Clinical, ethical and legal considerations in the treatment of newborns with non-ketotic hyperglycinaemia

Non-ketotic hyperglycinaemia (NKH) is a devastating neurometabolic disorder leading, in its classical form, to early death or severe disability and poor quality of life in survivors. Affected neonates may need ventilatory support during a short period of respiratory depression. The transient dependence on ventilation dictates urgency in decision-making regarding withdrawal of therapy. The occurrence of patients with apparent transient forms of the disease, albeit rare, adds uncertainty to the prediction of clinical outcome and dictates that the current practice of withholding or withdrawing therapy in these neonates be reviewed. Both bioethics and law take the view that treatment decisions should be based on the best interests of the patient. The medical-ethics approach is based on the principles of non-maleficence, beneficence, autonomy and justice. The law relating to withholding or withdrawing life-sustaining treatment is complex and varies between jurisdictions. Physicians treating newborns with NKH need to provide families with accurate and complete information regarding the disease and the relative probability of possible outcomes of the neonatal presentation and to explore the extent to which family members are willing to take part in the decision making process. Cultural and religious attitudes, which may potentially clash with bioethical and juridical principles, need to be considered.

Urban sustainability and market typologies : lessons from Tabriz Bazaar

The market is an essential component of urban form. Contemporary shopping malls can benefit from the inherent efficiencies of traditional markets. This paper addresses the development of sustainable models of market typologies based on a specific case study, the Bazaar of Tabriz in Iran.

As one of the biggest historical covered markets in the world (Moradi and Nassabi 2007), it remains an effective trading centre in the city. What are the lessons that make Tabriz a sustainable urban typology and what lessons can we draw from its spatial and operational structure?

To address this question, the paper presents two analytical studies of the urban and building morphology of Tabriz. First, the paper presents an analysis of the urban and social structure of the market based on Lynchian analysis. Second, it provides an analysis of the thermal, ventilation and lighting principles used in the buildings of the market and how they respond to the extreme climatic conditions of north-west Iran.

Rainfall and snow in one side and hot summers in the other, give the buildings in the city really critical performance in terms of life span during the years of operation.

The main target in this case study, is to illuminate the urban typological clarifications in the Bazaar of Tabriz, which wilt elucidate how parallel links between urban morphology (land cover) and urban typology (land use) in a defined urban planning can form a sustainable urban space. Moreover, how the case of this study can be an energy efficient complex with its own urban morphology.

The lessons of Tabriz for the development of contemporary markets are summarised in the paper and need to be addressed at two scales, namely the urban scale and the scale of the building.

Implementation of a management guideline aimed at minimizing the severity of primary graft dysfunction after lung transplant

Objective
Primary graft dysfunction, a severe form of lung injury that occurs in the first 72 hours after lung transplant, is associated with morbidity and mortality. We sought to assess the impact of an evidence-based guideline as a protocol for respiratory and hemodynamic management.

Methods
Preoperative and postoperative data for patients treated per the guideline (n = 56) were compared with those of a historical control group (n = 53). Patient data such as ratio of arterial Po2 to inspired oxygen fraction, central venous pressure, cumulative fluid balance, vasopressor dose, and serum urea and creatinine were measured and documented at specific times. Primary outcome was severity of primary graft dysfunction within the first 72 hours.

Results
Primary graft dysfunction grade was progressively lower in patients treated after introduction of the guideline (P = .01). Lower postoperative fluid balances (P = .01) and vasopressor doses (P = .007) were seen, with no associated renal dysfunction. There were no differences in duration of mechanical ventilation or mortality. Nonadherence to the guideline occurred in 10 cases (18%).

Conclusions
Implementation of an evidence-based guideline for managing respiratory and hemodynamic status is feasible and safe and was associated with reduction in severity of primary graft dysfunction. Further studies are required to determine whether such a guideline would lead to a consistent reduction in severity of primary graft dysfunction at other institutions. Creation of a protocol for postoperative care provides a template for further studies of novel therapies or management strategies for primary graft dysfunction.

Context dependency of comfort and energy performance in mixed mode offices

This article investigates the context dependency of comfort and energy performance in mixed-mode offices in the climate of Athens, Greece. It is based on a parametric study using the simulation software EnergyPlus. Context refers to different building design priorities on the real estate market (prestige, low cost and green), occupant behaviour scenarios (ideal and worst case) and cooling strategies (fixed and adaptive set points). Results are evaluated according to energy consumption and related greenhouse gas emissions, daylight autonomy, view and percentage of working time when heating and cooling are operating. The results indicate that a holistic approach to comfort and energy performance evaluation focused on the specific context of a building and its occupants is necessary to develop appropriate optimization strategies. In early design stages, such specific information is not yet available and ideal/worst-case scenarios can indicate the magnitude of influence of occupants compared to building design.

Review : nurses can improve patient nutrition in intensive care

Aims and objectives. To review the literature and identify opportunities for nutritional practice improvement in the critically ill and opportunities to improve nurses’ knowledge relating to enteral feeding.

Background. The literature reports varying nutritional practices in intensive care.

Design. Systematic review.

Methods. A systematic search, selection, analysis and review of nursing, medical and dietetic primary research articles was undertaken. Fifteen studies met the selection criteria.

Results. Delivery of nutrition to the critically ill varied widely. Patients were frequently underfed and less frequently, overfed. Both under- and overfeeding have been linked with unacceptable consequences including infections, extended weaning from mechanical ventilation, increased length of stay and increased mortality. Underfeeding was related to slow initiation and advancement of nutrition support and avoidable feed interruptions. The most common reasons for interrupting feeds were gastrointestinal intolerance and fasting for procedures. Certain nursing practices contributed to underfeeding such as the management of gastric residual volumes.

Conclusions. Consistent and reliable nutrition support in intensive care units is hampered by a lack of evidence leading to varying nutrition practices. Factors impeding delivery of enteral nutrition were considered avoidable. A new concept of a therapeutic range of energy delivery in the critically ill has emerged implying the need for re-evaluation of energy recommendations and improved delivery of enteral nutrition.

Relevance to clinical practice. This review supports the multi-disciplinary development and implementation of an evidence-based enteral feeding protocol in intensive care units as a strategy to improve adequacy of nutritional intake. Critical care nurses are well placed to improve this process.

Ten years of environmental university building

The authors have been involved in over ten years of environmental consulting and research on university buildings. Numerous simulations and measurement studies have occurred over this period of time. The intentions have always been to improve and optimise the environmental performing aspects of a building. This paper is a reporting of the implemented strategies, their pre-building research investigation as well as their operational outcomes. Their successes and failures are discussed here. This research is intended as a feedback loop to future design specification, commissioning and maintenance improvements. In hindsight many of the environmental concepts, when executed as planned, were successful. However, often those requiring extensive control, such as lighting, ventilation and mechanical air-conditioning were a failure. The observations between simulation and actual performance are also noted. The paper includes discussion about some of the obstacles in building procurement which can hinder the result of a good environmental performing building.

Pneumatic vehicle

A pneumatic vehicle is provided with a first sub-assembly with a chassis, part of the vehicle body, a pair of B-pillars, a pair of rear rails, wheels, an elongate aluminum compressed load bearing air tank oriented longitudinally in the chassis, side panels connected to the tank and the wheels, a heat exchanger to heat the compressed air, and an air motor driven by the heated, compressed air and connected to a wheel. A ventilation system has a restrictive solenoid valve for directing air to the heat exchanger. The air tank is provided with a carbon filament reinforced plastic layer, and a fiberglass and aramid-fiber layer. A second sub-assembly includes part of the vehicle body bonded to the first-sub-assembly using a structural adhesive, a pair of A-pillars, and a pair of roof rails. Seating includes inflatable components for adjustment.

CHASSIS FOR PNEUMATIC VEHICLE

A pneumatic vehicle is provided with a first sub-assembly with a chassis, part of the vehicle body, a pair of B-pillars, a pair of rear rails, wheels, an elongate aluminum compressed load bearing air tank oriented longitudinally in the chassis, side panels connected to the tank and the wheels, a heat exchanger to heat the compressed air, and an air motor driven by the heated, compressed air and connected to a wheel. A ventilation system has a restrictive solenoid valve for directing air to the heat exchanger. The air tank is provided with a carbon filament reinforced plastic layer, and a fiberglass and aramid-fiber layer. A second sub-assembly includes part of the vehicle body bonded to the first-sub-assembly using a structural adhesive, a pair of A-pillars, and a pair of roof rails. Seating includes inflatable components for adjustment.

PNEUMATIC POWERTRAIN FOR AN AUTOMOTIVE VEHICLE

A pneumatic vehicle is provided with a chassis, wheels, a compressed air tank, a heat exchanger to heat the compressed air, and an air motor driven by the heated air and connected to at least one wheel. A pneumatic vehicle is provided with a chassis, wheels, a compressed air tank, and an air motor driven by the compressed air and connected to a wheel. The vehicle also has a ventilation system for the passenger compartment, a heat exchanger, and a restrictive solenoid valve for directing ventilation system air to the heat exchanger. A pneumatic vehicle is provided with a chassis, wheels, an aluminum compressed air tank, a carbon filament reinforced plastic layer over the tank, a fiberglass and aramid-fiber layer over the carbon filament reinforced plastic layer, and an air motor driven by the compressed air and connected to at least one wheel.

PNEUMATIC VEHICLE

A pneumatic vehicle is provided with a first sub- assembly with a chassis, part of the vehicle body, a pair of B-pillars, a pair of rear rails, wheels, an elongate aluminum compressed load bearing air tank oriented longitudinally in the chassis, side panels connected to the tank and the wheels, a heat exchanger to heat the compressed air, and an air motor driven by the heated, compressed air and connected to a wheel. A ventilation system has a restrictive solenoid valve for directing air to the heat exchanger. The air tank is provided with a carbon filament reinforced plastic layer, and a fiberglass and aramid-fiber layer. A second sub-assembly includes part of the vehicle body bonded to the first-sub-assembly using a structural adhesive, a pair of A-pillars, and a pair of roof rails. Seating includes inflatable components for adjustment.

Comparison of the EN 15251 and Ashrae Standard 55 adaptive thermal comfort models in the context of a Mediterranean climate

Strong heat waves in the past decade and resulting legal cases which gave full responsibility for indoor thermal comfort to building professionals lead to an increased uncertainty how to maintain thermal comfort in offices without the use of a cooling system. Adaptive thermal comfort standards such as EN 15251 and Ashrae Standard 55 provide methodologies to evaluate comfort in naturally ventilated spaces. Based on a parametric study for a typical cellular office in the context of Athens, Greece, and using the building simulation software EnergyPlus, this study investigates the potentials for the applicability of natural ventilation in a Mediterranean climate. The Ashrae Standard 55 and EN 15251 adaptive thermal comfort models are compared in this context, and conclusions are drawn how the use of natural ventilation based on adaptive models can be further encourgaged.

Skeletal morbidity among survivors of critical illness

Objectives: To describe the incident fracture rate in survivors of critical illness and to compare fracture risk with populationmatched control subjects.

Design: Retrospective longitudinal case– cohort study.

Setting: A tertiary adult intensive care unit in Australia. Patients: All patients ventilated admitted to intensive care and requiring mechanical ventilation for >48 hrs between January 1998 and December 2005.

Interventions: None.

Measurements and Main Results: New fractures were identified in the study population for the postintensive care unit period (intensive care unit discharge to January 2008). The incident fracture rate and age-adjusted fracture risk of the female intensive care unit population were compared with the general population adult females derived from the Geelong Osteoporosis Study. Over the 8-yr period, a total of 739 patients (258 women, 481 men) were identified. After a median follow-up of 3.7 yrs (interquartile range, 2.0–5.9 yrs) for women and 4.0 yrs (interquartile range, 2.1–6.1 yrs) for men, incident fracture rates (95% confidence interval) per 100 patient years were 3.84 (2.58 –5.09) for females 2.41 (1.73–3.09) for males. Compared with an age-matched random population-based sample of women, elderly women were at increased risk for sustaining an osteoporosisrelated fracture after critical illness (hazard ratio, 1.65; 95% confidence interval, 1.08 –2.52; p .02).

Conclusions: The increase in fracture risk observed in postintensive care unit older females suggests an association between critical illness and subsequent skeletal morbidity. The explanation for this association is not explored in this study and includes the effects of pre-existing patient factors and/or direct effects of critical illness. Prospective research evaluating risk factors, the relationship between critical illness and bone turnover, the extent and duration of bone loss, and the associated morbidity in this population is warranted.