Pressure support versus T-tube for weaning from mechanical ventilation in adults

BackgroundMechanical ventilation is important in caring for patients with critical illness. Clinical complications, increased mortality, and high costs of health care are associated with prolonged ventilatory support or premature discontinuation of mechanical ventilation. Weaning refers to the process of gradually or abruptly withdrawing mechanical ventilation. the weaning process begins after partial or complete resolution of the underlying pathophysiology precipitating respiratory failure and ends with weaning success (successful extubation in intubated patients or permanent withdrawal of ventilatory support in tracheostomized patients).ObjectivesTo evaluate the effectiveness and safety of two strategies, a T-tube and pressure support ventilation, for weaning adult patients with respiratory failure that required invasive mechanical ventilation for at least 24 hours, measuring weaning success and other clinically important outcomes.Search methodsWe searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6); MEDLINE (via PubMed) (1966 to June 2012); EMBASE (January 1980 to June 2012); LILACS (1986 to June 2012); CINAHL (1982 to June 2012); SciELO (from 1997 to August 2012); thesis repository of CAPES (Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior) (http://capesdw.capes.gov.br/capesdw/) (August 2012); and Current Controlled Trials (August 2012).We reran the search in December 2013. We will deal with any studies of interest when we update the review.Selection criteriaWe included randomized controlled trials (RCTs) that compared a T-tube with pressure support (PS) for the conduct of spontaneous breathing trials and as methods of gradual weaning of adult patients with respiratory failure of various aetiologies who received invasive mechanical ventilation for at least 24 hours.Data collection and analysisTwo authors extracted data and assessed the methodological quality of the included studies. Meta-analyses using the random-effects model were conducted for nine outcomes. Relative risk (RR) and mean difference (MD) or standardized mean difference (SMD) were used to estimate the treatment effect, with 95% confidence intervals (CI).Main resultsWe included nine RCTs with 1208 patients; 622 patients were randomized to a PS spontaneous breathing trial (SBT) and 586 to a T-tube SBT. the studies were classified into three categories of weaning: simple, difficult, and prolonged. Four studies placed patients in two categories of weaning. Pressure support ventilation (PSV) and a T-tube were used directly as SBTs in four studies (844 patients, 69.9% of the sample). in 186 patients (15.4%) both interventions were used along with gradual weaning from mechanical ventilation; the PS was gradually decreased, twice a day, until it was minimal and periods with a T-tube were gradually increased to two and eight hours for patients with difficult and prolonged weaning. in two studies (14.7% of patients) the PS was lowered to 2 to 4 cm H2O and 3 to 5 cm H2O based on ventilatory parameters until the minimal PS levels were reached. PS was then compared to the trial with the T-tube (TT).We identified 33 different reported outcomes in the included studies; we took 14 of them into consideration and performed meta-analyses on nine. With regard to the sequence of allocation generation, allocation concealment, selective reporting and attrition bias, no study presented a high risk of bias. We found no clear evidence of a difference between PS and TT for weaning success (RR 1.07, 95% CI 0.97 to 1.17, 9 studies, low quality of evidence), intensive care unit (ICU) mortality (RR 0.81, 95% CI 0.53 to 1.23, 5 studies, low quality of evidence), reintubation (RR 0.92, 95% CI 0.66 to 1.26, 7 studies, low quality evidence), ICU and long-term weaning unit (LWU) length of stay (MD -7.08 days, 95% CI -16.26 to 2.1, 2 studies, low quality of evidence) and pneumonia (RR 0.67, 95% CI 0.08 to 5.85, 2 studies, low quality of evidence). PS was significantly superior to the TT for successful SBTs (RR 1.09, 95% CI 1.02 to 1.17, 4 studies, moderate quality of evidence). Four studies reported on weaning duration, however we were unable to combined the study data because of differences in how the studies presented their data. One study was at high risk of other bias and four studies were at high risk for detection bias. Three studies reported that the weaning duration was shorter with PS, and in one study the duration was shorter in patients with a TT.Authors' conclusionsTo date, we have found evidence of generally low quality from studies comparing pressure support ventilation (PSV) and with a T-tube. the effects on weaning success, ICU mortality, reintubation, ICU and LWU length of stay, and pneumonia were imprecise. However, PSV was more effective than a T-tube for successful spontaneous breathing trials (SBTs) among patients with simple weaning. Based on the findings of single trials, three studies presented a shorter weaning duration in the group undergoing PS SBT, however a fourth study found a shorter weaning duration with a T-tube.

L'azione economica tra etica e neurobiologia

The heated debate over the conflict between ethics and economics is often described as an epochal issue, an expression of present-day fragility, resulting from the implosion of the development model, which has characterised western society. The debate, however, exposes a paradox. Whilst, on the one hand, the neoclassical economic theory is radically criticized, on the other such criticism does not appear to delineate any solid, practicable alternative. Thus, the mainstream economic theory is still taught, practised by individuals as well as institutions, and further developed by the prevailing academic research. For this reason, a viable alternative needs to be sought, along with a new research methodology, which would allow to apply novel and more coherent theoretical assumptions into effective research and real cases. The theoretical instruments by which to create the models for human behaviour need to take into account the biological foundation of behaviour, expressed in evolutionary genetics terms. The aim of this paper is to establish whether our moral knowledge of economics may claim any scientific objectivity in light of advances in subject areas that differ in their scope and methods: moral philosophy, economics, cognitive neuroscience and artificial intelligence, each of which makes a specific contribution to understanding the operation of the human mind and towards forming the moral values onto which economic choice and action are founded. Given that the object of the study of economic science is the analysis of complex systems, nowadays the most efficient method seems to be artificial life simulation.

Valve surgery in active infective endocarditis: a simple score to predict in-hospital prognosis

Aims Surgery for infective endocarditis (IE) is associated with high mortality. Our objectives were to describe the experience with surgical treatment for IE in Spain, and to identify predictors of in-hospital mortality. Methods Prospective cohort of 1000 consecutive patients with IE. Data were collected in 26 Spanish hospitals. Results Surgery was performed in 437 patients (43.7%). Patients treated with surgery were younger and predominantly male. They presented fewer comorbid conditions and more often had negative blood cultures and heart failure. In-hospital mortality after surgery was lower than in the medical therapy group (24.3 vs 30.7%, p = 0.02). In patients treated with surgery, endocarditis involved a native valve in 267 patients (61.1%), a prosthetic valve in 122 (27.9%), and a pacemaker lead with no clear further valve involvement in 48 (11.0%). The most common aetiologies were Staphylococcus (186, 42.6%), Streptococcus (97, 22.2%), and Enterococcus (49, 11.2%). The main indications for surgery were heart failure and severe valve regurgitation. A risk score for in-hospital mortality was developed using 7 prognostic variables with a similar predictive value (OR between 1.7 and 2.3): PALSUSE: prosthetic valve, age ≥ 70, large intracardiac destruction, Staphylococcus spp, urgent surgery, sex [female], EuroSCORE ≥ 10. In-hospital mortality ranged from 0% in patients with a PALSUSE score of 0 to 45.4% in patients with PALSUSE score > 3. Conclusions The prognosis of IE surgery is highly variable. The PALSUSE score could help to identify patients with higher in-hospital mortality.

40 years of library and information studies education in Wales

Tedd, L.A. (2005). 40 years of library and information studies education in Wales. Education for Information, 23(1/2), 1-8.

Design issues for Assistive Robotics for the Elderly

Q. Meng and M.H. Lee, 'Design issues for Assistive Robotics for the Elderly', Advanced Engineering Informatics, 20(2), pp 171-186, 2006.

Dynamical Systems in the Sensorimotor Loop: On the Interrelation Between Internal and External Mechanisms of Evolved Robot Behavior

Huelse, M., Wischmann, S., Manoonpong, P., Twickel, A.v., Pasemann, F.: Dynamical Systems in the Sensorimotor Loop: On the Interrelation Between Internal and External Mechanisms of Evolved Robot Behavior. In: M. Lungarella, F. Iida, J. Bongard, R. Pfeifer (Eds.) 50 Years of Artificial Intelligence, LNCS 4850, Springer, 186 - 195, 2007.

Local studies collections online: an investigation in Irish public libraries

Barry, L., Tedd, L.A. (2008). Local studies collections online: an investigation in Irish public libraries. Program: electronic library and information systems, 42(2), 163-186.

Machine Translation and the Internet

Jones, E. H. G., Thomas, Ned, and King, Alan, 'Machine Translation and the Internet', Mercator Media Forums (2001) 5(1) pp.84-98 RAE2008

Masturbacja w świetle katolickiego spojrzenia na ludzką płciowość

Masturbacja jako zagadnienie naukowe nadal budzi kontrowersje. Autor niniejszego artykułu prezentuje ten temat w szerokim kontekście współczesnej psychologii, pedagogiki i innych dyscyplin wiedzy zajmujących się ludzką egzystencją. Moralny wymiar masturbacji musi być rozpatrywany świetle problematyki ludzkiego bycia, ponieważ tylko w takiej perspektywie można stworzyć uzasadnioną opinię o tej delikatnej kwestii.

Asesoría de diseño en producción de los productos para la cadena productiva del mopa mopa.

52 hojas : ilustraciones, fotografías a color.

[Asesoría de diseño en producción, mejoramiento y desarrollo de nuevos productos para Fúquene en trabajos en guadua (departamento de Cundinamarca)].

39 hojas : ilustraciones.

Witness

sermon text; MS Word document

The role of synchronization in digital communications using chaos - Part II: Chaotic modulation and chaotic synchronization.

For pt. I see ibid., vol. 44, p. 927-36 (1997). In a digital communications system, data are transmitted from one location to another by mapping bit sequences to symbols, and symbols to sample functions of analog waveforms. The analog waveform passes through a bandlimited (possibly time-varying) analog channel, where the signal is distorted and noise is added. In a conventional system the analog sample functions sent through the channel are weighted sums of one or more sinusoids; in a chaotic communications system the sample functions are segments of chaotic waveforms. At the receiver, the symbol may be recovered by means of coherent detection, where all possible sample functions are known, or by noncoherent detection, where one or more characteristics of the sample functions are estimated. In a coherent receiver, synchronization is the most commonly used technique for recovering the sample functions from the received waveform. These sample functions are then used as reference signals for a correlator. Synchronization-based coherent receivers have advantages over noncoherent receivers in terms of noise performance, bandwidth efficiency (in narrow-band systems) and/or data rate (in chaotic systems). These advantages are lost if synchronization cannot be maintained, for example, under poor propagation conditions. In these circumstances, communication without synchronization may be preferable. The theory of conventional telecommunications is extended to chaotic communications, chaotic modulation techniques and receiver configurations are surveyed, and chaotic synchronization schemes are described

Practice Links [Issue 34, October 2009]

Practice Links is a free e-publication for practitioners working in Irish social services, voluntary and nongovernmental sectors. Practice Links was created to enable practitioners to keep up-to-date with new publications, electronic resources and conference opportunities. Issue 34 includes notifications of Barnardos training sessions and details regarding a domestic violence research project.

Study abroad and complexity, accuracy and fluency (CAF) development: a longitudinal investigation of French and Chinese Learners of L2 English

This longitudinal study tracked third-level French (n=10) and Chinese (n=7) learners of English as a second language (L2) during an eight-month study abroad (SA) period at an Irish university. The investigation sought to determine whether there was a significant relationship between length of stay (LoS) abroad and gains in the learners' oral complexity, accuracy and fluency (CAF), what the relationship was between these three language constructs and whether the two learner groups would experience similar paths to development. Additionally, the study also investigated whether specific reported out-of-class contact with the L2 was implicated in oral CAF gains. Oral data were collected at three equidistant time points; at the beginning of SA (T1), midway through the SA sojourn (T2) and at the end (T3), allowing for a comparison of CAF gains arising during one semester abroad to those arising during a subsequent semester. Data were collected using Sociolinguistic Interviews (Labov, 1984) and adapted versions of the Language Contact Profile (Freed et al., 2004). Overall, the results point to LoS abroad as a highly influential variable in gains to be expected in oral CAF during SA. While one semester in the TL country was not enough to foster statistically significant improvement in any of the CAF measures employed, significant improvement was found during the second semester of SA. Significant differences were also revealed between the two learner groups. Finally, significant correlations, some positive, some negative, were found between gains in CAF and specific usage of the L2. All in all, the disaggregation of the group data clearly illustrates, in line with other recent enquiries (e.g. Wright and Cong, 2014) that each individual learner's path to CAF development was unique and highly individualised, thus providing strong evidence for the recent claim that SLA is "an individualized nonlinear endeavor" (Polat and Kim, 2014: 186).