Development of process control methodology for tracking the quality and safety of pain, agitation and sedation management in critical care units

Objective: To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. Design: A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Setting: Eight Scottish ICUs over a 12-month period. Patients: Mechanically ventilated patients. Interventions: None. Measurements and Main Results: The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman [rho] = 0.75) and were reliable in clinician-clinician (weighted kappa; [kappa] = 0.66) and clinician-researcher ([kappa] = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale ([rho] = 0.24) and was reliable in clinician-clinician ([kappa] = 0.58) and clinician-researcher ([kappa] = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale ([rho] = 0.54), and reliability in clinician-clinician ([kappa] = 0.29) and clinician-researcher ([kappa] = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Conclusions: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time

Prediction of Physical Properties of Yeast Cell Suspensions using Dielectric Spectroscopy

D.J. Currie, M.H. Lee and R.W. Todd, 'Prediction of Physical Properties of Yeast Cell Suspensions using Dielectric Spectroscopy', Conference on Electrical Insulation and Dielectric Phenomena, (CEIDP 2006), Annual Report, pp 672 ? 675, October 15th -18th 2006, Kansas City, Missouri, USA. Organised by IEEE Dielectrics and Electrical Insulation Society.

Planning humanitarian projects with educational focus in Guinea rural areas

Dissertação apresentada à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Acção Humanitária, Cooperação e Desenvolvimento

Measurement of the differential cross section for the reaction gamman-->pi- p from deuterium.

We report a measurement of the differential cross section for the gamman-->pi- p process from the CLAS detector at Jefferson Laboratory in Hall B for photon energies between 1.0 and 3.5 GeV and pion center-of-mass (c.m.) angles (thetac.m.) between 50 degrees and 115 degrees. We confirm a previous indication of a broad enhancement around a c.m. energy ([sqrt]s) of 2.1 GeV at thetac.m.=90 degrees in the scaled differential cross section s7dsigma/dt and a rapid falloff in a center-of-mass energy region of about 400 MeV following the enhancement. Our data show an angular dependence of this enhancement as the suggested scaling region is approached for thetac.m. from 70 degrees to 105 degrees.

Spatial distribution of bednet coverage under routine distribution through the public health sector in a rural district in Kenya.

Insecticide-treated nets (ITNs) are one of the most important and cost-effective tools for malaria control. Maximizing individual and community benefit from ITNs requires high population-based coverage. Several mechanisms are used to distribute ITNs, including health facility-based targeted distribution to high-risk groups; community-based mass distribution; social marketing with or without private sector subsidies; and integrating ITN delivery with other public health interventions. The objective of this analysis is to describe bednet coverage in a district in western Kenya where the primary mechanism for distribution is to pregnant women and infants who attend antenatal and immunization clinics. We use data from a population-based census to examine the extent of, and factors correlated with, ownership of bednets. We use both multivariable logistic regression and spatial techniques to explore the relationship between household bednet ownership and sociodemographic and geographic variables. We show that only 21% of households own any bednets, far lower than the national average, and that ownership is not significantly higher amongst pregnant women attending antenatal clinic. We also show that coverage is spatially heterogeneous with less than 2% of the population residing in zones with adequate coverage to experience indirect effects of ITN protection.

Investigation of acetylene-containing van der Waals complexes by cavity ring-down spectroscopy and ab initio calculations

info:eu-repo/semantics/nonPublished

Cost-effectiveness analysis of the diagnosis of meniscus tears.

BACKGROUND: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE: To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 1. METHODS: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.

Enhancing the Hodgkin-Huxley Equations: Simulations Based on the First Publication in the Biophysical Journal.

The experiments in the Cole and Moore article in the first issue of the Biophysical Journal provided the first independent experimental confirmation of the Hodgkin-Huxley (HH) equations. A log-log plot of the K current versus time showed that raising the HH variable n to the sixth power provided the best fit to the data. Subsequent simulations using n(6) and setting the resting potential at the in vivo value simplifies the HH equations by eliminating the leakage term. Our article also reported that the K current in response to a depolarizing step to ENa was delayed if the step was preceded by a hyperpolarization. While the interpretation of this phenomenon in the article was flawed, subsequent simulations show that the effect completely arises from the original HH equations.

The evolutionarily conserved transcription factor PRDM12 controls sensory neuron development and pain perception

PR homology domain-containing member 12 (PRDM12) is a highly evolutionary conserved member of the Prdm family of transcription factors that play essential roles in many cell fate decisions. In human, PRDM12 coding mutations have been recently identified in several patients with hereditary sensory and autonomic neuropathy (HSAN) (submitted elsewhere). Here we show that PRDM12 is involved in sensory neurogenesis in Xenopus and that several of the human Prdm12 mutants show altered structure, subcellular localization and function. In Drosophila, we demonstrate that the sensory neuron specific RNAi knockdown of the Prdm12 ortholog Hamlet induces impaired nociception and that a similar phenotype is observed in hypomorph hamlet mutants. In human fibroblasts of patients with PRDM12 mutations, we identified additional possible downstream target genes including thyrotropin-releasing hormone degrading enzyme (TRHDE). Knock-down of fly TRHDE in sensory neurons resulted in altered nociceptive neurons and impaired nociception. Collectively, these findings provide the first evidence showing that Prdm12 plays an important role in sensory neuron development. They also suggest that it has a critical evolutionarily conserved role in pain perception via modulation of the TRH signaling pathway.

Interacciones entre propiedades físicas y composición mineralógica y granulométrica de suelos argiudoles de la pampa ondulada

En la pampa ondulada se han descripto en las posiciones positivas del paisaje numerosas series de suelos, que presentan rasgos diferenciales originados a partir de composiciones texturales y mineralógicas distintas. Sin embargo, son escasos los trabajos que relacionen la composición mineralógica con las propiedades físicas y físico-químicas de perfiles completos de suelos. En esta tesis se estudiaron algunos suelos argiudoles de distintos sectores de la pampa ondulada localizados en Chivilcoy, Luján, San Pedro, Arminda y Oliveros. En todos sus horizontes se determinaron parámetros físicos, físico-químicos, mecánicos y mineralógicos. Los resultados obtenidos evidencian el desarrollo de estos suelos a partir de distintos sedimentos loéssicos diferenciados en su granulometría y mineralogía. Además de la preponderante contribución de materiales volcaniclásticos provenientes del oeste, en algunos suelos existen aportes de las Sierras Pampeanas y/o de la cuenca del Paraná. La fracción arcilla de los suelos muestra un aumento de minerales interestratificados de illita/esmectita desde el oeste al este de la región, en tanto la mineralogía magnética presenta diferencias entre los suelos, atribuibles a la composición litogénica. Las propiedades físicas relacionadas con la retención y dinámica del agua, mostraron ser dependientes del contenido de arcilla y de su composición mineralógica, diferenciándose así tres grupos: el suelo de Chivilcoy con la menor retención hídrica, el suelo de San Pedro con la mayor y los tres restantes con capacidades de retención intermedias. Por otro lado, los valores de retención son menores en los horizontes superficiales, máximos en los Bt e intermedios en los BC y C. Las propiedades de expansión-contracción determinadas a través del COLE mostraron una alta correlación con el Indice plástico de Atterberg. El COLE y el Indice plástico mostraron altos coeficientes de correlación con la CIC, siendo este un parámetro que integra el contenido de materia orgánica, el contenido de arcilla y la mineralogía de ésta. Finalmente, el criterio taxonómico de extensibilidad lineal para clasificar el subgrupo vértico no resultó por sí solo definitorio, por lo que sería necesario profundizar el estudio de las propiedades físicas y los criterios de distinción entre los argiudoles típicos y vérticos de la pampa ondulada.

Interacciones entre propiedades físicas y composición mineralógica y granulométrica de suelos argiudoles de la pampa ondulada

En la pampa ondulada se han descripto en las posiciones positivas del paisaje numerosas series de suelos, que presentan rasgos diferenciales originados a partir de composiciones texturales y mineralógicas distintas. Sin embargo, son escasos los trabajos que relacionen la composición mineralógica con las propiedades físicas y físico-químicas de perfiles completos de suelos. En esta tesis se estudiaron algunos suelos argiudoles de distintos sectores de la pampa ondulada localizados en Chivilcoy, Luján, San Pedro, Arminda y Oliveros. En todos sus horizontes se determinaron parámetros físicos, físico-químicos, mecánicos y mineralógicos. Los resultados obtenidos evidencian el desarrollo de estos suelos a partir de distintos sedimentos loéssicos diferenciados en su granulometría y mineralogía. Además de la preponderante contribución de materiales volcaniclásticos provenientes del oeste, en algunos suelos existen aportes de las Sierras Pampeanas y/o de la cuenca del Paraná. La fracción arcilla de los suelos muestra un aumento de minerales interestratificados de illita/esmectita desde el oeste al este de la región, en tanto la mineralogía magnética presenta diferencias entre los suelos, atribuibles a la composición litogénica. Las propiedades físicas relacionadas con la retención y dinámica del agua, mostraron ser dependientes del contenido de arcilla y de su composición mineralógica, diferenciándose así tres grupos: el suelo de Chivilcoy con la menor retención hídrica, el suelo de San Pedro con la mayor y los tres restantes con capacidades de retención intermedias. Por otro lado, los valores de retención son menores en los horizontes superficiales, máximos en los Bt e intermedios en los BC y C. Las propiedades de expansión-contracción determinadas a través del COLE mostraron una alta correlación con el Indice plástico de Atterberg. El COLE y el Indice plástico mostraron altos coeficientes de correlación con la CIC, siendo este un parámetro que integra el contenido de materia orgánica, el contenido de arcilla y la mineralogía de ésta. Finalmente, el criterio taxonómico de extensibilidad lineal para clasificar el subgrupo vértico no resultó por sí solo definitorio, por lo que sería necesario profundizar el estudio de las propiedades físicas y los criterios de distinción entre los argiudoles típicos y vérticos de la pampa ondulada.

The Exodus evacuation model applied to building evacuation scenarios

The purpose of this paper is to demonstrate the potential of the EXODUS evacuation model in building environments. The latest PC/workstation version of EXODUS is described and is also applied to a large hypothetical supermarket/restaurant complex measuring 50 m x 40 m. A range of scenarios is presented where population characteristics (such as size, individual travel speeds, and individual response times), and enclosure configuration characteristics (such as number of exits, size of exits, and opening times of exits) are varied. The results demonstrate a wide range of occupant behavior including overtaking, queuing, redirection, and conflict avoidance. Evacuation performance is measured by a number of model predicted parameters including individual exit flow rates, overall evacuation flow rates, total evacuation time, average evacuation time per occupant, average travel distance, and average wait time. The simulations highlight the profound impact that variations in individual travel speeds and occupant response times have in determining the overall evacuation performance. 1. Jin, T., and Yamada T., "Experimental Study of Human Behavior in Smoke Filled Corridors," Proceedings of The Second International Symposium on Fire Safety Science, 1988, pp. 511-519. 2. Galea, E.R., and Galparsoro, J.M.P., "EXODUS: An Evacuation Model for Mass Transport Vehicles," UK CAA Paper 93006 ISBN 086039 543X, CAA London, 1993. 3. Galea, E.R., and Galparsoro, J.M.P., "A Computer Based Simulation Model for the Prediction of Evacuation from Mass Transport Vehicles," Fire Safety Journal, Vol. 22, 1994, pp. 341-366. 4. Galea, E.R., Owen, M., and Lawrence, P., "Computer Modeling of Human Be havior in Aircraft Fire Accidents," to appear in the Proceedings of Combus tion Toxicology Symposium, CAMI, Oklahoma City, OK, 1995. 5. Kisko, T.M. and Francis, R.L., "EVACNET+: A Computer Program to Determine Optimal Building Evacuation Plans," Fire Safety Journal, Vol. 9, 1985, pp. 211-220. 6. Levin, B., "EXITT, A Simulation Model of Occupant Decisions and Actions in Residential Fires," Proceedings of The Second International Symposium on Fire Safety Science, 1988, pp. 561-570. 7. Fahy, R.F., "EXIT89: An Evacuation Model for High-Rise Buildings," Pro ceedings of The Third International Sym posium on Fire Safety Science, 1991, pp. 815-823. 8. Thompson, P.A., and Marchant, E.W., "A Computer Model for the Evacuation of Large Building Populations," Fire Safety Journal, Vol. 24, 1995, pp. 131-148. 9. Still, K., "New Computer System Can Predict Human Behavior Response to Building Fires," FIRE 84, 1993, pp. 40-41. 10. Ketchell, N., Cole, S.S., Webber, D.M., et.al., "The Egress Code for Human Move ment and Behavior in Emergency Evacu ations," Engineering for Crowd Safety (Smith, R.A., and Dickie, J.F., Eds.), Elsevier, 1993, pp. 361-370. 11. Takahashi, K., Tanaka, T. and Kose, S., "An Evacuation Model for Use in Fire Safety Design of Buildings," Proceedings of The Second International Symposium on Fire Safety Science, 1988, pp. 551- 560. 12. G2 Reference Manual, Version 3.0, Gensym Corporation, Cambridge, MA. 13. XVT Reference Manual, Version 3.0 XVT Software Inc., Boulder, CO. 14. Galea, E.R., "On the Field Modeling Approach to the Simulation of Enclosure Fires, Journal of Fire Protection Engineering, Vol. 1, No. 1, 1989, pp. 11-22. 15. Purser, D.A., "Toxicity Assessment of Combustion Products," SFPE Handbook of Fire Protection Engineering, National Fire Protection Association, Quincy, MA, pp. 1-200 - 1-245, 1988. 16. Hankin, B.D., and Wright, R.A., "Pas senger Flows in Subways," Operational Research Quarterly, Vol. 9, 1958, pp. 81-88. 17. HMSO, The Building Regulations 1991 - Approved Document B, section B 1 (1992 edition), HMSO publications, London, pp. 9-40. 18. Polus A., Schofer, J.L., and Ushpiz, A., "Pedestrian Flow and Level of Service," Journal of Transportation Engineering, Vol. 109, 1983, pp. 46-47. 19. Muir, H., Marrison, C., and Evans, A., "Aircraft Evacuations: the Effect of Passenger Motivation and Cabin Con figuration Adjacent to the Exit," CAA Paper 89019, ISBN 0 86039 406 9, 1989. 20. Muir, H., Private communication to appear as a CAA report, 1996.

Modelling induction skull melting design modifications

Induction Skull Melting (ISM) is a technique for heating, melting, mixing and, possibly, evaporating reactive liquid metals at high temperatures with a minimum contact at solid walls. The presented numerical modelling involves the complete time dependent process analysis based on the coupled electromagnetic, temperature and turbulent velocity fields during the melting and liquid shape changes. The simulation model is validated against measurements of liquid metal height, temperature and heat losses in a commercial size ISM furnace. The observed typical limiting temperature plateau for increasing input electrical power is explained by the turbulent convective heat losses. Various methods to increase the superheat within the liquid melt, the process energy efficiency and stability are proposed.

Chattels: I have bought it all for you

Outlines the ways by which personal property can be acquired through the gift of chattels, referring to case law including the Court of Appeal rulings in Re Cole (A Bankrupt) and Re Kirkland, and through the declaration of trust, with reference to the Chancery Division ruling in Rowe v Prance. Compares this to the use of constructive trusts or proprietary estoppel to secure assets and considers the need to prove detrimental reliance.