranial Doppler in the ICU: a review

Objective: Transcranial Doppler (TCD) ultrasonography is a technique that uses a hand-held Doppler transducer (placed on the surface of the cranial skin) to measure the velocity and pulsatility of blood flow within the intracranial and the extracranial arteries. This review critically evaluates the evidence for the use of TCD in the critical care population. Discussion: TCD has been frequently employed for the clinical evaluation of cerebral vasospasm following subarachnoid haemorrhage (SAH). To a lesser degree, TCD has also been used to evaluate cerebral autoregulatory capacity, monitor cerebral circulation during cardiopulmonary bypass and carotid endarterectomies and to diagnose brain death. Technological advances such as M mode, colour Doppler and three-dimensional power Doppler ultrasonography have extended the scope of TCD to include other non-critical care applications including assessment of cerebral emboli, functional TCD and the management of sickle cell disease. Conclusions: Despite publications suggesting concordance between TCD velocity measurements and cerebral blood flow there are few randomized controlled studies demonstrating an improved outcome with the use of TCD monitoring in neurocritical care. Newer developments in this technology include venous Doppler, functional Doppler and use of ultrasound contrast agents.

Assessment of statistical change criteria used to define significant change in neuropsychological test performance following cardiac surgery

Objective: This paper compares four techniques used to assess change in neuropsychological test scores before and after coronary artery bypass graft surgery (CABG), and includes a rationale for the classification of a patient as overall impaired. Methods: A total of 55 patients were tested before and after surgery on the MicroCog neuropsychological test battery. A matched control group underwent the same testing regime to generate test–retest reliabilities and practice effects. Two techniques designed to assess statistical change were used: the Reliable Change Index (RCI), modified for practice, and the Standardised Regression-based (SRB) technique. These were compared against two fixed cutoff techniques (standard deviation and 20% change methods). Results: The incidence of decline across test scores varied markedly depending on which technique was used to describe change. The SRB method identified more patients as declined on most measures. In comparison, the two fixed cutoff techniques displayed relatively reduced sensitivity in the detection of change. Conclusions: Overall change in an individual can be described provided the investigators choose a rational cutoff based on likely spread of scores due to chance. A cutoff value of ≥20% of test scores used provided acceptable probability based on the number of tests commonly encountered. Investigators must also choose a test battery that minimises shared variance among test scores.

Failure of normal glycaemic regulation in a patient with severe hypothermia

This report describes the case of an 88-year-old non-diabetic female who presented to the emergency department following a presumed hypoijtycaemic collapse due to self-neglect. Subsequent rewarming and resuscitation demonstrated a number of the significant consequences of severe hypothermia, including apparent secondary impairment of glycaemic autoregulation. The phenomenon of reversible inhibition of insulin secretion due to severe hypothermia has been documented previously in the field of cardiac surgery. The hyperglycaemia was not treated with any antihyperglycaernic agent, and her recovery was uneventful. Subsequent blood sugar level monitoring was normal. If insulin is administered to the hypothermic patient, intensive monitoring of blood glucose is essential due to the increase in endogenous insulin secretion on rewarming. (c) 2005 Elsevier Ireland Ltd. All rights reserved.

Vascular remodelling in the internal mammary artery graft and association with elevated endothelin-1 expression

Introduction: The vasoconstricting peptide Endothelin-1 (ET-1) has been associated with atherosclerotic cardiovascular disease, AAA, hypertension and hypercholesterolemia. It is known to stimulate quiescent vascular smooth muscle cells (VSMC) into the growth cycle and has been linked to intimal thickening following endothelial injury and is associated with vessel wall remodelling in salt-sensitive hypertension models. Enhanced ET-1 expression has been reported in the internal mammary artery (IMA) and was markedly higher in patients undergoing cardiac bypass surgery who were diabetic and /or hypercholesterolemic. Aims: To firstly review the histopathology of the IMA and secondly, determine the relationship between ET-1 expression in this vessel and mitogenic activity in the medial VSMC. Methods: Vessel tissue collected at the time of CABG surgery was formalin-fixed and paraffin-embedded for histological investigation. Cross sections of the left distal IMAwere stained with Alcian Blue/Verhoeff’s van Gieson to assess medial degeneration and identify the elastic lamellae and picrosirius red to determine the collagen content (specifically type I and type III). Immunohistochemistry staining was used to assess VSMC growth (PCNA label), tissue ET-1 expression, VSMC (SMCa-actin) area and macrophage/monocyte (anti-CD68) infiltration. Quantitative analysis was performed to measure the VSMC area in relation to ET-1 staining. Results: Fifty-five IMA specimens from the CABG patients (10F; 45M; mean age 65 years) were collected for this study. Fourteen donor IMAspecimens were used as controls (7F; 7M; mean age 45 years). Significant medial hypertrophy, VSMC disorganisation and elastic lamellae destruction was detected in the CABG IMA. The amount of Alcian blue staining in the CABG IMA was almost double that of the control (31.85+/14.52% Vs 17.10+/9.96%, P= .0006). Total collagen and type I collagen content was significantly increased compared with controls (65.8+/18.3% Vs 33.7 + / 13.7%, P= .07), (14.2 + /10.0% Vs 4.8 + /2.8%, P= .01), respectively. Tissue ET-1 and PCNA labelling were also significantly elevated the CABG IMA specimens relative to the controls (69.99 + /18.74%Vs 23.33 + /20.53%, P= .0001, and 37.29 + /12.88% Vs 11.06 + /8.18, P= .0001), respectively. There was mild presence of macrophages and monocytes in both CABG and control tissue. Conclusions: The IMA from CABG patients has elevated levels of type I collagen in the extracellular matrix indicative of fibrosis and was coupled with deleterious structural remodelling. Abnormally high levels of ET-1 were measured in the medial SMC layer and was associated with VSMC growth but not related to any chronic inflammatory response within the vessel wall.

Endothelin A receptor localization in the internal mammary artery

Introduction: The vasoconstricting peptide endothelin-1 (ET-1) binds two G-protein-coupled receptor subtypes, the Endothelin A (ETA) and Endothelin B (ETB) receptors. The ETB receptor subtype has been predominantly localised to the arterial and venous endothelial cells both in-vivo and in culture. Stimulation of ET-1 through this receptor subtype can modulate the expression of endothelial nitric oxide and accelerate endothelial cell wound healing. In comparison the ETA receptor is abundantly expressed in medial vascular smooth muscle cells and mediates the vasoconstrictor action of ET-1 and is thought to play a key role in angiogenesis. Aims: To determine the levels of ETA receptor expression and localisation in the internal mammary artery (IMA). Methods: Twenty-four IMA sections were examined from patients undergoing coronary artery bypass (CABG) surgery (5F; 19M; mean age 67 years). And 14 organ donor IMA specimens were used as controls (7M; 7F; mean age 45 years. The tissue was fixed in formalin and processed for histology. Immunohistochemistry was performed on cross-sections of the left distal IMA to assess the areas of ETA receptor staining. The percentage are of ETA receptor staining in the media was calculated using image analysis software connected to an optical microscope and semiquantitative assessment was used to grade staining intensity, that is, mild (+), moderate (++) and strong (+++). Results: ETA receptor staining was significantly elevated in the media of the CABG specimens compared with the donor controls (46.88+/11.52% Vs 18.58+/7.65%, P = .0001). Interestingly, the endothelium (++) of the IMA, as well as the small microvessels in the adventitia (+++) stained positive for ETA receptor expression. Without using a haematoxylin counterstain, the nuclei of the cell stained more intensely (+++) with respect to the cytoplasm in both the medial smooth muscle (++) and endothelial cells (++). Fibroblasts in the medial adventitia junction were also positive for ETA receptor expression (+++). Further, this receptor subtype was also strongly expressed by inflammatory cells (monocytes and macrophages). Conclusions: These results demonstrate that the ETA receptor expression is increased in the medial SMC layer of the CABG IMA specimens and also present in the endothelium, vasa vasorum, fibroblasts and inflammatory cell types. Thus it is possible that in addition to affecting vascular tone, ET-1 may play an important role in IMA remodelling.

The production of male of-only offspring in beef cattle - a proof of principle project

The Australian beef industry places the greatest value in bulls, in comparison to cows, for prime beef production. Male carcasses can be sold for a larger profit due to their increased muscle mass. This project aims to demonstrate the feasibility of producing male animals that can sire male only offspring, through a transgenic approach in mice that could later be translated into livestock production systems. The mouse Sry (Sex determining region on the Y) gene has been shown to provide the initiating molecular signal leading to male sex determination in mammals. Sry has also been shown to cause sex reversal in XX mice transgenic for the gene. In this project Sry will be targeted to a locus not subject to X-inactivation on the X chromosome of XY mice. These mice will be bred to determine how the transgene is passed on, to determine expression of the transgene, and to assess its activity in causing XX sex reversal. The male mice transgenic for the Sry gene on their X chromosome will be produced using tetraploid aggregation, which in a single step produces 100% ES cell derived embryos. The same target locus can later be used to introduce the bovine SRY gene onto the X chromosome of bovidae species and using germ cell transplantation produce sex reversed animals. This would bypass the need for expensive chimera crosses and provide farmers with a stud bull capable of producing only sons.

Test strategies on functionally partitioned module-based programmable architecture for base-band processing

A specialised reconfigurable architecture for telecommunication base-band processing is augmented with testing resources. The routing network is linked via virtual wire hardware modules to reduce the area occupied by connecting buses. The number of switches within the routing matrices is also minimised, which increases throughput without sacrificing flexibility. The testing algorithm was developed to systematically search for faults in the processing modules and the flexible high-speed routing network within the architecture. The testing algorithm starts by scanning the externally addressable memory space and testing the master controller. The controller then tests every switch in the route-through switch matrix by making loops from the shared memory to each of the switches. The local switch matrix is also tested in the same way. Next the local memory is scanned. Finally, pre-defined test vectors are loaded into local memory to check the processing modules. This algorithm scans all possible paths within the interconnection network exhaustively and reports all faults. Strategies can be inserted to bypass minor faults

Stratigrafia fisica ed analisi di facies dei depositi torbiditici della Formazione delle Arenarie del Monte Cervarola tra la Val Secchia e la Val Scoltenna (Aquitaniano-Burdigaliano, Appennino Settentrionale)

The Cervarola Sandstones Formation (CSF), Aquitanian-Burdigalian in age, was deposited in an elongate, NW-stretched foredeep basin formed in front of the growing Northern Apennines orogenic wedge. The stratigraphic succession of the CSF, in the same way of other Apennine foredeep deposits, records the progressive closure of the basin due to the propagation of thrust fronts toward north-east, i.e. toward the outer and shallower foreland ramp. This process produce a complex foredeep characterized by synsedimentary structural highs and depocenters that can strongly influence the lateral and vertical turbidite facies distribution. Of consequence the main aim of this work is to describe and discuss this influence on the basis of a new high-resolution stratigraphic framework performed by measuring ten stratigraphic logs, for a total thickness of about 2000m, between the Secchia and Scoltenna Valleys (30km apart). In particular, the relationship between the turbidite sedimentation and the ongoing tectonic activity during the foredeep evolution has been describe through various stratigraphic cross sections oriented parallel and perpendicular to the main tectonic structures. On the basis of the high resolution physical stratigraphy of the studied succession, we propose a facies tract and an evolutionary model for the Cervarola Sandstones in the studied area. Thanks to these results and the analogies with others foredeep deposits of the northern Apennines, such as the Marnoso-arenacea Formation, the Cervarola basin has been interpreted as a highly confined foredeep controlled by an intense synsedimentary tectonic activity. The most important evidences supporting this hypothesis are: 1) the upward increase, in the studied stratigraphic succession (about 1000m thick), of sandstone/mudstone ratio, grain sizes and Ophiomorpha-type trace fossils testifying the high degree of flow deceleration related to the progressive closure and uplift of the foredeep. 2) the occurrence in the upper part of the stratigraphic succession of coarse-grained massive sandstones overlain by tractive structures such as megaripples and traction carpets passing downcurrent into fine-grained laminated contained-reflected beds. This facies tract is interpreted as related to deceleration and decoupling of bipartite flows with the deposition of the basal dense flows and bypass of the upper turbulent flows. 3) the widespread occurrence of contained reflected beds related to morphological obstacles created by tectonic structures parallel and perpendicular to the basin axis (see for example the Pievepelago line). 4) occurrence of intra-formational slumps, constituted by highly deformed portion of fine-grained succession, indicating a syn-sedimentary tectonic activity of the tectonic structures able to destabilize the margins of the basin. These types of deposits increase towards the upper part of the stratigraphic succession (see points 1 and 2) 5) the impressive lateral facies changes between intrabasinal topographic highs characterized by fine-grained and thin sandstone beds and marlstones and depocenters characterized by thick to very thick coarse-grained massive sandstones. 6) the common occurrence of amalgamation surfaces, flow impact structures and mud-draped scours related to sudden deceleration of the turbidite flows induced by the structurally-controlled confinement and morphological irregularities. In conclusion, the CSF has many analogies with the facies associations occurring in other tectonically-controlled foredeeps such as those of Marnoso-arenacea Formation (northern Italy) and Annot Sandstones (southern France) showing how thrust fronts and transversal structures moving towards the foreland, were able to produce a segmented foredeep that can strongly influence the turbidity current deposition.

Uso do protocolo no serviço de psicologia e avaliação psicodinâmica em candidatos à cirurgia bariátrica

A clínica da Obesidade Mórbida e a Cirurgia Bariátrica exige estudos e acompanhamentos do paciente. Os benefícios e riscos do emagrecimento por tratamento cirúrgico devem servir como ponto de alerta aos profissionais da saúde. O uso do questionário no serviço de psicologia é norteado pela escuta psicológica. Objetivos: 1) Descrever o perfil sócio-demográfico candidatos à cirurgia bariátrica. 2) Analisar a percepção dos pacientes sobre características de personalidade associadas à obesidade e transtornos alimentares. 3) Descrever os conteúdos psicodinâmicos da narrativa do sujeito e avaliar o sistema tensional inconsciente de dois pacientes por meio do Teste das Relações Objetais de Phillipson (TRO). Método: O delineamento metodológico com análise de dados pelo método epidemiológico e estudo de caso clínico, orientação psicanalítica. Na primeira etapa foram consultados 300 questionários do serviço de psicologia e na segunda dois pacientes com ganho de peso após 24 meses. São pacientes que procuraram tratamento em clínica especializada, em uma metrópole do sudeste brasileiro, sob consentimento pós-informado. Os questionários foram preenchidos por 227 mulheres e 73 homens; com média de idade igual a 36 anos; escolaridade ensino médio e superior, 53%; maioria casados; IMC entre grave e super mórbido (94,3%). Técnicas cirúrgicas indicadas Capella Bypass e Fobi-Capella (67%). Resultados: características psicológicas referidas pelos pacientes, a ansiedade apontou em 93,7% das respostas, seguidas por impulsividade, depressão, tolerância à frustração, baixa auto-estima, resolvedor de problemas dos outros (mais de 50%). No histórico familiar da obesidade está em mais de 70% depressão e uso do álcool em 30%; realização de psicoterapia (30%) e medicamentos para depressão e ansiedade (10%). Na segunda etapa, foi realizado o diagnóstico psicodinâmico, por meio do Teste das Relações Objetais de Phillipson com duas pacientes, cuja análise indicou necessidade de psicoterapia psicanalítica, pois tinham fixações na posição esquizoparanóide e apresentavam dificuldade em lidar com perdas e baixa motivação para mudança e insigth. Conclusões: Com a aplicação do questionário e o registro das observações empíricas, este questionário de entrevista semidirigida preenche condições de melhor acessar e avaliar os conteúdos revelados pelos pacientes. As contradições entre as respostas e o discurso, no contato individual com o psicólogo, apontam a necessidade de investimento no preparo do paciente para a cirurgia e mais acentuadamente o acompanhamento psicológico no primeiro ano do pós-operatório. Há um pensamento mágico a ser trabalhado durante a aplicação do questionário sobre as crenças frente à cirurgia e o emagrecimento e assim convocar o paciente a ocupar o lugar do sujeito implicado em seu processo pré e pós-operatório. O TRO contribuiu na compreensão do diagnóstico psicodinâmico de pacientes com ganho de peso após cirurgia e reforçou a necessidade de maior investimento no pré-operatório.(AU)

New networked technologies and carers of people with dementia: an interview study

Dementia is one of the greatest contemporary health and social care challenges, and novel approaches to the care of its sufferers are needed. New information and communication technologies (ICT) have the potential to assist those caring for people with dementia, through access to networked information and support, tracking and surveillance. This article reports the views about such new technologies of 34 carers of people with dementia. We also held a group discussion with nine carers for respondent validation. The carers' actual use of new ICT was limited, although they thought a gradual increase in the use of networked technology in dementia care was inevitable but would bypass some carers who saw themselves as too old. Carers expressed a general enthusiasm for the benefits of ICT, but usually not for themselves, and they identified several key challenges including: establishing an appropriate balance between, on the one hand, privacy and autonomy and, on the other: maximising safety; establishing responsibility for and ownership of the equipment and who bears the costs; the possibility that technological help would mean a loss of valued personal contact; and the possibility that technology would substitute for existing services rather than be complementary. For carers and dementia sufferers to be supported, the expanding use of these technologies should be accompanied by intensive debate of the associated issues.

Flow and pressure drop on the shellside of cylindrical heat exchangers

This work presents pressure distributions and fluid flow patterns on the shellside of a cylindrical shell-and-tube heat exchanger. The apparatus used was constructed from glass enabling direct observation of the flow using a dye release technique and had ten traversable pressure instrumented tubes permitting detailed pressure distributions to be obtained. The `exchanger' had a large tube bundle (278 tubes) and main flow areas typical of practical designs. Six geometries were studied: three baffle spacings both with and without baffle leakage. Results are also presented of three-dimensional modelling of shellside flows using the Harwell Laboratory's FLOW3D code. Flow visualisation provided flow patterns in the central plane of the bundle and adjacent to the shell wall. Comparison of these high-lighted significant radial flow variations. In particular, separated regions, originating from the baffle tips, were observed. The size of these regions was small in the bundle central plane but large adjacent to the shell wall and extended into the bypass lane. This appeared to reduce the bypass flow area and hence the bypass flow fraction. The three-dimensional flow modelling results were presented as velocity vector and isobar maps. The vector maps illustrated regions of high and low velocity which could be prone to tube vibration and fouling. Separated regions were also in evidence. A non-uniform crossflow was discovered with, in general, higher velocities in the central plane of the bundle than near the shell wall._The form of the isobar maps calculated by FLOW3D was in good agreement with experimental results. In particular, larger pressure drops occurred across the inlet than outlet of a crossflow region and were higher near the upstream than downstream baffle face. The effect of baffle spacing and baffle leakage on crossflow and window pressure drop measurements was identified. Agreement between the current measurements, previously obtained data and commonly used design correlations/models was, in general, poor. This was explained in terms of the increased understanding of shellside flow. The bulk of previous data, which dervies from small-scale rigs with few tubes, have been shown to be unrepresentative of typical commerical units. The Heat Transfer and Fluid Flow Service design program TASC provided the best predictions of the current pressure drop results. However, a number of simple one-dimensional models in TASC are, individually, questionable. Some revised models have been proposed.

A study on the flow characteristics of an industrial radiant tube burner

The thesis presents an experimentally validated modelling study of the flow of combustion air in an industrial radiant tube burner (RTB). The RTB is used typically in industrial heat treating furnaces. The work has been initiated because of the need for improvements in burner lifetime and performance which are related to the fluid mechanics of the com busting flow, and a fundamental understanding of this is therefore necessary. To achieve this, a detailed three-dimensional Computational Fluid Dynamics (CFD) model has been used, validated with experimental air flow, temperature and flue gas measurements. Initially, the work programme is presented and the theory behind RTB design and operation in addition to the theory behind swirling flows and methane combustion. NOx reduction techniques are discussed and numerical modelling of combusting flows is detailed in this section. The importance of turbulence, radiation and combustion modelling is highlighted, as well as the numerical schemes that incorporate discretization, finite volume theory and convergence. The study first focuses on the combustion air flow and its delivery to the combustion zone. An isothermal computational model was developed to allow the examination of the flow characteristics as it enters the burner and progresses through the various sections prior to the discharge face in the combustion area. Important features identified include the air recuperator swirler coil, the step ring, the primary/secondary air splitting flame tube and the fuel nozzle. It was revealed that the effectiveness of the air recuperator swirler is significantly compromised by the need for a generous assembly tolerance. Also, there is a substantial circumferential flow maldistribution introduced by the swirier, but that this is effectively removed by the positioning of a ring constriction in the downstream passage. Computations using the k-ε turbulence model show good agreement with experimentally measured velocity profiles in the combustion zone and proved the use of the modelling strategy prior to the combustion study. Reasonable mesh independence was obtained with 200,000 nodes. Agreement was poorer with the RNG  k-ε and Reynolds Stress models. The study continues to address the combustion process itself and the heat transfer process internal to the RTB. A series of combustion and radiation model configurations were developed and the optimum combination of the Eddy Dissipation (ED) combustion model and the Discrete Transfer (DT) radiation model was used successfully to validate a burner experimental test. The previously cold flow validated k-ε turbulence model was used and reasonable mesh independence was obtained with 300,000 nodes. The combination showed good agreement with temperature measurements in the inner and outer walls of the burner, as well as with flue gas composition measured at the exhaust. The inner tube wall temperature predictions validated the experimental measurements in the largest portion of the thermocouple locations, highlighting a small flame bias to one side, although the model slightly over predicts the temperatures towards the downstream end of the inner tube. NOx emissions were initially over predicted, however, the use of a combustion flame temperature limiting subroutine allowed convergence to the experimental value of 451 ppmv. With the validated model, the effectiveness of certain RTB features identified previously is analysed, and an analysis of the energy transfers throughout the burner is presented, to identify the dominant mechanisms in each region. The optimum turbulence-combustion-radiation model selection was then the baseline for further model development. One of these models, an eccentrically positioned flame tube model highlights the failure mode of the RTB during long term operation. Other models were developed to address NOx reduction and improvement of the flame profile in the burner combustion zone. These included a modified fuel nozzle design, with 12 circular section fuel ports, which demonstrates a longer and more symmetric flame, although with limited success in NOx reduction. In addition, a zero bypass swirler coil model was developed that highlights the effect of the stronger swirling combustion flow. A reduced diameter and a 20 mm forward displaced flame tube model shows limited success in NOx reduction; although the latter demonstrated improvements in the discharge face heat distribution and improvements in the flame symmetry. Finally, Flue Gas Recirculation (FGR) modelling attempts indicate the difficulty of the application of this NOx reduction technique in the Wellman RTB. Recommendations for further work are made that include design mitigations for the fuel nozzle and further burner modelling is suggested to improve computational validation. The introduction of fuel staging is proposed, as well as a modification in the inner tube to enhance the effect of FGR.