Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children (Review)

Abstract
Background: Automated closed loop systems may improve adaptation of the mechanical support to a patient's ventilatory needs and
facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of
ventilation.

Objectives: To compare the duration of weaning from mechanical ventilation for critically ill ventilated adults and children when managed
with automated closed loop systems versus non-automated strategies. Secondary objectives were to determine differences
in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); MEDLINE (OvidSP) (1948 to August 2011); EMBASE (OvidSP) (1980 to August 2011); CINAHL (EBSCOhost) (1982 to August 2011); and the Latin American and Caribbean Health Sciences Literature (LILACS). In addition we received and reviewed auto-alerts for our search strategy in MEDLINE, EMBASE, and CINAHL up to August 2012. Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles.

Selection criteria: We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning
strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an intensive care unit (ICU).

Data collection and analysis: Two authors independently extracted study data and assessed risk of bias. We combined data into forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria.

Main results: Pooled data from 15 eligible trials (14 adult, one paediatric) totalling 1173 participants (1143 adults, 30 children) indicated that automated closed loop systems reduced the geometric mean duration of weaning by 32% (95% CI 19% to 46%, P =0.002), however heterogeneity was substantial (I2 = 89%, P < 0.00001). Reduced weaning duration was found with mixed or
medical ICU populations (43%, 95% CI 8% to 65%, P = 0.02) and Smartcare/PS™ (31%, 95% CI 7% to 49%, P = 0.02) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (17%, 95% CI 8% to 26%) and ICU length of stay (LOS) (11%, 95% CI 0% to 21%). There was no difference in mortality rates or hospital LOS. Overall the quality of evidence was high with the majority of trials rated as low risk.

Authors' conclusions: Automated closed loop systems may result in reduced duration of weaning, ventilation, and ICU stay. Reductions are more
likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized
controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.

Testing the role of sensory systems in the migratory heading of a songbird

The identification of the sensory cues and mechanisms by which migratory birds are able to reach the same breeding and wintering grounds year after year has eluded biologists despite more than 50 years of intensive study. While a number of environmental cues have been proposed to play a role in the navigation of birds, arguments still persist about which cues are essential for the experience based navigation shown by adult migrants. To date, few studies have tested the sensory basis of navigational cues used during actual migration in the wild: mainly laboratory based studies or homing during the non-migratory season have been used to investigate this behaviour. Here we tested the role of olfactory and magnetic cues in the migration of the catbird (Dumetella carolinensis) by radio tracking the migration of birds with sensory manipulations during their actual migratory flights. Our data suggest that adult birds treated with zinc sulphate to produce anosmia were unable to show the same orientation as control adults, and instead reverted to a direction similar to that shown by juveniles making their first migration. The magnetic manipulation had no effect on the orientation of either adults or juveniles. These results allow us to propose that the olfactory sense may play a role in experience based migration in adult catbirds. While the olfactory sense has been shown to play a role in the homing of pigeons and other birds, this is the first time it has been implicated in migratory orientation.

Dispersion interactions in room-temperature ionic liquids: Results from a non-empirical density functional

The role of dispersion or van de Waals (VDW) interactions in imidazolium-based room-temperature ionic liquids is studied within the framework of density functional theory, using a recently developed non-empirical functional [M. Dion, H. Rydberg, E. Schroder, D. C. Langreth, and B. I. Lundqvist, Phys. Rev. Lett. 92, 246401 (2004)], as efficiently implemented in the SIESTA code [G. Roman-Perez and J. M. Soler, Phys. Rev. Lett. 103, 096102 (2009)]. We present results for the equilibrium structure and lattice parameters of several crystalline phases, finding a general improvement with respect to both the local density (LDA) and the generalized gradient approximations (GGA). Similar to other systems characterized by VDW bonding, such as rare gas and benzene dimers as well as solid argon, equilibrium distances and volumes are consistently overestimated by approximate to 7%, compared to -11% within LDA and 11% within GGA. The intramolecular geometries are retained, while the intermolecular distances and orientations are significantly improved relative to LDA and GGA. The quality is superior to that achieved with tailor-made empirical VDW corrections ad hoc [M. G. Del Popolo, C. Pinilla, and P. Ballone, J. Chem. Phys. 126, 144705 (2007)]. We also analyse the performance of an optimized version of this non-empirical functional, where the screening properties of the exchange have been tuned to reproduce high-level quantum chemical calculations [J. Klimes, D. Bowler, and A. Michaelides, J. Phys.: Condens. Matter 22, 074203 (2010)]. The results for solids are even better with volumes and geometries reproduced within 2% of experimental data. We provide some insight into the issue of polymorphism of [bmim][Cl] crystals, and we present results for the geometry and energetics of [bmim][Tf] and [mmim][Cl] neutral and charged clusters, which validate the use of empirical force fields. (C) 2011 American Institute of Physics. [doi:10.1063/1.3652897]

Mucoadhesive, syringeable drug delivery systems for controlled application of metronidazole to the periodontal pocket: In vitro release kinetics, syringeability, mechanical and mucoadhesive properties

Novel mucoadhesive formulations containing hydroxyethylcellulose (HEC; 3 and 5%, w/w) or Carbopol (3 and 5%, w/w), polycarbophil (PC; 1 and 3%, w/w) and metronidazole (5%, w/w) at pH 6.8 were designed for the treatment of periodontal diseases. Each formulation was characterised in terms of hardness, compressibility, adhesiveness and cohesiveness (using Texture Profile Analysis), drug release, adhesion to a mucin disc (measured as a detachment force using the texture analyser in tensile mode) and, finally, syringeability (using the texture analyser in compression mode). Drug release from all formulations was non-diffusion controlled. Drug release was significantly decreased as the concentration of each polymeric component was increased, due to both the concomitant increased viscosity of the formulations and, additionally, the swelling kinetics of PC following contact with dissolution fluid. Increasing the concentrations of each polymeric component significantly increased formulation hardness, compressibility, adhesiveness, mucoadhesion and syringeability, yet decreased cohesiveness. Increased product hardness, compressibility and syringeability were due to polymeric effects on formulation viscosity. The effects on cohesiveness may be explained both by increased viscosity and also by the increasing semi-solid nature of products containing 5% HEC or Carbopol and PC (1 or 3%). The observations concerning formulation adhesiveness/mucoadhesion illustrate the adhesive nature of each polymeric component. Greatest adhesion was noted in formulations where neutralisation of PC was maximally suppressed. For the most part, increased time of contact between formulation and mucin significantly increased the required force of detachment, due to the greater extent of mucin polymer hydration and interpenetration with the formulations. Significant statistical interactions were observed between the effects of each polymer on drug release and mechanical/mucoadhesive properties. These interactions may be explained by formulatory effects on the extent of swelling of PC. In conclusion, the formulations described offered a wide range of mechanical and drug release characteristics. Formulations containing HEC exhibited superior physical characteristics for improved drug delivery to the periodontal pocket and are now the subject of long-term clinical investigations. (C) 1997 Elsevier Science B.V.

Towards identification of Wiener systems with the least amount of a priori information on the nonlinearity

In this paper, we investigate what constitutes the least amount of a priori information on the nonlinearity so that the FIR linear part is identifiable in the non-Gaussian input case. Three types of a priori information are considered including quadrant information, point information and locally monotonous information. In all three cases, identifiability has been established and corresponding identification algorithms are developed with their convergence proofs.

Non-parametric nonlinear system identification: A data-driven orthogonal basis function approach

In this paper, a data driven orthogonal basis function approach is proposed for non-parametric FIR nonlinear system identification. The basis functions are not fixed a priori and match the structure of the unknown system automatically. This eliminates the problem of blindly choosing the basis functions without a priori structural information. Further, based on the proposed basis functions, approaches are proposed for model order determination and regressor selection along with their theoretical justifications. © 2008 IEEE.

Hierarchical Bayesian models in ecology: Reconstructing species interaction networks from non-homogeneous species abundance data

The relationships among organisms and their surroundings can be of immense complexity. To describe and understand an ecosystem as a tangled bank, multiple ways of interaction and their effects have to be considered, such as predation, competition, mutualism and facilitation. Understanding the resulting interaction networks is a challenge in changing environments, e.g. to predict knock-on effects of invasive species and to understand how climate change impacts biodiversity. The elucidation of complex ecological systems with their interactions will benefit enormously from the development of new machine learning tools that aim to infer the structure of interaction networks from field data. In the present study, we propose a novel Bayesian regression and multiple changepoint model (BRAM) for reconstructing species interaction networks from observed species distributions. The model has been devised to allow robust inference in the presence of spatial autocorrelation and distributional heterogeneity. We have evaluated the model on simulated data that combines a trophic niche model with a stochastic population model on a 2-dimensional lattice, and we have compared the performance of our model with L1-penalized sparse regression (LASSO) and non-linear Bayesian networks with the BDe scoring scheme. In addition, we have applied our method to plant ground coverage data from the western shore of the Outer Hebrides with the objective to infer the ecological interactions. (C) 2012 Elsevier B.V. All rights reserved.

Millimetre-wave broadband wireless systems and enabling MMIC technologies

Chapter eleven on Mm-wave broadband wireless systems and enabling MMIC technologies, is contributed by Jian Zhang, Mury Thian, Guochi Huang, George Goussetis and Vincent F. Fusco, from Queen's University Belfast, UK. Millimeter wave bands provide large available bandwidths for high data rate wireless communication systems, which are envisaged to shift data throughput well in the GBps range. This capability has over past few years driven rapid developments in the technology underpinning broadband wireless systems as well as in the standardisation activity from various non-governmental consortia and the band allocation from spectrum regulators globally. This chapter provides an overview of the recent developments on V-band broadband wireless systems with the emphasis placed on enabling MMIC technologies. An overview of the key applications and available standards is presented. System-level architectures for broadband wireless applications are being reviewed. Examples of analysis, design and testing on MMIC components in SiGe BiCMOS are presented and the outlook of the technology is discussed.

Controlled fragrance delivery in functionalised ionic liquid-enzyme systems

It is often believed that both ionic liquids and surfactants generally behave as non-specific denaturants of proteins. In this paper, it is shown that amphiphilic ionic liquids bearing a long alkyl chain and a target molecule, where the target molecule is appended via a carboxylic ester functionality, can represent super-substrates that enable the catalytic activity of an enzyme, even at high concentrations in solution. Menthol has been chosen as the target molecule for slow and controlled fragrance delivery, and it was found that the rate of the menthol release can be controlled by the chemical structure of the ionic liquid. At a more fundamental level, this study offers an insight into the complex hydrophobic, electrostatic, and hydrogen bond interactions between the enzyme and substrate.

Investigation of the M2/G2/1/ ∞, N Queue with Restricted Admission of Priority Customers and its Application to HSDPA Mobile Systems

This paper investigates a queuing system for QoS optimization of multimedia traffic consisting of aggregated streams with diverse QoS requirements transmitted to a mobile terminal over a common downlink shared channel. The queuing system, proposed for buffer management of aggregated single-user traffic in the base station of High-Speed Downlink Packet Access (HSDPA), allows for optimum loss/delay/jitter performance for end-user multimedia traffic with delay-tolerant non-real-time streams and partially loss tolerant real-time streams. In the queuing system, the real-time stream has non-preemptive priority in service but the number of the packets in the system is restricted by a constant. The non-real-time stream has no service priority but is allowed unlimited access to the system. Both types of packets arrive in the stationary Poisson flow. Service times follow general distribution depending on the packet type. Stability condition for the model is derived. Queue length distribution for both types of customers is calculated at arbitrary epochs and service completion epochs. Loss probability for priority packets is computed. Waiting time distribution in terms of Laplace-Stieltjes transform is obtained for both types of packets. Mean waiting time and jitter are computed. Numerical examples presented demonstrate the effectiveness of the queuing system for QoS optimization of buffered end-user multimedia traffic with aggregated real-time and non-real-time streams.

Perceptual investigation of image placement with Ambisonics for non-centred listeners

Ambisonics is a scalable spatial audio technique that attempts to present a sound scene to listeners over as large an area as possi- ble. A localisation experiment was carried out to investigate the performance of a first and third order system at three listening positions - one in the centre and two off-centre. The test used a reverse target-pointer adjustment method to determine the error, both signed and absolute, for each combination of listening posi- tion and system. The signed error was used to indicate the direc- tion and magnitude of the shifts in panning angle introduced for the off-centre listening positions. The absolute error was used as a measure of the performance of the listening position and systems combinations for a comparison of their overall performance. A comparison was made between the degree of image shifting be- tween the two systems and the robustness of their off-centre per- formance.

Linear Optics Simulation of Quantum Non-Markovian Dynamics

The simulation of open quantum dynamics has recently allowed the direct investigation of the features of system-environment interaction and of their consequences on the evolution of a quantum system. Such interaction threatens the quantum properties of the system, spoiling them and causing the phenomenon of decoherence. Sometimes however a coherent exchange of information takes place between system and environment, memory effects arise and the dynamics of the system becomes non-Markovian. Here we report the experimental realisation of a non-Markovian process where system and environment are coupled through a simulated transverse Ising model. By engineering the evolution in a photonic quantum simulator, we demonstrate the role played by system-environment correlations in the emergence of memory effects.

Managing adaptivity in parallel systems

The management of non-functional features (performance, security, power management, etc.) is traditionally a difficult, error prone task for programmers of parallel applications. To take care of these non-functional features, autonomic managers running policies represented as rules using sensors and actuators to monitor and transform a running parallel application may be used. We discuss an approach aimed at providing formal tool support to the integration of independently developed autonomic managers taking care of different non-functional concerns within the same parallel application. Our approach builds on the Behavioural Skeleton experience (autonomic management of non-functional features in structured parallel applications) and on previous results on conflict detection and resolution in rule-based systems. © 2013 Springer-Verlag Berlin Heidelberg.

A Hamiltonian approach to simulation of acoustic systems involving nonlinear interactions

Nonlinear interactions take place in most systems that arise in music acoustics, usually as a result of player-instrument coupling. Several time-stepping methods exist for the numerical simulation of such systems. These methods generally involve the discretization of the Newtonian description of the system. However, it is not always possible to prove the stability of the resulting algorithms, especially when dealing with systems where the underlying force is a non-analytic function of the phase space variables. On the other hand, if the discretization is carried out on the Hamiltonian description of the system, it is possible to prove the stability of the derived numerical schemes. This Hamiltonian approach is applied to a series of test models of single or multiple nonlinear collisions and the energetic properties of the derived schemes are discussed. After establishing that the schemes respect the principle of conservation of energy, a nonlinear single-reed model is formulated and coupled to a digital bore, in order to synthesize clarinet-like sounds.