CAUTI prevention bundles: improving best practices within Western Health for continued success

Background: Persons in acute care settings who have indwelling urethral catheters are at higher risk of acquiring a urinary tract infection (UTI). Other complications related to prolonged indwelling urinary catheters include decreased mobility, damage to the meatus and/or urethra, increase use of antibiotics, increased length of stay, and pain. UTIs in acute care settings account for 30 to 40% of all health care associated infections (HAIs). Of these, 80% are catheter associated UTIs (CAUTIs). Purpose: To utilized the CDC (2009) bundle approach for CAUTI prevention and create a program which supports a multimodal method to improving urinary catheter use, maintenance, and removal, including a continuing competency program where role expansion is anticipated. Methods: A comprehensive review of the literature was conducted. Physicians were consulted through a power point presentation followed by a letter explaining the project, a questionnaire, and two selections of relevant literature. Nursing staff and allied health professionals from the target units of 3A and 3B medicine attended one of two lunch and learns. They were presented the project via a power point presentation and the same questionnaire as distributed to physicians. Results: Five e-learning modules, a revised policy, and clinical pathway have been developed to support staff with best practice knowledge transfer. Conclusion: Behaviour changes need to be approached with a framework, extensive consultation, and education. Sustainability of any practice change cannot occur without having completed the background work to ensure staff have access to tools to support the change.

Dosimetric Evaluation of Metal Artefact Reduction using Metal Artefact Reduction (MAR) Algorithm and Dual-energy Computed Tomography (CT) Method

Purpose: Computed Tomography (CT) is one of the standard diagnostic imaging modalities for the evaluation of a patient’s medical condition. In comparison to other imaging modalities such as Magnetic Resonance Imaging (MRI), CT is a fast acquisition imaging device with higher spatial resolution and higher contrast-to-noise ratio (CNR) for bony structures. CT images are presented through a gray scale of independent values in Hounsfield units (HU). High HU-valued materials represent higher density. High density materials, such as metal, tend to erroneously increase the HU values around it due to reconstruction software limitations. This problem of increased HU values due to metal presence is referred to as metal artefacts. Hip prostheses, dental fillings, aneurysm clips, and spinal clips are a few examples of metal objects that are of clinical relevance. These implants create artefacts such as beam hardening and photon starvation that distort CT images and degrade image quality. This is of great significance because the distortions may cause improper evaluation of images and inaccurate dose calculation in the treatment planning system. Different algorithms are being developed to reduce these artefacts for better image quality for both diagnostic and therapeutic purposes. However, very limited information is available about the effect of artefact correction on dose calculation accuracy. This research study evaluates the dosimetric effect of metal artefact reduction algorithms on severe artefacts on CT images. This study uses Gemstone Spectral Imaging (GSI)-based MAR algorithm, projection-based Metal Artefact Reduction (MAR) algorithm, and the Dual-Energy method.

Materials and Methods: The Gemstone Spectral Imaging (GSI)-based and SMART Metal Artefact Reduction (MAR) algorithms are metal artefact reduction protocols embedded in two different CT scanner models by General Electric (GE), and the Dual-Energy Imaging Method was developed at Duke University. All three approaches were applied in this research for dosimetric evaluation on CT images with severe metal artefacts. The first part of the research used a water phantom with four iodine syringes. Two sets of plans, multi-arc plans and single-arc plans, using the Volumetric Modulated Arc therapy (VMAT) technique were designed to avoid or minimize influences from high-density objects. The second part of the research used projection-based MAR Algorithm and the Dual-Energy Method. Calculated Doses (Mean, Minimum, and Maximum Doses) to the planning treatment volume (PTV) were compared and homogeneity index (HI) calculated.

Results: (1) Without the GSI-based MAR application, a percent error between mean dose and the absolute dose ranging from 3.4-5.7% per fraction was observed. In contrast, the error was decreased to a range of 0.09-2.3% per fraction with the GSI-based MAR algorithm. There was a percent difference ranging from 1.7-4.2% per fraction between with and without using the GSI-based MAR algorithm. (2) A range of 0.1-3.2% difference was observed for the maximum dose values, 1.5-10.4% for minimum dose difference, and 1.4-1.7% difference on the mean doses. Homogeneity indexes (HI) ranging from 0.068-0.065 for dual-energy method and 0.063-0.141 with projection-based MAR algorithm were also calculated.

Conclusion: (1) Percent error without using the GSI-based MAR algorithm may deviate as high as 5.7%. This error invalidates the goal of Radiation Therapy to provide a more precise treatment. Thus, GSI-based MAR algorithm was desirable due to its better dose calculation accuracy. (2) Based on direct numerical observation, there was no apparent deviation between the mean doses of different techniques but deviation was evident on the maximum and minimum doses. The HI for the dual-energy method almost achieved the desirable null values. In conclusion, the Dual-Energy method gave better dose calculation accuracy to the planning treatment volume (PTV) for images with metal artefacts than with or without GE MAR Algorithm.

Theory and Practice in Sustainability Science: Influence of Urban Form on the Urban Heat Island and Implications for Urban Systems

As the world population continues to grow past seven billion people and global challenges continue to persist including resource availability, biodiversity loss, climate change and human well-being, a new science is required that can address the integrated nature of these challenges and the multiple scales on which they are manifest. Sustainability science has emerged to fill this role. In the fifteen years since it was first called for in the pages of Science, it has rapidly matured, however its place in the history of science and the way it is practiced today must be continually evaluated. In Part I, two chapters address this theoretical and practical grounding. Part II transitions to the applied practice of sustainability science in addressing the urban heat island (UHI) challenge wherein the climate of urban areas are warmer than their surrounding rural environs. The UHI has become increasingly important within the study of earth sciences given the increased focus on climate change and as the balance of humans now live in urban areas.

In Chapter 2 a novel contribution to the historical context of sustainability is argued. Sustainability as a concept characterizing the relationship between humans and nature emerged in the mid to late 20th century as a response to findings used to also characterize the Anthropocene. Emerging from the human-nature relationships that came before it, evidence is provided that suggests Sustainability was enabled by technology and a reorientation of world-view and is unique in its global boundary, systematic approach and ambition for both well being and the continued availability of resources and Earth system function. Sustainability is further an ambition that has wide appeal, making it one of the first normative concepts of the Anthropocene.

Despite its widespread emergence and adoption, sustainability science continues to suffer from definitional ambiguity within the academe. In Chapter 3, a review of efforts to provide direction and structure to the science reveals a continuum of approaches anchored at either end by differing visions of how the science interfaces with practice (solutions). At one end, basic science of societally defined problems informs decisions about possible solutions and their application. At the other end, applied research directly affects the options available to decision makers. While clear from the literature, survey data further suggests that the dichotomy does not appear to be as apparent in the minds of practitioners.

In Chapter 4, the UHI is first addressed at the synoptic, mesoscale. Urban climate is the most immediate manifestation of the warming global climate for the majority of people on earth. Nearly half of those people live in small to medium sized cities, an understudied scale in urban climate research. Widespread characterization would be useful to decision makers in planning and design. Using a multi-method approach, the mesoscale UHI in the study region is characterized and the secular trend over the last sixty years evaluated. Under isolated ideal conditions the findings indicate a UHI of 5.3 ± 0.97 °C to be present in the study area, the magnitude of which is growing over time.

Although urban heat islands (UHI) are well studied, there remain no panaceas for local scale mitigation and adaptation methods, therefore continued attention to characterization of the phenomenon in urban centers of different scales around the globe is required. In Chapter 5, a local scale analysis of the canopy layer and surface UHI in a medium sized city in North Carolina, USA is conducted using multiple methods including stationary urban sensors, mobile transects and remote sensing. Focusing on the ideal conditions for UHI development during an anticyclonic summer heat event, the study observes a range of UHI intensity depending on the method of observation: 8.7 °C from the stationary urban sensors; 6.9 °C from mobile transects; and, 2.2 °C from remote sensing. Additional attention is paid to the diurnal dynamics of the UHI and its correlation with vegetation indices, dewpoint and albedo. Evapotranspiration is shown to drive dynamics in the study region.

Finally, recognizing that a bridge must be established between the physical science community studying the Urban Heat Island (UHI) effect, and the planning community and decision makers implementing urban form and development policies, Chapter 6 evaluates multiple urban form characterization methods. Methods evaluated include local climate zones (LCZ), national land cover database (NCLD) classes and urban cluster analysis (UCA) to determine their utility in describing the distribution of the UHI based on three standard observation types 1) fixed urban temperature sensors, 2) mobile transects and, 3) remote sensing. Bivariate, regression and ANOVA tests are used to conduct the analyses. Findings indicate that the NLCD classes are best correlated to the UHI intensity and distribution in the study area. Further, while the UCA method is not useful directly, the variables included in the method are predictive based on regression analysis so the potential for better model design exists. Land cover variables including albedo, impervious surface fraction and pervious surface fraction are found to dominate the distribution of the UHI in the study area regardless of observation method.

Chapter 7 provides a summary of findings, and offers a brief analysis of their implications for both the scientific discourse generally, and the study area specifically. In general, the work undertaken does not achieve the full ambition of sustainability science, additional work is required to translate findings to practice and more fully evaluate adoption. The implications for planning and development in the local region are addressed in the context of a major light-rail infrastructure project including several systems level considerations like human health and development. Finally, several avenues for future work are outlined. Within the theoretical development of sustainability science, these pathways include more robust evaluations of the theoretical and actual practice. Within the UHI context, these include development of an integrated urban form characterization model, application of study methodology in other geographic areas and at different scales, and use of novel experimental methods including distributed sensor networks and citizen science.

Coarse-silt-fraction mineralogy at DSDP Legs 56 and 57 Holes

Soviet sedimentologists use the term "coarse silt" to denote the size fraction 0.1 to 0.05 mm (50-100 µm). Petelin (1961) has shown that this fraction is most diagnostic for terrigeneous and volcanogenic mineral assemblages and provinces in Recent deep-sea sediments, because of its greatest variability of both heavy and light non-opaque minerals, which may be easily identified by the common immersion method. We believe that the fraction is suitable for mineralogical study of unconsolidated and friable sediments from DSDP cores as well, if the objective is to investigate their source area and transporation tracks. In the case of fine-grained oceanic sediments, mineral composition of the coarse silt does not differ markedly from that of the "coarse fraction" (>62 µm).

Sea-surface reconstructions of the western Pacific Ocean during the last 5.3 million years

The late Neogene was a time of cryosphere development in the northern hemisphere. The present study was carried out to estimate the sea surface temperature (SST) change during this period based on the quantitative planktonic foraminiferal data of 8 DSDP sites in the western Pacific. Target factor analysis has been applied to the conventional transfer function approach to overcome the no-analog conditions caused by evolutionary faunal changes. By applying this technique through a combination of time-slice and time-series studies, the SST history of the last 5.3 Ma has been reconstructed for the low latitude western Pacific. Although the present data set is close to the statistical limits of factor analysis, the clear presence of sensible variations in individual SST time-series suggests the feasibility and reliability of this method in paleoceanographic studies. The estimated SST curves display the general trend of the temperature fluctuations and reveal three major cool periods in the late Neogene, i.e. the early Pliocene (4.7 3.5 Ma), the late Pliocene (3.1-2.7 Ma), and the latest Pliocene to early Pleistocene (2.2-1.0 Ma). Cool events are reflected in the increase of seasonality and meridional SST gradient in the subtropical area. The latest Pliocene to early Pleistocene cooling is most important in the late Neogene climatic evolution. It differs from the previous cool events in its irreversible, steplike change in SST, which established the glacial climate characteristic of the late Pleistocene. The winter and summer SST decreased by 3.3-5.4°C and 1.0 2.1C in the subtropics, by 0.9°C and 0.6C in the equatorial region, and showed little or no cooling in the tropics. Moreover, this cooling event occurred as a gradual SST decrease during 2.2 1.0 Ma at the warmer subtropical sites, while that at cooler subtropical site was an abrupt SST drop at 2.2 Ma. In contrast, equatorial and tropical western Pacific experienced only minor SST change in the entire late Neogene. In general, subtropics was much more sensitive to climatic forcing than tropics and the cooling events were most extensive in the cooler subtropics. The early Pliocene cool periods can be correlated to the Antarctic ice volume fluctuation, and the latest Pliocene early Pleistocene cooling reflects the climatic evolution during the cryosphere development of the northern hemisphere.

Implementing a structural continuity constraint and a halting method for the topology optimization of energy absorbers

This study investigates topology optimization of energy absorbing structures in which material damage is accounted for in the optimization process. The optimization objective is to design the lightest structures that are able to absorb the required mechanical energy. A structural continuity constraint check is introduced that is able to detect when no feasible load path remains in the finite element model, usually as a result of large scale fracture. This assures that designs do not fail when loaded under the conditions prescribed in the design requirements. This continuity constraint check is automated and requires no intervention from the analyst once the optimization process is initiated. Consequently, the optimization algorithm proceeds towards evolving an energy absorbing structure with the minimum structural mass that is not susceptible to global structural failure. A method is also introduced to determine when the optimization process should halt. The method identifies when the optimization method has plateaued and is no longer likely to provide improved designs if continued for further iterations. This provides the designer with a rational method to determine the necessary time to run the optimization and avoid wasting computational resources on unnecessary iterations. A case study is presented to demonstrate the use of this method.

Model reduction for nonlinear aerodynamics and aeroelasticity using a Discrete Empirical Interpolation Method

A novel surrogate model is proposed in lieu of Computational Fluid Dynamics (CFD) solvers, for fast nonlinear aerodynamic and aeroelastic modeling. A nonlinear function is identified on selected interpolation points by
a discrete empirical interpolation method (DEIM). The flow field is then reconstructed using a least square approximation of the flow modes extracted
by proper orthogonal decomposition (POD). The aeroelastic reduce order
model (ROM) is completed by introducing a nonlinear mapping function
between displacements and the DEIM points. The proposed model is investigated to predict the aerodynamic forces due to forced motions using
a N ACA 0012 airfoil undergoing a prescribed pitching oscillation. To investigate aeroelastic problems at transonic conditions, a pitch/plunge airfoil
and a cropped delta wing aeroelastic models are built using linear structural models. The presence of shock-waves triggers the appearance of limit
cycle oscillations (LCO), which the model is able to predict. For all cases
tested, the new ROM shows the ability to replicate the nonlinear aerodynamic forces, structural displacements and reconstruct the complete flow
field with sufficient accuracy at a fraction of the cost of full order CFD
model.

Model reduction for nonlinear aeroelasticity using the Discrete Empirical Interpolation Method

A novel surrogate model is proposed in lieu of computational fluid dynamic (CFD) code for fast nonlinear aerodynamic modeling. First, a nonlinear function is identified on selected interpolation points defined by discrete empirical interpolation method (DEIM). The flow field is then reconstructed by a least square approximation of flow modes extracted by proper orthogonal decomposition (POD). The proposed model is applied in the prediction of limit cycle oscillation for a plunge/pitch airfoil and a delta wing with linear structural model, results are validate against a time accurate CFD-FEM code. The results show the model is able to replicate the aerodynamic forces and flow fields with sufficient accuracy while requiring a fraction of CFD cost.

Artificial Neural Network and Neutron Aplication in a Volume Fraction Calculation in Annular and Stratified Multiphase System

Multiphase flows, type oil–water-gas are very common among different industrial activities, such as chemical industries and petroleum extraction, and its measurements show some difficulties to be taken. Precisely determining the volume fraction of each one of the elements that composes a multiphase flow is very important in chemical plants and petroleum industries. This work presents a methodology able to determine volume fraction on Annular and Stratified multiphase flow system with the use of neutrons and artificial intelligence, using the principles of transmission/scattering of fast neutrons from a 241Am-Be source and measurements of point flow that are influenced by variations of volume fractions. The proposed geometries used on the mathematical model was used to obtain a data set where the thicknesses referred of each material had been changed in order to obtain volume fraction of each phase providing 119 compositions that were used in the simulation with MCNP-X –computer code based on Monte Carlo Method that simulates the radiation transport. An artificial neural network (ANN) was trained with data obtained using the MCNP-X, and used to correlate such measurements with the respective real fractions. The ANN was able to correlate the data obtained on the simulation with MCNP-X with the volume fractions of the multiphase flows (oil-water-gas), both in the pattern of annular flow as stratified, resulting in a average relative error (%) for each production set of: annular (air= 3.85; water = 4.31; oil=1.08); stratified (air=3.10, water 2.01, oil = 1.45). The method demonstrated good efficiency in the determination of each material that composes the phases, thus demonstrating the feasibility of the technique.

The Accuracy and Reliability of Traditional Surface Flow Type Mapping: Is It Time for A New Method of Characterising Physical River Habitat?

Surface flow types (SFT) are advocated as ecologically relevant hydraulic units, often mapped visually from the bankside to characterise rapidly the physical habitat of rivers. SFT mapping is simple, non-invasive and cost-efficient. However, it is also qualitative, subjective and plagued by difficulties in recording accurately the spatial extent of SFT units. Quantitative validation of the underlying physical habitat parameters is often lacking, and does not consistently differentiate between SFTs. Here, we investigate explicitly the accuracy, reliability and statistical separability of traditionally mapped SFTs as indicators of physical habitat, using independent, hydraulic and topographic data collected during three surveys of a c. 50m reach of the River Arrow, Warwickshire, England. We also explore the potential of a novel remote sensing approach, comprising a small unmanned aerial system (sUAS) and Structure-from-Motion photogrammetry (SfM), as an alternative method of physical habitat characterisation. Our key findings indicate that SFT mapping accuracy is highly variable, with overall mapping accuracy not exceeding 74%. Results from analysis of similarity (ANOSIM) tests found that strong differences did not exist between all SFT pairs. This leads us to question the suitability of SFTs for characterising physical habitat for river science and management applications. In contrast, the sUAS-SfM approach provided high resolution, spatially continuous, spatially explicit, quantitative measurements of water depth and point cloud roughness at the microscale (spatial scales ≤1m). Such data are acquired rapidly, inexpensively, and provide new opportunities for examining the heterogeneity of physical habitat over a range of spatial and temporal scales. Whilst continued refinement of the sUAS-SfM approach is required, we propose that this method offers an opportunity to move away from broad, mesoscale classifications of physical habitat (spatial scales 10-100m), and towards continuous, quantitative measurements of the continuum of hydraulic and geomorphic conditions which actually exists at the microscale.

Size distribution and volume fraction of T1 phase precipitates from TEM images: Direct measurements and related correction

Transmission Electron Microscopy (TEM) can be used to measure the size distribution and volume fraction of fine scale precipitates in metallic systems. However, such measurements suffer from a number of artefacts that need to be accounted for, related to the finite thickness of the TEM foil and to the projected observation in two dimensions of the microstructure. We present a correction procedure to describe the 3D distribution of disc-like particles and apply this method to the plate-like T1 precipitates in an Al-Li-Cu alloy in two ageing conditions showing different particle morphologies. The precipitates were imaged in a High-Angular Annular Dark Field Microscope (HAADF-STEM). The corrected size distribution is further used to determine the precipitate volume fraction. Atom probe tomography (APT) is finally utilised as an alternative way to measure the precipitate volume fraction and test the validity of the electron microscopy results.

Validation de la reproductibilité d’outils de mesure de la fraction d’éjection du ventricule gauche en médecine nucléaire

La fraction d’éjection du ventricule gauche est un excellent marqueur de la fonction cardiaque. Plusieurs techniques invasives ou non sont utilisées pour son calcul : l’angiographie, l’échocardiographie, la résonnance magnétique nucléaire cardiaque, le scanner cardiaque, la ventriculographie radioisotopique et l’étude de perfusion myocardique en médecine nucléaire. Plus de 40 ans de publications scientifiques encensent la ventriculographie radioisotopique pour sa rapidité d’exécution, sa disponibilité, son faible coût et sa reproductibilité intra-observateur et inter-observateur. La fraction d’éjection du ventricule gauche a été calculée chez 47 patients à deux reprises, par deux technologues, sur deux acquisitions distinctes selon trois méthodes : manuelle, automatique et semi-automatique. Les méthodes automatique et semi-automatique montrent dans l’ensemble une meilleure reproductibilité, une plus petite erreur standard de mesure et une plus petite différence minimale détectable. La méthode manuelle quant à elle fournit un résultat systématiquement et significativement inférieur aux deux autres méthodes. C’est la seule technique qui a montré une différence significative lors de l’analyse intra-observateur. Son erreur standard de mesure est de 40 à 50 % plus importante qu’avec les autres techniques, tout comme l’est sa différence minimale détectable. Bien que les trois méthodes soient d’excellentes techniques reproductibles pour l’évaluation de la fraction d’éjection du ventricule gauche, les estimations de la fiabilité des méthodes automatique et semi-automatique sont supérieures à celles de la méthode manuelle.

Validation de la reproductibilité d’outils de mesure de la fraction d’éjection du ventricule gauche en médecine nucléaire

La fraction d’éjection du ventricule gauche est un excellent marqueur de la fonction cardiaque. Plusieurs techniques invasives ou non sont utilisées pour son calcul : l’angiographie, l’échocardiographie, la résonnance magnétique nucléaire cardiaque, le scanner cardiaque, la ventriculographie radioisotopique et l’étude de perfusion myocardique en médecine nucléaire. Plus de 40 ans de publications scientifiques encensent la ventriculographie radioisotopique pour sa rapidité d’exécution, sa disponibilité, son faible coût et sa reproductibilité intra-observateur et inter-observateur. La fraction d’éjection du ventricule gauche a été calculée chez 47 patients à deux reprises, par deux technologues, sur deux acquisitions distinctes selon trois méthodes : manuelle, automatique et semi-automatique. Les méthodes automatique et semi-automatique montrent dans l’ensemble une meilleure reproductibilité, une plus petite erreur standard de mesure et une plus petite différence minimale détectable. La méthode manuelle quant à elle fournit un résultat systématiquement et significativement inférieur aux deux autres méthodes. C’est la seule technique qui a montré une différence significative lors de l’analyse intra-observateur. Son erreur standard de mesure est de 40 à 50 % plus importante qu’avec les autres techniques, tout comme l’est sa différence minimale détectable. Bien que les trois méthodes soient d’excellentes techniques reproductibles pour l’évaluation de la fraction d’éjection du ventricule gauche, les estimations de la fiabilité des méthodes automatique et semi-automatique sont supérieures à celles de la méthode manuelle.

Barriers and facilitators to initial and continued attendance at community-based lifestyle programmes among families of overweight and obese children: a systematic review

The success of childhood weight management programmes relies on family engagement. While attendance offers many benefits including the support to make positive lifestyle changes, the majority of families referred to treatment decline. Moreover, for those who do attend, benefits are often compromised by high programme attrition. This systematic review investigated factors influencing attendance at community-based lifestyle programmes among families of over-weight or obese children. A narrative synthesis approach was used to allow for the inclusion of quantitative, qualitative and mixed-method study designs. Thirteen studies met the inclusion criteria. Results suggest that parents provided the impetus for programme initiation, and this was driven largely by a concern for their child's psychological health and wellbeing. More often than not, children went along without any real reason or interest in attending. Over the course of the programme, however, children's positive social experiences such as having fun and making friends fostered the desire to continue. The stigma surrounding excess weight and the denial of the issue amongst some parents presented barriers to enrolment and warrant further study. This study provides practical recommendations to guide future policy makers, programme delivery teams and researchers in developing strategies to boost recruitment and minimise attrition.

An approximate method for the solution of an influence function foil rolling model

Fleck and Johnson (Int. J. Mech. Sci. 29 (1987) 507) and Fleck et al. (Proc. Inst. Mech. Eng. 206 (1992) 119) have developed foil rolling models which allow for large deformations in the roll profile, including the possibility that the rolls flatten completely. However, these models require computationally expensive iterative solution techniques. A new approach to the approximate solution of the Fleck et al. (1992) Influence Function Model has been developed using both analytic and approximation techniques. The numerical difficulties arising from solving an integral equation in the flattened region have been reduced by applying an Inverse Hilbert Transform to get an analytic expression for the pressure. The method described in this paper is applicable to cases where there is or there is not a flat region.