Prevalence of swallowing difficulties and medication modification in customers of community pharmacists

BACKGROUND: People may alter their solid oral medication dosage forms to make it easier to swallow. However, modification of solid medication dosage forms can lead to undesirable effects, and people may alter the dosage forms without informing the health professionals involved in their care. AIM: To estimate the prevalence of swallowing difficulties and medication modification amongst community pharmacy consumers, and to investigate consumer views, attitudes, and interactions with health professionals regarding such issues. METHODS: Consumers were recruited from five community pharmacies in Brisbane, Queensland and invited to participate in a structured interview. RESULTS: A total of 369 consumers participated in the study. Overall, 16.5% of people reported experiencing swallowing difficulties, and 10.6% of all respondents reported modifying medication dosage forms. Almost half (44.2%) of those surveyed did not think there would be issues with modifying medication dosage forms. Some consumers would not seek advice from health professionals if they experienced swallowing problems and/or would not seek advice from health professionals before modifying their medication dosage forms, regardless of their thoughts about any problems associated with this practice. CONCLUSION: Some consumers appeared to be accustomed to modifying medication dosage forms, even when there was no apparent or obvious need. People were also reluctant to seek advice from health professionals regarding swallowing difficulties, or modifying medication dosage forms. Health professionals must be assertive in educating consumers about swallowing problems, and medication dosage form modification.

Oral medication delivery in impaired swallowing: Thickening liquid medications for safe swallowing alters dissolution characteristics

Acetaminophen (paracetamol) is available in a wide range of oral formulations designed to meet the needs of the population across the age-spectrum, but for people with impaired swallowing, i.e. dysphagia, both solid and liquid medications can be difficult to swallow without modification. The effect of a commercial polysaccharide thickener, designed to be added to fluids to promote safe swallowing by dysphagic patients, on rheology and acetaminophen dissolution was tested using crushed immediate-release tablets in water, effervescent tablets in water, elixir and suspension. The inclusion of the thickener, comprised of xanthan gum and maltodextrin, had a considerable impact on dissolution; acetaminophen release from modified medications reached 12-50% in 30 minutes, which did not reflect the pharmacopeia specification for immediate release preparations. Flow curves reflect the high zero-shear viscosity and the apparent yield stress of the thickened products. The weak gel nature, in combination with high G’ values compared to G” (viscoelasticity) and high apparent yield stress, impact drug release. The restriction on drug release from these formulations is not influenced by the theoretical state of the drug (dissolved or dispersed), and the approach typically used in clinical practice (mixing crushed tablets into pre-prepared thickened fluid) cannot be improved by altering the order of incorporation or mixing method.

Functional Outcome after Free Flap Reconstructions in Oral and Pharyngeal Cancer

Oral cancer ranks among the 10 most common cancers worldwide. Since it is commonly diagnosed at locally advanced stage, curing the cancer demands extensive tissue resection. The emergent defect is reconstructed generally with a free flap transfer. Repair of the upper aerodigestive track with maintenance of its multiform activities is challenging. The aim of the study was to extract comprehensive treatment outcomes for patients having undergone microvascular free flap transfer because of large oral cavity or pharyngeal cancer. Ninety-four patients were analyzed for postoperative survival and complications. Forty-four patients were followed-up and analyzed for functional outcome, which was determined in terms of quality of life, speech, swallowing, and intraoral sensation. Quality of life was assessed using the University of Washington Head and Neck Questionnaire. Speech was analyzed for aerodynamic parameters and for nasal acoustic energy, as well as perceptually for articulatory proficiency, voice quality, and intelligibility. Videofluorography was performed to determine the swallowing ability. Intraoral sensation was measured by moving 2-point discrimination. The 3-year overall survival was over 40%. The 1-year disease-free survival was 43%. Postoperative complications arose in over half of the patients. Flap success rate was high. Perioperative mortality varied between 2% and 11%. Unemployment and heavy drinking were the strongest predictors of survival. Sociodemographic factors were found to associate with quality of life. The global quality of life score deteriorated and did not return to the preoperative level. Significant reduction was detectable in the domains measuring chewing and speech, and in appearance and shoulder function. The basic elements necessary for normal speech were maintained. Speech intelligibility reduced and was related to the misarticulations of the /r/ and /s/ phonemes. Deviant /r/ and /s/ persisted in most patients. Hoarseness and hypernasality occurred infrequently. One year postoperatively, 98% of the patients had achieved oral nutrition and half of them were on a regular masticated diet. Overt and silent aspiration was encountered throughout the follow-up. At 12-month swallow test, 44% of the patients aspirated, 70% of whom silently. Of these patients, 15% presented with pulmonary changes referring to aspiration. Intraoral sensation weakened but was unrelated to oral functions. The results provide new data for oral reconstructions and highlight the importance of the functional outcome of the treatment for an oral cancer patient. The mouth and the pharynx encompass a unit of utmost functional complexity. Surgery should continue to make progress in this area, and methods that lead to good function should be developed. Operational outcome should always be evaluated in terms of function.

Is there a difference in sound acoustics between aspirating versus non-aspirating swallows in children with dysphagia?

Cervical auscultation (CA) may be used to complement the clinical feeding examination when assessing for oropharyngeal aspiration (OPA). Data exists on the acoustic properties of normal and abnormal swallowing sounds in adults and children. However, there are no published paediatric studies comparing the acoustic properties of sounds comparing OPA with non-OPA swallows. We aimed to determine if there is an acoustic difference between modified barium swallow (MBS)-identified OPA and non-OPA swallow sounds in children.

Optimal explicit terminal guidance for a launch vehicle

It is observed that general explicit guidance schemes exhibit numerical instability close to the injection point. This difficulty is normally attributed to the demand for exact injection which, in turn, calls for finite corrections to be enforced in a relatively short time. The deviations in vehicle state which need corrective maneuvers are caused by the off-nominal operating conditions. Hence, the onset of terminal instability depends on the type of off-nominal conditions encountered. The proposed separate terminal guidance scheme overcomes the above difficulty by minimizing a quadratic penalty on injection errors rather than demanding an exact injection. There is also a special requirement in the terminal phase for the faster guidance computations. The faster guidance computations facilitate a more frequent guidance update enabling an accurate terminal thrust cutoff. The objective of faster computations is realized in the terminal guidance scheme by employing realistic assumptions that are accurate enough for a short terminal trajectory. It is observed from simulations that one of the guidance parameters (P) related to the thrust steering angular rates can indicate the onset of terminal instability due to different off-nominal operating conditions. Therefore, the terminal guidance scheme can be dynamically invoked based on monitoring of deviations in the lone parameter P.

Optimizing deployment of multiple decoys to enhance ship survivability

In this paper we model a scenario where a ship uses decoys to evade a hostile torpedo. We address the problem of enhancing ship survivability against enemy torpedoes by using single and multiple decoy deployments. We incorporate deterministic ship maneuvers and realistic constraints on turn rates, field of view, etc in the model. We formulate the objective function to quantify and maximize the survivability of the ship in terms of maximizing the intercept time. We introduce the concept of optimal deployment regions, same side deployment, and zig-zag deployment strategies. Finally, we present simulation results.

Impact-Angle-Constrained Suboptimal Model Predictive Static Programming Guidance of Air-to-Ground Missiles

A nonlinear suboptimal guidance law is presented in this paper for successful interception of ground targets by air-launched missiles and guided munitions. The main feature of this guidance law is that it accurately satisfies terminal impact angle constraints in both azimuth as well as elevation simultaneously. In addition, it is capable of hitting the target with high accuracy as well as minimizing the lateral acceleration demand. The guidance law is synthesized using recently developed model predictive static programming (MPSP). Performance of the proposed MPSP guidance is demonstrated using three-dimensional (3-D) nonlinear engagement dynamics by considering stationary, moving, and maneuvering targets. Effectiveness of the proposed guidance has also been verified by considering first. order autopilot lag as well as assuming inaccurate information about target maneuvers. Multiple munitions engagement results are presented as well. Moreover, comparison studies with respect to an augmented proportional navigation guidance (which does not impose impact angle constraints) as well as an explicit linear optimal guidance (which imposes the same impact angle constraints in 3-D) lead to the conclusion that the proposed MPSP guidance is superior to both. A large number of randomized simulation studies show that it also has a larger capture region.

Rendezvous of Multiple UAVs with Collision Avoidance Using Consensus

This paper addresses the problem of multiple unmanned aerial vehicle (UAV) rendezvous when the UAVs have to perform maneuvers to avoid collisions with other UAVs. The proposed solution consists of using velocity control and a wandering maneuver, if needed, of the UAVs based on a consensus among them on the estimated time of arrival at the point of the rendezvous. This algorithm, with a slight modification is shown to be useful in tracking stationary or slowly moving targets with a standoff distance. The proposed algorithm is simple and computationally efficient. The simulation results demonstrate the efficacy of the proposed approach. DOI: 10.1061/(ASCE)AS.1943-5525.0000145. (C) 2012 American Society of Civil Engineers.

An efficient hybrid approach for design of automotive wheel bearings

Wheel bearings play a crucial role in the mobility of a vehicle by minimizing motive power loss and providing stability in cornering maneuvers. Detailed engineering analysis of a wheel bearing subsystem under dynamic conditions poses enormous challenges due to the nonlinearity of the problem caused by multiple factional contacts between rotating and stationary parts and difficulties in prediction of dynamic loads that wheels are subject to. Commonly used design methodologies are based on equivalent static analysis of ball or roller bearings in which the latter elements may even be represented with springs. In the present study, an advanced hybrid approach is suggested for realistic dynamic analysis of wheel bearings by combining lumped parameter and finite element modeling techniques. A validated lumped parameter representation serves as an efficient tool for the prediction of radial wheel load due to ground reaction which is then used in detailed finite element analysis that automatically accounts for contact forces in an explicit formulation.

Capturability of augmented proportional navigation (APN) guidance with nonlinear engagement dynamics

Proportional Navigation (PN) and its variants are widely used guidance philosophies. However, in the presence of target maneuver, PN guidance law is effective only for a restrictive set of initial geometries. To account for target maneuvers, the concept of Augmented Proportional Navigation (APN) guidance law was introduced and analyzed in a linearized interceptor-target engagement framework presented in literature. However, there is no work in the literature, that addresses the capturability performance of the APN guidance law in a nonlinear engagement framework. This paper presents such an analysis and obtains the conditions for capturability. It also shows that a shorter time of interception is obtained when APN is formulated in the nonlinear framework as proposed in this paper. Simulation results are given to support the theoretical findings.

Generalized model predictive static programming and its application to 3D impact angle constrained guidance of air-to-surface missiles

A new `generalized model predictive static programming (G-MPSP)' technique is presented in this paper in the continuous time framework for rapidly solving a class of finite-horizon nonlinear optimal control problems with hard terminal constraints. A key feature of the technique is backward propagation of a small-dimensional weight matrix dynamics, using which the control history gets updated. This feature, as well as the fact that it leads to a static optimization problem, are the reasons for its high computational efficiency. It has been shown that under Euler integration, it is equivalent to the existing model predictive static programming technique, which operates on a discrete-time approximation of the problem. Performance of the proposed technique is demonstrated by solving a challenging three-dimensional impact angle constrained missile guidance problem. The problem demands that the missile must meet constraints on both azimuth and elevation angles in addition to achieving near zero miss distance, while minimizing the lateral acceleration demand throughout its flight path. Both stationary and maneuvering ground targets are considered in the simulation studies. Effectiveness of the proposed guidance has been verified by considering first order autopilot lag as well as various target maneuvers.

Differential evolution based 3-D guidance law for a realistic interceptor model

This paper presents a novel, soft computing based solution to a complex optimal control or dynamic optimization problem that requires the solution to be available in real-time. The complexities in this problem of optimal guidance of interceptors launched with high initial heading errors include the more involved physics of a three dimensional missile-target engagement, and those posed by the assumption of a realistic dynamic model such as time-varying missile speed, thrust, drag and mass, besides gravity, and upper bound on the lateral acceleration. The classic, pure proportional navigation law is augmented with a polynomial function of the heading error, and the values of the coefficients of the polynomial are determined using differential evolution (DE). The performance of the proposed DE enhanced guidance law is compared against the existing conventional laws in the literature, on the criteria of time and energy optimality, peak lateral acceleration demanded, terminal speed and robustness to unanticipated target maneuvers, to illustrate the superiority of the proposed law. (C) 2013 Elsevier B. V. All rights reserved.

Robust Reentry Guidance of a Reusable Launch Vehicle Using Model Predictive Static Programming

A robust suboptimal reentry guidance scheme is presented for a reusable launch vehicle using the recently developed, computationally efficient model predictive static programming. The formulation uses the nonlinear vehicle dynamics with a spherical and rotating Earth, hard constraints for desired terminal conditions, and an innovative cost function having several components with associated weighting factors that can account for path and control constraints in a soft constraint manner, thereby leading to smooth solutions of the guidance parameters. The proposed guidance essentially shapes the trajectory of the vehicle by computing the necessary angle of attack and bank angle that the vehicle should execute. The path constraints are the structural load constraint, thermal load constraint, bounds on the angle of attack, and bounds on the bank angle. In addition, the terminal constraints include the three-dimensional position and velocity vector components at the end of the reentry. Whereas the angle-of-attack command is generated directly, the bank angle command is generated by first generating the required heading angle history and then using it in a dynamic inversion loop considering the heading angle dynamics. Such a two-loop synthesis of bank angle leads to better management of the vehicle trajectory and avoids mathematical complexity as well. Moreover, all bank angle maneuvers have been confined to the middle of the trajectory and the vehicle ends the reentry segment with near-zero bank angle, which is quite desirable. It has also been demonstrated that the proposed guidance has sufficient robustness for state perturbations as well as parametric uncertainties in the model.

An integrated estimation/guidance approach for seeker-less interceptors

This paper addresses the problem of intercepting highly maneuverable threats using seeker-less interceptors that operate in the command guidance mode. These systems are more prone to estimation errors than standard seeker-based systems. In this paper, an integrated estimation/guidance (IEG) algorithm, which combines interactive multiple model (IMM) estimator with differential game guidance law (DGL), is proposed for seeker-less interception. In this interception scenario, the target performs an evasive bang-bang maneuver, while the sensor has noisy measurements and the interceptor is subject to acceleration bound. The IMM serves as a basis for the synthesis of efficient filters for tracking maneuvering targets and reducing estimation errors. The proposed game-based guidance law for two-dimensional interception, later extended to three-dimensional interception scenarios, is used to improve the endgame performance of the command-guided seeker-less interceptor. The IMM scheme and an optimal selection of filters, to cater to various maneuvers that are expected during the endgame, are also described. Furthermore, a chatter removal algorithm is introduced, thus modifying the differential game guidance law (modified DGL). A comparison between modified DGL guidance law and conventional proportional navigation guidance law demonstrates significant improvement in miss distance in a pursuer-evader scenario. Simulation results are also presented for varying flight path angle errors. A numerical study is provided which demonstrates the performance of the combined interactive multiple model with game-based guidance law (IMM/DGL). Simulation study is also carried out for combined IMM and modified DGL (IMM/modified DGL) which exhibits the superior performance and viability of the algorithm reducing the chattering phenomenon. The results are illustrated by an extensive Monte Carlo simulation study in the presence of estimation errors.

Guidelines for reducing porpoise mortality in tuna purse seining

More than a decade has passed since the passage of the Marine Mammal Protection Act of 1972. During that time the U.S. tuna purse seine neet reduced its incidental porpoise mortality rate more than 10-fold. This was made possible through the development of gear and techniques aimed at reducing the frequency of many low probability events that contribute to the kill. Porpoise are killed by becoming entangled or entrapped in folds and canopies of the net and suffocating. The configuration of the net, both before and during the backdown release procedure, is a major determinant of the number of porpoise killed. Speedboats can be used to tow on the corkllne to prevent net collapse and also to adjust the net configuration to reduce net canopies prior to backdown. Deepening a net can reduce the probability of porpoise being killed by prebackdown net collapse. The effects of environmental conditions and mechanical failures on net configuration can result in high porpoise mortality unless mitigated by skilled vessel maneuvers or prevented by the timely use of speedboats to adjust the net. The backdown procedure is the only means to effectively release captured porpoise from a purse seine. It is also the time during the set when most of the mortality occurs. The use of small mesh safety panels and aprons in the backdown areas of nets reduces porpoise entanglement, and Increases the probability of an effective release. The tie-down points on the net for preparing the backdown channel must be properly located in order to optimize porpoise release. A formula uses the stretched depth of the net to calculate one of these points, making it a simple matter to locate the other. Understanding the dynamics of the backdown procedure permits a thorough troubleshooting of performance, thus preventing the repetition of poorly executed backdowns and thereby reducing mortality. Porpoise that cannot be released must be rescued by hand. A rescuer in a rigidly inflated raft can rescue porpoise effectively at any time during a net set. Hand rescue can make the difference between above average kill and zero kill sets. In all circumstances, the skill and motivation of the captain and his crew are the final determinants in the prevention of incidental porpoise mortality in tuna seining. (PDF file contains 22 pages.)